regional workshop on monitoring and evaluation of hiv/aids program new delhi, india, 14th february...

Regional Workshop on Monitoring and Evaluation of HIV/AIDS ProgramNew Delhi, India, 14th February 2011

Situation of HIV Epidemic in Asia and the Health Sector Response

Presentation by:

Dr. Partha Haldar Country Office for India, World Health OrganizationNew Delhi, India

2

Scheme of the presentation

1. Description of the epidemic What is the burden of the HIV epidemic in Asia?

Prevalence, Incidence, Women, Children In different MARPs

2. What is the transmission dynamics of HIV in Asia?3. What are the Vulnerabilities?

MARPs (type, size, behaviour) STIs (type, popl grp affected)

4. Health sector response to the epidemic Prevention, Care, support and treatment

3

EA

EA

EA

Countries in Asia: South-East Asia & South Asia

4

Percentages and denominators !!Better to remember, what you are dealing with HIV Epidemic in Asia started around 1990s Overall adult HIV prevalence in Asia is around 0.3%

compared to 4.9% in Sub Saharan Africa (SSA) National adult HIV prevalence in most of the Asian

countries are actually low (<1%) (Ban, Mal, SL, <0.1%; Bh, TL, 0.1%; Ino, 0.2%; In, 0.3%, Np, 0.4%;

Myr, 0.6%; Th 1.4%) However, large population sizes (60% of world popln)

means even with low prevalence, large number of people are infected

Thus, around 4.9 million people are living with HIV in Asia compared to 22.5 million in SSA

Source: WHO 2009, WHO 2010; UNAIDS Global Report 2010

5

HIV situation, South & South-East Asia, 2001 and 2009

Source: WHO, UNAIDS, Global Report 2010

6

HIV in Asia- a comparison of 2001 vs 2009

Source: WHO, UNAIDS, Global Report 2010

7

What is this burden as a proportion of the global HIV burden?

- Second highest HIV burden in the world after SSA - Accounting for 15% of people living with HIV globally

Regions

Estimated Number of People living with HIV/AIDS (million)

Sub Saharan Africa 22.5Asia 4.9North America, Western and Central Europe 2.3Eastern Europe 1.4Central and South America 1.4Middle East and North Africa 0.46Caribbean 0.24Oceania 0.057Total 33.3

8

Select countries account for major portions of the HIV Burden in Asia

Of the total HIV burden in Asia:

India 60% India and Thailand

70% First seven countries

almost 95%

S. No. Country

Estimated Number of People living with HIV/AIDS

1 India 2,400,000 2 Thailand 530,000 3 Indonesia 310,000 4 Vietnam 280,000 5 Myanmar 240,000 6 Malaysia 100,000 7 Pakistan 98,000 8 Nepal 64,000 9 Cambodia 63,000

10 Philipines 8,700 11 Lao PDR 8,500 12 Japan 6,400 13 Bangladesh 6,300 14 Republic of Korea 5,200 15 Singapore 3,400 16 Sri Lanka 2,800 17 Bhutan 999 18 Mongolia 100 19 Maldives 99

Source: WHO, UNAIDS, Global Report 2010, (Note: China, between 0.24 to 0.47 million)

People living with HIV in select countries in Asia

9

Even within the countries, the burden is concentrated National epidemics are mainly concentrated

E.g. in India, more than half (56%) is in high prevalence states

In China, five provinces account for 53%

10

“Overall”, the HIV epidemic in Asia is, stable An estimated 4.9 million people were living with HIV

in 2009 Overall, it is stable around this figure


11

HIV prevalence, select Asian countries

Source: HIV prevalence curves generated by Spectrum using surveillance data reported by Ministries of Health, SEAR countries WHO,

12

The epidemic is stable or declining in most of the countries Most national HIV epidemics appear to have stabilized No country in the region has a generalized epidemic Thailand: only country in this region which has prevalence

close to 1% (stabilized) Cambodia: adult prevalence decreased from 1.2% (yr

2001) to 0.5% (yr 2009) India: sustained decline from 0.41% (yr 2000) to 0.31% (yr

2009)

13

But, there are historically low prevalence countries that are now showing an increase HIV prevalence is increasing in low-prevalence

countries: Bangladesh Pakistan (mainly IDU driven) Indonesia Philippines

14

HIV prevalence varies within countries E.g. in India, (national adult HIV prevalence 0.31%) Within the country, Manipur 1.40%, followed by Andhra

Pradesh (0.90%), Mizoram (0.81%), Nagaland (0.78%), Karnataka (0.63%) and Maharashtra (0.55%).

