HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes

Abstract

Objective: To determine the rates of death and infection from HIV in India.

Design: Nationally representative survey of deaths.

Setting: 1.1 million homes in India. Population 123,000 deaths at all ages from 2001 to 2003.

Main outcome measures: HIV mortality and infection.

Results: HIV accounted for 8.1% (99% confidence interval 5.0% to 11.2%) of all deaths among adults aged 25-34 years. In this age group, about 40% of deaths from HIV were due to AIDS, 26% were due to tuberculosis, and the rest were attributable to other causes. Nationally, HIV infection accounted for about 100,000 (59,000 to 140,000) deaths or 3.2% (1.9% to 4.6%) of all deaths among people aged 15-59 years. Deaths from HIV were concentrated in the states and districts with higher HIV prevalence and in men. The mortality results imply an HIV prevalence at age 15-49 years of 0.26% (0.13% to 0.39%) in 2004, comparable to results from a 2005/6 household survey that tested for HIV (0.28%). Collectively, these data suggest that India had about 1.4-1.6 million HIV infected adults aged 15-49 years in 2004-6, about 40% lower than the official estimate of 2.3 million for 2006. All cause mortality increased in men aged 25-34 years between 1997 and 2002 in the states with higher HIV prevalence but declined after that. HIV prevalence in young pregnant women, a proxy measure of incidence in the general population, fell between 2000 and 2007. Thus, HIV mortality and prevalence may have fallen further since our study.

Conclusion: HIV attributable death and infection in India is substantial, although it is lower than previously estimated.

Fig 1 Million Death Study RHIME activities. RGI=Registrar General of India

Fig 2 Age specific trends in probability of death from tuberculosis versus other diseases among urban men aged 15 years or older, 1990-2000. The age specific HIV attributable percentage of deaths from tuberculosis in men in India in the high HIV states in 1994-2000 was 23.5% (99% CI 13.6% to 33.5%) at age 25-34 and 11.8% (6.8% to 16.8%) at age 15-59

Fig 3 Age distribution of deaths from AIDS and tuberculosis by sex at age 15-59 years in 2001-3 in India

Fig 4 HIV prevalence among women aged 15-49 years in 2003 and AIDS as a percentage of deaths at age 15-49 among districts in the four southern states in 2001-3. 115 districts (using 2001 census boundaries) are included for antenatal clinic (ANC) sites; 94 districts (using 1991 census boundaries) are included for mortality

Fig 5 Spatial distribution of HIV prevalence among antenatal clinic (ANC) and voluntary counselling and testing centre (VCTC) attenders in high HIV states, 2003-7. This procedure interpolates prevalence rates between specific point locations to generate a continuous surface. District aggregated VCTC prevalence estimates were geo-located to the district’s centroid (geometric centre). HIV prevalence estimates were geo-located to the city/town of each testing site. For VCTC maps, isolines are drawn at 40%, 30%, 20%, and 7.5% (red to yellow). VCTC maps for all years use same colour scale. For ANC maps, isolines are drawn at 5%, 4%, 2%, and 1% (red to yellow). ANC maps for all years use same colour scale. Percentages are overall prevalence. AP=Andhra Pradesh, KN=Karnataka, MH=Maharashtra, TN=Tamil Nadu. District boundaries are as in fig 4

Fig 6 Trends in all cause mortality rates at ages 25-34 in southern states, 1996-2007. Sample Registration System death rates are calculated on basis of two year rolling averages starting with 1996 death rates, weighted by population size for Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu

Fig 7 Trends in HIV prevalence among pregnant women aged 15-24 from 2000-7 in high and low HIV states. Low HIV states exclude northeast states (about 1.2% of India’s population), as injecting drug use dominates transmission in this region and may not be reflected well in trends of HIV in pregnant women. HIV prevalence estimates are age standardised to aggregate study population, 2000-7. All trend tests are adjusted for age, literacy, urban/rural residence, migrant status, state, clinic type, and year. Annual number of antenatal clinic attenders of all ages tested each year (2000-7) in high HIV states were 9599, 12 641, 15 030, 59 404, 63 105, 63 240, 64 283, and 67 265; numbers in low HIV states were 12 386, 22 386, 25 764, 44 790, 26 704, 26 248, 68 207, and 71 356. Numbers of surveillance sites in high HIV states were 36, 48, 54, 220, 234, 234, 235, and 242 (with 25 continuous sites); numbers in low HIV states were 56, 100, 114, 215, 118, 119, 339, and 345 (with 45 continuous sites)