Rural Indian HIV epidemic being neglected despite complex patterns, high prevalence

Although HIV infection in India was thought to be mainly concentrated in urban areas, a “rural epidemic” is beginning to be documented in the southern Indian state of Karnataka. In the Bagalkot district, HIV prevalence and associated factors were found to vary widely, even between villages, but with the highest prevalence found in rural areas. These results have important implications for prevention and care programmes to be implemented in the area, report Marissa Becker, from the University of Manitoba, Canada, and co-authors.

Antenatal surveillance data have suggested that the mainly agricultural district of Bagalkot is a high prevalence area, so the district has been selected for a demonstration project on HIV prevention in rural areas.

“Some potential explanations for why Bagalkot is particularly vulnerable to HIV infection include a large volume of female sex work within the district and the fact that sex workers tend to be younger, have higher rates of illiteracy and receive more clients than their southern counterparts,” note the authors in the latest issue of the journal AIDS

This pattern is probably linked with a traditional system of religious sex work called Devadasi. So, the team of researchers from Canada and Bangalore, India, gathered baseline information in a community based study of 4949 individuals aged 15-49 years randomly selected from ten villages and six towns.

Overall HIV prevalence was 2.9%, with 2.4% of respondents found HIV-positive in urban areas and 3.6% in rural areas (odds ratio 0.65; 95% CI 0.45–0.95). Significant differences in HIV prevalence were seen between the ten villages, ranging from 0 to 8.2%. Reported multiple sexual partners, receiving money for sex and a history of medical injections were significantly associated with HIV infection, as were older age, being widowed, divorced, separated or deserted, lower education levels and being a woman of a lower caste.

The study also found that almost 70% of respondents had never seen a condom, while only 9% of respondents had ever used a condom. As in other studies, positive antibody testing for herpes simplex virus 2 was linked with HIV-positivity.

A multiple logistic regression model found that men aged 30-39 years, people in certain sub-districts, people whose marriage had dissolved, women who had had more than five medical injections in the past year, respondents having ten or more medical injections in the past year, and Hindus, especially lower-caste individuals, were at greater risk of HIV infection.

Unmarried people and those with higher education levels had reduced risk. The authors note that the association with marital status may be due to infection through a spouse who has subsequently died, because of abandonment due to serostatus, or because widowed women are more vulnerable to sexual exploitation.

The association of HIV-positivity with lower-caste Hindus is possibly explained by these respondents being more likely to be Devadasi sex workers – this vulnerable group is very important in directing HIV prevention efforts, the authors conclude.

The authors stress the need to deliver education programmes to rural, largely non-literate populations, and the importance of further research to understand the heterogeneity of the epidemic as well as to develop tools to rapidly detect higher risk areas.

“An HIV epidemic as heterogeneous and diverse as India’s will require a response that is both comprehensive in terms of coverage of vulnerable populations, and is of sufficient scale to address the epidemic in the vast rural areas where the majority of the population lives, and which as yet are largely neglected by prevention programs,” the report concludes.