Besides, Goa, Chandigarh, Gujarat, Punjab and Tamil Nadu have > (0.31%),

Delhi, Orissa, West Bengal, Chhattisgarh & Puducherry have shown estimated adult HIV prevalence of 0.28-0.30%.

All other states/UTs have lower levels of HIV.

15

In India, declining in historic HP states

Figure 2: Adult HIV Prevalence Trend in High Prevalence States and Mizoram, 2006-09

Karnataka

Andhra Pradesh

Maharashtra

Manipur

Nagaland

Tamil Nadu

Mizoram

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2006 2007 2008 2009Year

Prev

alen

ce (%

)

Source: National AIDS Control Organization, India (HIV Estimations, 2010); Note: Mizoram is not classified as HP state

16

However, increasing in historic LP states in India

Figure 3a: Adult HIVPrevalence in Low Prevalence states, 2006-09

Meghalaya

Orissa

Chandigarh

Arunachal Pradesh

Assam

Jharkhand

Kerala

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

2006 2007 2008 2009Year

Prev

alen

ce(%

)

`

Source: National AIDS Control Organization, India (HIV Estimations, 2010)

17

HIV incidence in Asia (“overall trend”)

An estimated 360,000 people were newly infected in 2009 (450,000 in 2001), a 20% reduction over eight years

Overall incidence shows a declining trend


18

Incidence rates vary by countries

Source: WHO, 2010: Number of new infections estimated by Spectrum model using surveillance data reported by national AIDS programmes, Member countries, South-East Asia Region.

19

HIV Incidence in Asia (contd.)

Between 2001 and 2009, incidence fell by more than 25% in: India (60%), Nepal and Thailand

However, the epidemic remained stable during this time in: Malaysia and Sri Lanka

During this period, incidence increased by 25% in: Bangladesh and Philippines (otherwise low % level)

20

HIV incidence vary within countriesE.g. in India: Of the estimated 120,000 new infections in 2009, six high prevalence states account for only 39% of

the cases, while otherwise low prevalence states of Orissa,

Bihar, West Bengal, Uttar Pradesh, Rajasthan, Madhya Pradesh and Gujarat account for 41% of new infections

21

HIV burden in Women (SEA)

Proportion of females among reported AIDS cases, South-East Asia Region, 1990–2009

37%

Global average =51%

Source: WHO, 2010:

22

HIV burden in Women (contd.)

An estimated 1.3 million women (aged >15 yrs) are living with HIV in SEA

Except Bhutan and Timor-Leste, F:M ratio < 1 Proportion of women with HIV has increased over

period of time Reasons for higher vulnerability of women: barrier

(access) to health care; stigma, gender inequality,

23

HIV burden in Children (S&SEA)

Prevalence: Estimated no of children (<15 yrs) living with HIV increased from

140,000 (yr 2005) to 160,000 ( yr 2009) Incidence:

Estimated number of children (<15 yrs) getting newly infected with HIV 22,000 (yr 2009) from 26,000 (yr 1999)

15% decline Reason: increasing access to PMTCT of HIV drop in

number of children getting infected AIDS related deaths among children declined from 18,000

(yr 2004) to 15,000 (yr 2009)

24

AIDS related mortality

Number of deaths have largely stabilized


25

AIDS related mortality

Number of deaths have stabilized Estimated AIDS related deaths 300,000 (yr 2009)

compared to 250,000 in 2001 Variations exist by countries Almost 50% of these deaths occurred in India

(estimated 172,000) The trend of annual AIDS deaths in India is

showing a steady decline since the roll out of free ART programme in 2004.

26

Significance of prevalence and incidence Both the measures are important Prevalence reflects the load/burden

at a point in time Affected by both new infections and

mortality Needed to determine care and

treatment needs Incidence reflects the rate of

spread or progress of HIV epidemic Better measure to understand the

epidemiology and to assess the impact of preventive interventions

Although incidence is a preferred measure, it is difficult to obtain.

