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India's New HIV/AIDS Numbers

Global experts of various kinds used to describe India as the "AIDS capital of the world" and the Central Intelligence Agency had forecast that there would be 20-25 million HIV cases by 2012. Now, as a result of new surveys, the government has more than halved its earlier estimate and the HIV population is placed at 2.47 million. An examination of the problems of the old surveys and a discussion of the new methodology.

a countrywide community-based household survey”. It is however, pertinent to note that data from the latest round of

India’s New HIV/AIDS Numbers

Global experts of various kinds used to describe India as the “AIDS capital of the world” and the Central Intelligence Agency had forecast that there would be 20-25 million HIV cases by 2012. Now, as a result of new surveys, the government has more than halved its earlier estimate and the HIV population is placed at

2.47 million. An examination of the problems of the old surveys and a discussion of the new methodology.

PALLAVA BAGLA

I
t just may be premature to start celebrating that the case load for people infected with the dreaded Human Immunodeficiency Virus (HIV) has come down by half to 2.47 million as per the latest estimate released by the government. There are more unknowns than knowns in the methodology adopted by the National AIDS Control Organisation (NACO) to arrive at this optimistic figure.

To make an analogy, the AIDS estimation survey is very much akin to the “exit polls” conducted by pollsters during election time, and as a consequence, suffers from similar handicaps. To make a popular point all the pollsters failed in predicting the meteoric rise of Mayawati of the Bahujan Samajwadi Party, despite some exit polls having had a sample size of about 70,000. This was because it seems the dalit voters were under-represented in the sampling. In a way, the intelligent Indian voter and the cunning AIDS bug both conceal their true nature, as a consequence, predictions can more often than not be way off the mark.

What is crystal clear now is that the spectre of a giant AIDS holocaust waiting to explode in India, is not a scenario that was based on any reality, to that extent that phantom of an AIDS time bomb or Abomb has certainly been defused. Several high profile scare mongers like the former director of the World Bank and then chief of the Global Fund, Richard Feachem, who in 2004 dubbed India as the “AIDS capital of the world”, may have to eat crow. If the new government estimate is accurate, then the most unintelligent and highly alarmist estimate that by 2010 India will have 20-25 million HIV positive cases came from the Central Intelligence Agency (CIA) of America through its 2002 report from the National Intelligence Council. In the past years UNAIDS has on several occasions questioned the veracity of the NACO data but now it seems they will have to eat humble pie.

According to NACO’s latest estimate, the prevalence of HIV/AIDS in India has to be scaled down from one in hundred or about 0.9 per cent to one in three hundred or 0.36 per cent, a dramatic drop. “It is hard to know how much of this drop is due to a new computer programme than because of the efforts of the AIDS control programme” quips Prabhat Jha, a well known epidemiologist and director of the centre for Global Health Research, University of Toronto, Canada. The new data is incidentally endorsed by WHO, UNDP, UNAIDS among others.

A new multi-pronged methodology, fresh mathematical models and a novel community-based dataset had given confidence to the union health minister Anbumani Ramadoss to say that “there are an estimated 2 to 3.1 million people infected with HIV/AIDS” down from the government’s own figure of 2006 which put the same number at 5.2 million which according to the minister, who himself was a medical doctor, a “reason to be happy”.

Taking a direct potshot at the several alarmist foreign experts, the minister said “we have always been found fault with for underestimating the seriousness of the epidemic. That was a disturbing allegation as we were and continue to be very committed to containing and reversing the HIV AIDS epidemic”. While it hurt, explained Ramadoss, he did not expect an apology from these experts. According to the health minister “today we have with us a far more reliable estimate of the burden of HIV disease in India. These estimates are based mainly on two important sources of data. First, we continue to have the data from our sentinel surveillance [in pregnant women], now expanded to 1,122 sites from the earlier 703 sentinel sites. This year we have the additional inputs from the National Family Health Survey, which is sentinel surveillance (2006) were not released on this occasion. As a consequence in a way, the country is left with comparing “apples with oranges”. Ashok Alexander, director Avahaan, the India AIDS control programme of the Bill and Melinda Gates Foundation, says “India has an obsession with absolute numbers and we were getting too excited about small victories”.

