Routes of HIV transmission in India: assessing the reliability of information from AIDS case surveillance.

India's AIDS case surveillance system attributes 86% of HIV infections to sexual risks, 2.4% to injection drug use, 2.0% to blood transfusions, 3.6% to perinatal transmission, and 6.0% to others or not specified. To assess the reliability of this information, we examined the process of AIDS case surveillance in four high HIV-prevalence districts in southern India. We reviewed forms and interviewed doctors, counsellors, officials of State AIDS Control Societies, and a convenience sample of people living with HIV/AIDS. Current surveillance practices are not sensitive to parenteral exposures; forms have no space to report blood exposures other than transfusions and injections, and counsellors often ignore parenteral risks. The system does not distinguish high from lower risk sexual behaviours; all cases with sexual risks are reported in one category. We propose changes in forms and practices to improve the reliability and usefulness of information on risks from AIDS case reporting.

How much does heterosexual commercial sex contribute to India's HIV epidemic?

Through a search, we identified five models of India's HIV epidemic, all of which articulate the hypothesis that heterosexual commercial sex drives India's HIV epidemic. All five models assume more female sex workers (FSWs) than have been mapped (counted), and more than can be inferred from men's sexual behaviour. With best and highest plausible evidence-based estimates (15-20% of 300,000-700,000 FSWs are HIV-positive; FSWs have 570 client contacts per year; clients use condoms with 60-75% of FSW contacts; and the rate of HIV transmission from FSWs to clients is 0.0011-0.002 per unprotected contact), FSWs and clients account for 2-15% of HIV-infected adults, far less than model-based estimates of 44-68%. Overestimating the contribution of commercial sex to India's HIV epidemic misleads prevention programmes to ignore other risks, and promotes the stigmatizing assumption that HIV infection is a sign of immoral behaviour.

Reconnaissance assessment of risks for HIV transmission through health care and cosmetic services in India.

Available information shows frequent unsterile medical injections in India, but less is known about other invasive procedures. To assess the variety and frequency of blood exposures in health care and cosmetic services, we interviewed people living with HIV/AIDS in four districts with high HIV prevalence. Eighty percent reported from 1-300 injections in the five years before testing HIV-positive. Common lifetime exposures include dental care (31%), surgery (20%), blood tests (100%), and tattooing (47%). Through observation and interviews with doctors, dentists, and others, we found evidence for common to routine re-use of unsterilized equipment for blood tests (lancets), dental care, tattoos, and surgery. Health-care professionals and the public are misinformed about HIV survival outside the body and underestimate HIV transmission efficiency through blood exposures. The challenge to implement infection control for all invasive procedures remains undefined, while attention focuses on partial solutions, including single use of disposable syringes.