What are the methods to get HIV prevalence?

What are the available data sources?

What are the methods to get HIV incidence?

What special softwares are used? Which is better? Which is feasible?

27

Message, till now…

1. HIV prevalence in Asia: overall declining

2. HIV incidence in Asia: overall declining

3. Magnitude differs greatly between countries

4. Some showing decline (India, Thailand, Nepal)

5. Some showing increase (Bangladesh, Philippines, Indonesia, Pakistan)

6. Burden is concentrated in specific geographical areas within the countries


Routes of transmission

29

Distribution of reported HIV/ AIDS cases by mode of transmission, selected South-East Asian Countries

Unsafe sex and injecting drug use are the main risk behaviors driving the HIV epidemic in South-East Asia

Source: National AIDS programme, Ministry of Health, SEAR countries, 2007


Concentrated nature of the epidemic

Most At Risk Population (MARPs) also known as High Risk Group (HRG) population

31

Concentrated nature of the epidemic Although the overall HIV prevalence is around

0.3%, certain population groups are highly infected

These include: Female Sex Workers (FSW) Injecting Drug Users (IDU) Men who have Sex with Men (MSM), & TG

32

HIV prevalence by population group, Myanmar and Thailand, 2009

Source: National AIDS Program, 2009 HIV sentinel surveillance report

- Wide variations,- 10-40 times higher than general population

33

HIV prevalence by population group, India 2008-09, Annual HIV Sentinel Surveillance

9.2

7.3

4.9

0.49

0.31

0 1 2 3 4 5 6 7 8 9 10

Injecting Drug Users

Men having sex w ith Men

Female Sex Workers

Women attending AntenatalClinics

National

Percent Positive

Source: 2008-2009 HIV sentinel surveillance, National AIDS Control Organization, India

34

HIV prevalence by population group, Viet Nam, 2001-2006

Source: 2001-2006 sentinel surveillance, MOH, Viet Nam

Highest HIV prevalence was found in IDU, SW compared with other

sentinel groups

35

HIV prevalence by population group, Lao PDR, HSS 2004

36

Percentage of female sex workers infected with HIV, South-East Asia Region, 2007–2010

Source: WHO SEAR Office

Of 281 sentinel sites for FSW, in 33% sites, HIV prev was <1%, 39% sites it was 1-5%, 25% sites it was 5-20%; highest is noted in Southern India

37

HIV prevalence in FSW, 2010

Indonesia: Tanah Papua (16%), Bali (14%), and Batam (12%)

Myanmar: all five sites >5% Thailand: allof 51 sites had <5%, except four sites <5% in Bangladesh, Maldives, Nepal and

TimorLeste No HIV detected in FSW in Sri Lanka

38

Trend of HIV prevalence among FSW, SEA, 2000-2008

Source: WHO SEAR Office

39

HIV trends among FSW, India, 2003-2007

Source: HIV sentine surveillance, National AIDS Control Organization, India


MSM

41

HIV prevalence among men who have sex with men, selected cities, South-East Asia Region, 2003–2009

Source: Sentinel surveillance reports, national AIDS programmes, South-East Asia Region.

Trend ?

Trend ?

42

Rising trend in all the South Indian states

Source: HIV sentine surveillance, National AIDS Control Organization, India

43

HIV transmission among MSM is ongoing Myanmar 29%, India 7.3%, Indonesia 5%,

Thailand, (around 28-31%)

China: rising prevalence among MSM in Shandong, Jiangsu provinces and Beijing


IDU

45

HIV in IDU

Estimated 4.5 million people in Asia inject drugs More than half of them are in China Other large numbers are in India, Vietnam and

Pakistan On an average, HIV prev = 16% (with variations) Myanmar= 19-38%, Thailand = 30-50%, Vietnam =

32-58%, China= 7-13%, India = 0-56%

46

HIV prevalence among injecting drug users, South-East Asia, 2007-2009

New spots, worry, fuel, explode

epidemic

Mostly known areas; need

control and CST

47

In India, Decline in Manipur, Nagaland Rise in Meghalaya, Mizoram, WB, Mumbai, Kerala and

Delhi New spots: in Amritsar and Ropar (Punjab), Chandigarh,

Delhi and Orissa

48

Variations with in the country


HIV among general population

50

HIV prevalence among military recruits,Myanmar and Thailand, 1989–2009

Source: Sentinel Surveillance Reports, National AIDS Programmes, South-East Asia Region.

