Kaiser Daily HIV/AIDS Report Summarizes Responses in the Lancet to Study on HIV Prevalence in India
The Lancet in its July 8 edition published five correspondences in response to a study on HIV prevalence in South India published in the March 30 online edition of the journal, as well as a response from the study's authors and a correspondence responding to a Lancet analysis of the study. For the study, Rajesh Kumar of the Post Graduate Institute of Medical Education and Research in Chandigarh, India, and colleagues examined HIV prevalence among 294,000 women ages 15 to 34 attending prenatal clinics in four states in southern India and 14 states in the north, as well as prevalence among 59,000 men ages 15 to 34 attending clinics for sexually transmitted infections in the same regions. The researchers found that among women ages 15 to 24 attending prenatal clinics in the southern states of Tamil Nadu, Andhra Pradesh, Maharashtra and Karanataka, HIV prevalence decreased to 1.1% in 2004 from 1.7% in 2001, a relative decline of 35%. Among men ages 20 to 29 attending STI clinics, the researchers recorded a 36% relative decline in HIV prevalence over the same time period. The study finds no significant decrease in HIV prevalence among women ages 25 to 34 or among men and women in the northern states, where the epidemic is driven by injection drug use. The researchers said the study's findings might signify a decrease in the number of new infections acquired through heterosexual contact in India, and they credited the decline among young people to an increase in condom use among commercial sex workers and their clients in the southern part of the country (Kaiser Daily HIV/AIDS Report, 3/30). Responses to the study are summarized below.
Correspondence Responding to Study
- Adrienne Germain, Brian Brink: While the study's findings "justif[y] sustained investment" in HIV prevention in southern India, a "narrow focus on condom use among 'high-risk' groups," such as commercial sex workers, cannot be the only "solution," Germain of the International Women's Health Coalition and Brink of the Anglo American Corporation of South Africa write in a correspondence. "Reversing HIV/AIDS requires a paradigm shift and budget allocations to prevention programs that address the several factors that make girls and women disproportionately vulnerable," the authors write (Germain/Brink, Lancet, 7/8).
- M.D. Gupte et al.: The way Kumar and colleagues combined and compared some of the data from prenatal clinics was "incorrect," Gupte of India's National Institute of Epidemiology and colleagues write in a correspondence. In addition, the "comparability" of HIV prevalence at clinics in both north and south India "could be a source of selection bias," and "characteristics of women enrolled in [pre]natal clinics in different years might be different," the authors say (Gupte et al., Lancet, 7/8).
- T. Jacob John: Although the findings of the study are "good news," it is "important to distinguish between the achievements of Tamil Nadu and those of the other states," John, former head of the National HIV Reference Laboratory, writes in a correspondence. Tamil Nadu "has had a clear decline" in HIV prevalence since 2000-2001, and the state's success in reducing prevalence might be "predominately, if not solely," the reason for the overall decline in the southern states the study examined, according to John (John, Lancet, 7/8).
- Peter Newman et al.: Although Kumar and colleagues' recommendation that men who have sex with men be included in India's HIV prevention programs should be "applaud[ed]," the recommendation misses "crucial obstacles" in preventing the spread of the virus among the group, Newman of the University of Toronto and colleagues write. MSM in India are faced with the "ongoing context of stigma, violence and criminalization," which has been shown to be "antithetical to public health" and "often conspire[s] to prevent HIV prevention," the authors conclude (Newman et al, Lancet, 7/8).
- C.R. Soman, Aju Mathew: Kumar and colleagues "redefin[e] the geography of India" in their study, Soman, of the group Health Action by People, and Kerala, India, resident Mathew write in a correspondence. The study excludes the southern state of Kerala and includes the western state of Maharashtra in its analysis of HIV prevalence in south India, and three northern states with higher HIV prevalence were excluded from the examination of north India, according to Soman and Mathew. The authors conclude that "broad generalizations based on deliberate selection of states" are "premature" until more prenatal clinics are established in every Indian state (Soman/Mathew, Lancet, 7/8).
- Kumar et al.: The study examined "south" Indian states based on an "historic" HIV prevalence of more than 1.5%, rather than a "political boundary," the study's authors write in a correspondence response. The response also says the study supports the importance of HIV prevention programs focusing solely on "100% coverage with peer-based condoms, education and negotiation skills and basic clinical services for all those at high risk of transmitting HIV." The authors add that while increased condom use might not prevent gender discrimination, violence or HIV transmission between married couples, it could prevent "perpetrators" of discrimination and violence -- as well as men who could transmit the virus to their wives -- from contracting the virus (Kumar et al., Lancet, 7/8).
Correspondence Responding to Analysis
- T.B. Hallett, G.P Garnett: A decline in HIV incidence can be seen "even in the absence of individual behavior change, and is related to the diminishing number of those at most risk" of contracting the virus "as the epidemic matures," Hallett and Garnett of Imperial College London write in a correspondence. "Attributing declining incidence to changing behavior would only be possible with accurate projections of HIV incidence in the absence of behavior change, which we do not have," the authors say (Hallett/Garnett, Lancet, 7/8).