Unpeeling the Methodology

Let us now tease apart whatever we know or not about these new datasets, the limitations and handicaps of such new approaches. Sentinel surveillance, was thrust on India by several United Nations agencies as being the “gold standard” and best way to track the AIDS epidemic in India. In this approach for about eight weeks every year clinics frequented by pregnant women are intensively monitored and patients tested for HIV. The hope being that by tracking young sexually active women, trends may emerge on how the epidemic was progressing at specific locations. In addition, people visiting clinics treating sexually-transmitted diseases like syphilis and gonorrhoea were also monitored which would indicate how the disease was progressing in the so-called “high risk” groups.

When collated and viewed over a snap shot of time, the sentinel surveillance gives a good indicator of the trends of the epidemic whether its spread is on an upward curve or is it slowing down. For several years Indian experts have been pointing out that deriving absolute numbers of infections from this dataset was inaccurate and that it was “probably” leading to an erroneous estimation of the absolute numbers. But, in the wake of the very loud scare mongers, the sane voice of the home-grown conservatives was always drowned out. So much so that in 2006, when an Indian expert Lalit Dandona, now heading the George Institute of Public Health in Hyderabad, published what is now being labelled as “robust” data from Guntur district that exemplified this gross over-estimation. His study was derided and ridiculed even by the experts from the UNAIDS! In an earlier The Lancet publication, Jha and coauthors were the first to show that the AIDS epidemic was indeed slowing down in southern India. All efforts were made to discredit this work too. Both, pieces of research now stand vindicated.

Economic and Political Weekly July 28, 2007

When in 2005, the country embarked upon the third, five yearly exhaustive assessment exercise called the National Family Health Survey (NFHS-3), in its wisdom the ministry of health and family welfare decided to gather data on the prevalence of HIV/AIDS by carrying out an AIDS test as part of this mega analysis. The NFHS is by design a random statistical survey done in the community, and meant to provide signals of what is happening in the larger population, and because of this very nature it under-represents certain populations. In this nationwide exercise about one lakh people in the age group 1554 voluntarily undertook an AIDS test. This new data reveals that the prevalence of HIV/AIDS was 0.28 per cent, which means that merely about 280 HIV positive cases were actually detected by the surveyors. This when broken down further for the 28 states and seven union territories (no AIDS testing was done in Nagaland which resented the blood collection) results in an AIDS positivity which falls in single digits, not good enough to calibrate data, say experts. Meaningful results can only be interpreted when the number of positive cases are several thousand in number.

Jha feels the NFHS was actually “under powered” to correctly portray the true picture of the AIDS epidemic in India, he feels the sample size should have been at least four times higher. To once again bring in the UP election results scenario, in the same fashion as the pollsters underrepresented the dalit voter and got their predictions wrong, the NFHS is in a way under-representing the high risk groups, and hence, erring towards an underestimate.

But to the credit of NACO, they did some nifty “mathematical calibrations to adjust for weightages across states” explains Arvind Pandey, director of the government-funded National Institute of Medical Statistics, New Delhi. He says, it is these “intelligent adjustments” that resulted in the final HIV/AIDS prevalence figure of 0.36 per cent being arrived at, giving the public health planners reason to cheer that the control programme is working.

In making the estimate of 0.36 per cent, another black box called the Integrated Behavioural and Biologic Assessment (IBBA) system data was also it seems factored in, a fact incidentally not made public by the government but by UNAIDS in its several official fact sheets where it admits that “new data have come from three main sources”. According to UNAIDS the IBBA is a “targeted surveillance system focusing on groups at higher risk of HIV infection, located in the states with high prevalence”. The report of the IBBA has not been made public and not much is known about this exercise, but Pandey does admit that IBBA’s data “compared well” with data from NACO’s sentinel surveillance. The IBBA was funded by Avahan.

While complimenting the work of NACO in putting brakes on the AIDS epidemic, Ramadoss also added a word of caution by saying that while “experts from India and round the world were consulted and after a lot of hard work … the results show that there are an estimated 2 million to 3.1 million people infected with HIV/AIDS with a prevalence level of about 0.36 per cent. While the prevalence appears to be less than the previous estimate of 0.9 per cent, these figures are not comparable. By using the same methodology for the past years that we used this year, there is only a marginal reduction in the prevalence. Moreover, in terms of human lives affected, the numbers are still large and worrying. There is no doubt in my mind that we cannot let down our vigil but continue to work hard to ensure that the HIV/AIDS are under total control.” These cautionary words of wisdom come from an earthy politician who probably comprehends how flawed surveys and exit polls can be.

EPW

Email: pbagla@vsnl.com

Economic and Political Weekly July 28, 2007

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