51

HIV prevalence among antenatal clinic attendees in high HIV burden countries, South-East Asia Region, 2000–2009

Source: Sentinel Surveillance Reports, National AIDS Programmes, South-East Asia Region.

Sustained decline, though, geographic

variations exist

52

Message till now…

HIV epidemic is concentrated within specific population groups (MARPs), FSW, MSM+TG, ISU

Level of HIV prevalence is very high among MARP Declining trend in some countries, in some popln grp,

increasing in other Large variations exists within countries This ‘strategic’ information comes from sentinel

surveillance How to interpret information from sentinel surveillance data

is crucial to make meaningful interpretation What happens when consolidating data from ‘all sites’


Dynamics of HIV transmission in Asia

The Asian Epidemic

54

Dynamics of HIV transmission in Asia

females

Male ClientsmalesMSM IDUs

FSW

Children

Spouses

Others in Gen. Population:

-Past SW & MSM

-Iatrogenic (Gisselquist et al)

The temporal order is important

(Adopted from Tim Brown’s)

Dual Risk

55

Dynamics of HIV transmission in India

females

Male ClientsmalesMSM IDUs

FSW

Children

Spouses

Others in Gen. Population:

-Past SW & MSM

-Iatrogenic (Gisselquist et al)

The temporal order is important

(Adopted from Tim Brown’s)

Size of MARPs 2-3 million

6% of adult males

56

Waves of HIV epidemic

Temporality is important !!

57

Asian epidemic not driven by casual sex in general population, but, by commercial sex

Source: Commission of AIDS: Redefining AIDS in Asia,

58

Message of this section…

Main drivers of the epidemic, globally Unpaid Heterosexual intercourse between general

male and general female (Main driver of African epidemic)

Commercial Sex work Injecting drug use Unprotected anal sex between

Men who have sex with men

Main drivers of the Asian epidemic

Main drivers of the Asian epidemic


The health sector response to the HIV epidemic

Next part of my presentation…

60

Why Should We Understand Response? Strategically Planned and Effectively Implemented

Response can halt and reverse the HIV epidemic Timing of Response has major impact on the

course and magnitude of HIV epidemic Consolidation of Lessons Learnt will help improve

the Future Response Understanding of past and current response sets a

baseline for future action

61

What constitutes Programme Response? Prevention among General Population

Prevention Programmes for MARPs

Care and Support Programmes for PLHA

Improving the Social Environment

62

What is the crucial (strategic) information we need to know? What are the drivers of the epidemic?

Which are the (particular) MARPs What is their size? What is their profile? (dual risk?)

What are the vulnerabilities? STIs (levels, trends, geo distribution, by popl grps) Risk behavior (levels, changes by intervn, by pop grps) Other vulnerabilities (e.g. migration) Specific geographic vulnerabilities

63

Size of MARPs: Measurement issues

Hidden populations

Stigma

Denominator

Case definition

Case detection

Representativeness

Consistency

Appropriateness


What do we know about risk behaviors of populations at risk for HIV?

65

Condom Use Among Female Sex Workers

FSW - Condom Use

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bangla

desh

Cambo

dia (B

B)

Cambo

dia (N

on-B

B)

China

Indi

a Fiji

Indo

nesia

Lao

Mal

aysia

Mon

golia

Mya

nmar

Nepal

Pakist

anPNG

Philip

pines

Sri La

nka

Thaila

nd

Viet N

am

Per

cen

t

2005 2007

Source: UNGASS Report;

reporting the use of a condom with their most recent client

66

Condom Use Among MSM

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bangl

ades

h

Cambo

dia

China

India

Indo

nesia La

o

Mon

golia

Nepal

Pakist

anPNG

Philipp

ines

Sri La

nka

Thail

and

Viet N

am

Pe

r c

en

t

2005 2007

Source: UNGASS Report; Condom use reported among MSM India ranged between 40.5-63.8% across survey locations, thus an arithmetic mean is used

reporting the use of a condom the last time they had anal sex with a male partner

67

Knowledge and use of condoms among men who have sex with men, Timor Leste, 2010

Source: Integrated bio-behavioral survey, National AIDS Programme, Ministry of Health, Timor-Leste, 2010.

