Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

Sema K Sgaier1, Mariam Claeson2, Charles Gilks3, Banadakoppa M Ramesh4,
Peter D Ghys5, Alkesh Wadhwani1, Aparajita Ramakrishnan1, Annie Tangri1,
Chandramouli K6
1Global Health, Bill & Melinda Gates Foundation, New Delhi, India
2Human Development, South Asia Region, The World Bank, New Delhi, India
3UNAIDS, New Delhi, India
4Karnataka Health Promotion Trust, Bangalore, India
5UNAIDS, Geneva, Switzerland
6Food Safety and Standards Authority of India, New Delhi, India

Correspondence to Dr Sema K Sgaier, Bill & Melinda Gates Foundation, Capital Court Building, 3rd Floor, Left Wing, Olof Palme, Munirka, New Delhi 110067, India; Sema.Sgaier@gatesfoundation.org

Contributors SKS conceptualised the manuscript, conducted the literature search, compiled and analysed the data, and wrote the manuscript. AT assisted with the data analysis. MC, CG, AW, AR, BMR, PDG and KC provided critical content and editorial inputs and helped to draft and review the manuscript.
Accepted 14 February 2012
Published Online First 17 April 2012

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Abstract
Tremendous global efforts have been made to collect data on the HIV/AIDS epidemic. Yet, significant challenges remain for generating and analysing evidence to allocate resources efficiently and implement an effective AIDS response. India offers important lessons and a model for intelligent and integrated use of data on HIV/AIDS for an evidence-based response. Over the past 15 years, the number of data sources has expanded and the geographical unit of data generation, analysis and use for planning has shifted from the national to the state, district and now subdistrict level. The authors describe and critically analyse the evolution of data sets in India and how they have been utilised to better understand the epidemic, advance policy, and plan and implement an increasingly effective, well-targeted and decentralised national response to HIV and AIDS. The authors argue that India is an example of how ‘know your epidemic, know your response’ message can effectively be implemented at scale and presents important lessons to help other countries design their evidence generation systems.

Background
The HIV epidemic was discovered almost 30 years and we still have 2.7 (range 2.4–2.8) million new infections per year.1 Evidence-based resource allocation to increase the efficiency and effectiveness of national programmes has become a global focus.2 While data collection efforts have been extensive globally, too few have been able to embody the Know your epidemic, Know your response message advocated by the HIV/AIDS community at large.3 Two questions remain critical: what data should be collected and how should it be used to help design and implement an effective national response?

In India, best viewed as a ‘subcontinent’ with a population of 1.2 billion people and with 35 states and union territories, 640 districts and 5924 subdistricts,4 the response to HIV has been led by the National AIDS Control Organization (NACO), established in 1986. It has evolved and intensified over 2 decades, in three well-designed National AIDS Control Programs (NACP-I, 1992–1999; NACP-II, 2000–2006; and NACP-III, 2007–2012).5 Current evidence indicates that the response has been appropriately focused and effective (Supplementary Material 1). National HIV prevalence among sex workers (between 2003 and 2008)6 and new infections among adults (between 2000 and 2009)7 have reduced by more than 50%.

How did India do it? India's development and use of evidence to make critical policy and programmatic decisions are part of the answer. Over the past 15 years, the number of data sources has expanded and became more strategic, and the unit of data generation, analysis and use for planning has shifted from the national to the state, district and now subdistrict levels at least in the priority states. This has enabled India to focus on the right geographical areas, populations and solution levers and to fine tune and decentralise its response over time. We describe and critically analyse India's strategic data collection framework and present its lessons, which could help guide other countries design or enhance their current platform for generation of evidence related to the HIV/AIDS epidemic.................

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