Gap exists between knowledge and use of

condom

68

Safe Injection among IDU

Source: UNGASS Report; among IDU in India ranged between 11.7 -71% across survey locations, thus an arithmetic mean is used

reporting the use of sterile injecting equipment the last time they injected

IDU - Safe Injection

0

10

20

30

40

50

60

70

80

90

100

Ban

glade

sh

Cam

bodia

Chin

a F

iji

India

Indo

nesia

Lao

Mala

ysia

Mya

nmar

Nep

al

Pak

istan

PNG

Phil

ippine

s

Sri

Lank

a

Tha

iland

Viet

Nam

Pe

rce

nt

2005 2007

Needle sharing among IDU is still common in many areas

69

Comprehensive Correct Knowledge* about Transmission & Prevention of HIV/AIDS, India

* Correctly identify two major ways of preventing sexual transmission of HIV (Consistent condom use and having one faithful uninfected sex partner), reject two most common local misconceptions about HIV transmission (transmission of HIV/AIDS through mosquito bites and sharing of meals with HIV/AIDS patients), and know that a healthy-looking person can transmit HIV.GP: General Population (15-49 yrs), Youth: 15-24 yrs


Sexually Transmitted Infections

71

Prevalence of sexually transmitted infections,by population group, Indonesia, 2007

72

Seroprevalence of Syphilis, China, 2000-05

0. 45

3. 04

6. 81

12. 49

14. 56

0

2

4

6

8

10

12

14

16

ANC FSW cl i ents Drug user FSW MSM

%

73

Self-Reported STI Prevalence in last 12 months (Gen. Pop), India

Source: BSS 2001 and 2006, National AIDS Control Organization, India

74

High STI prevalence among FSW, India

State Syphilis percentage (district)

Maharashtra 11.5 - 51% (Kolhapur, Parbhani, Pune, Mumbai, Yevatmal; 2005)

Nagaland 22.1% (Dimapur, 2005)

West Bengal 21.4% (2004)

AP 17.4% (Hyderabad, 2005)

Gujarat 17.4% (Ahmedabad, 2003)

11.6% (Vadodara, 2004)

Kerala 16.7% (Calicut, 2001)

Karnataka 13.8% (Bangalore, 2005)

TN 11 - 12% (Chennai, Coimbatore, Dharmapuri, Madurai; 2005)

75

High STI prevalence among MSM, IndiaState Syphilis percentage (district)AP 15.7% (Hyderabad, 2006-07)

13% (East Godavari, 2006-07)

Maharashtra 14.6% (Pune, 2006,07)

11.7% (Mumbai, 2002-03)

Gujarat 12.4% (Surat, 2005)

TN 12-18% (4 districts, 2006-07)

Mumbai 14.6% (Pune, 2006,07)

11.7% (2002-03)Transgenders-Syphilis percentage (district)

Mumbai 25%

Gujarat 20.9% (Ahmedabad, 2006)

TN 16.6% (5 districts, 2006-07)

76

What did we learn till now…

Epidemic burden in Asia Modes of transmission Dynamics of transmission Vulnerabilities


The health sector response to the HIV epidemic

78


Prevention Programmes for HRGs



79


Blood Safety, STI Care, Counseling and Testing, PPTCT, HIV-TB Cross-Referrals, BCC, Youth Interventions




80


Prevention Programmes for HRGs BCC, Condom Promotion, STI Care, Needle Exchange, OST,

Empowerment, Enabling Environment Care and Support Programmes for PLHA


81



Care and Support Programmes for PLHA CD4 Testing, ART, Treatment of OIs, PEP, Nutritional and

Psychological Support, Drop-in-centres Improving the Social Environment

82




Improving the Social Environment Reducing Stigma & Discrimination, Mainstreaming, PLHA

Networks, Work-place Interventions, Legal and Legislative framework


Coverage and reach with preventive services

84

Percentage of MARPs reached with HIV prevention programme - FSW

FSW - Prevention reached

0

10

20

30

40

50

60

70

80

90

100

Bangla

desh

Cambo

dia

China

Indi

a

Indo

nesia

Lao

Mon

golia

Mya

nmar

Nepal

Pakist

an

Philip

pines

PNG

Sri La

nka

Thaila

nd

Viet N

am

Per

cen

t

2006 2008

Source: UNGASS Report; different question was asked in Cambodia

85

Percentage of MARPs reached with HIV prevention programme - MSM

MSM - Prevention reached

0

10

20

30

40

50

60

70

80

90

100

Per

cen

t

2005 2007

Source: UNGASS Report; India reported 17-97% MSM prevention coverage across survey locations, thus an arithmetic mean is used

86

Percentage of MARPs reached with HIV prevention programme - IDU

IDU - Prevention reached

0

10

20

30

40

50

60

70

80

90

100

Per c

ent

2005 2007

Source: UNGASS Report; Note: India reported 10-83% of IDU coverage across survey locations, an arithmetic mean is used here

87

TIs for HRGs in India

Source: National AIDS Control Organization, India

0

250

500

750

2006 2007 2008 2009

758 700 1,271 1,311

FSW

IDUMigrants

MSMTruckers

- >1500 TIs (including 220 donor TIs)

Year

Num

ber

of T

Is

Total number of TIs

88

Number of sites providing methadone maintenance therapy, by type of facility, 2002–2009

Source: WHO SEAR Office Report 2010

- The total number ofPWID in the SEA Region is over 500,000

-those reported to be accessing OST is less than 15,000.

-The proportion of IDU accessing OST in each of the countries in the Region in2009–2010 is <1% to 4%.

89

Coverage of syphilis screening among antenatal clinic attendees, selected countries, South-East Asia Region, 2006–2009


90

Yearly syphilis sero-positivity, ANC clinics, India,


Yearly syphilis sero-positivity, ANC clinics, India, CMIS, Apr 2005-Mar 2009

0.8

1.71.1 0.9

0

1

2

3

4

5

2005-06 2006-07 2007-08 2008-09

perc

enta

ge p

ositiv

e

In general population, Prevalence of individual STIs like syphilis, NG, CT ranges

from 0 – 3.9%

91

Percentage of voluntary blood donation, South-East Asia Region, 2004–2008


Screening forHep B, Hep C

92

Blood Safety, India


> 8m blood units collected

Blo

od

un

its (

mill

ion

s)

Year

93

Percentage of most-at-risk populations receiving HIV testing and counselling, Myanmar, 2006–2009


- Routine prog data / survey- Positive trend among FSW- Coverage is low among MSM, IDUIn region:- 8133 facilities for T&C-Policy guidelines-Govt, NGO, private

94

Scale up of HIV Counseling & Testing, India


>5.5m pregnant women & 13m clients

tested at 5135 centers in 2009

Nu

mb

er

test

ed

(m

illio

ns)

No

. o

f ce

nte

rs

Year

95

Number of people with advanced HIV infection receiving ART, by country, 2003–2009, SEA


- People on ART increased 10 times from 2003 to 2009 (577,000)- 40% females- 5% childrenIn region:- 1800 facilities for ART-Policy guidelines-Govt- almost 90% of the need in India and Thailand

96

ART scale up in India: Rapid and Effective


- >320,000 individuals on ART across 272 ART centers

- 89% of people who initiated ART were alive and on treatment after 12 months of starting treatment;

- Other 11% died or LFU

Nu

mb

er

on

AR

T

No

. o

f ce

nte

rs

Month in Year

97

To summarize… the HIV epidemic in Asia Is declining, However, large variations exist in terms of

geographical areas and popl grp affected New spots of infection are arising Universal access of services for:

Prevention, including PMTCT Care, support and treatment

Strategic information is crucial to inform each bit of the scenario for a successful program

98

Future directions

Preventing HIV transmission among FSW, clients of sex workers, MSM and IDU

Improving access to health care for MARPs by addressing stigma and discrimination

Prevention of perinatal HIV transmission by increasing access to PMTCT; fostering integration with MCH services to improve coverage

Ensuring timely access to ART by effective linkages between T&C and ART

Ensuring evidence based programmatic decisions (strategic decisions)


Thank you

regional workshop on monitoring and evaluation of hiv/aids program new delhi, india, 14th february...

Documents

hiv incidence

hiv burden

india slide

india hiv estimations

estimated adult hiv

situation of hiv epidemic

india source

treatment slide