India’s HIV/AIDS Strategy: Evaluating the National AIDS and STD Control Programme’s Performance and Addressing Key Challenges in Phase-V (2021–2026)

The programme operates on a targeted approach to reach vulnerable populations, including high-risk groups such as sex workers, injecting drug users, and men who have sex with men. It also addresses the general population through awareness campaigns, testing services, and access to treatment. The program’s overarching goal is to reduce new HIV infections, improve the quality of life for people living with HIV (PLHIV), and eliminate stigma and discrimination associated with the disease.

Treatment strategies emphasize rapid initiation of antiretroviral therapy (ART), advanced disease management, and universal viral load testing to ensure effective control of the epidemic. The programme is evaluated through a robust strategic information system and periodic third-party assessments to monitor progress and address challenges.

Performance of NACP

Epidemiological data from the HIV Sentinel Surveillance Plus 2021 report highlights progress in reducing new HIV infections by 46% between 2010 and 2021. However, this is below the required trajectory to meet the 80% reduction target by 2025-26. In 2020, India reported an adult HIV prevalence of 0.22%, with approximately 23.18 lakh people PLHIV. Among these, 78% were aware of their HIV status, 83% of those diagnosed were on ART, and 85% of those on ART achieved viral suppression. These figures indicate progress toward the 95-95-95 targets but also underscore the gaps in achieving universal coverage​.

HIV/AIDS Epidemic Indicators (2020)

Strategy Document: National AIDS and STD Control Programme Phase-V (2021-26)

Northeastern states like Manipur, Mizoram, and Nagaland report adult HIV prevalence rates significantly higher than the national average, with some districts exceeding 1%. Key populations, including female sex workers, men who have sex with men, transgender individuals, and injecting drug users, show prevalence rates 7–28 times higher than the general population. In states like Punjab and Mizoram, injecting drug use contributes to over 25% of new infections.

Programmatic data shows that the uptake of HIV testing and treatment services has improved over time. For example, the number of general clients tested for HIV increased from 142.64 lakh in 2014-15 to 288.7 lakh in 2019-20. Similarly, the number of pregnant women tested for HIV rose from 106.1 lakh in 2014-15 to 265.3 lakh in 2019-20. However, the COVID-19 pandemic disrupted services in 2020-21, leading to a decline in testing rates, with only 179.8 lakh general clients from 288.7 lakh in 2019-20.

Despite these challenges, significant strides have been made in treatment access. By 2020-21, 14.94 lakh PLHIV were receiving ART, including 1.06 lakh in the private sector. Universal viral load testing, a key initiative under NACP V, has expanded significantly, with 8.9 lakh tests conducted in 2020-21 compared to just 2.13 lakh in 2018-19. These efforts have contributed to a substantial decline in AIDS-related mortalities, which dropped by 82% from 2010 to 2020, far surpassing the global average reduction of 47%​. The program has also made strides in increasing access to ART, with approximately 14.94 lakh people living with HIV receiving ART by 2020-21.

Progress on Key Performance Indicators (2014-15 to 2020-21)

Strategy Document: National AIDS and STD Control Programme Phase-V (2021-26)

*Inclusive of 1.06 lakh PLHIV on ART in the private sector.

The data indicates a 46% reduction in new HIV infections between 2010 and 2021, demonstrating significant progress. However, this falls short of the 80% reduction target set for 2025-26, highlighting the need for intensified efforts. 

Spanning from 2021 to 2026, the 5th phase, like its predecessors, is a fully funded Central Scheme with a sanctioned budget of ₹15,471.94 crore. Building on the achievements and lessons of earlier phases, NACP V integrates global strategies like UNAIDS Global AIDS Strategy (2021–2026) and WHO’s Global Health Sector Strategies (2022–2030). Its primary objectives include reducing annual new HIV infections and AIDS-related mortalities by 80% from 2010 baseline levels, achieving the dual elimination of vertical transmission of HIV and syphilis, and eradicating HIV/AIDS-related stigma and discrimination.

It focuses on achieving the ambitious 95-95-95 targets, ensuring that 95% of people living with HIV (PLHIV) know their status, 95% of those diagnosed receive treatment, and 95% of treated individuals achieve viral suppression. Beneficiaries of NACP V include at-risk populations, PLHIV, sex workers, men who have sex with men, transgender individuals, and injecting drug users.

Challenges That Need Be Addressed in Phase V

Targeted intervention of HIV Risks Among IDUs

HIV spread due to substance abuse is a ticking time bomb in the youth. India’s efforts to combat HIV will remain ineffective without a holistic and intersectional approach that addresses the needs of the most at-risk populations, including Injecting Drug Users (IDUs). Without integrating these dimensions, HIV prevention and control efforts are unlikely to yield sustainable results. The prevalence of HIV among IDUs in India varies widely, ranging from 9.9% in integrated biological and behavioral surveillance data to 52.9% in studies conducted in northeastern regions.

In a study on 14,481 IDUs from 15 Indian cities. Participants reported high rates of needle/syringe sharing. The median (site range) estimated HIV prevalence and incidence were 18.1% (5.9, 44.9) and 2.9 per 100 person-years (0, 12.4), respectively. HIV prevalence was higher in Northeast sites while HIV incidence was higher in North/Central sites. The odds of prevalent HIV were over 3-fold higher in women than men. Other factors associated with HIV prevalence or incidence included duration since first injection, injection of pharmaceutical drugs, and needle/syringe sharing. 

In a study conducted with 801 HIV-positive individuals from 14 locations across India, it was found that, except for four sites, more than 50% of those actively injecting reported sharing needles. Stimulant injectors were significantly younger than exclusive opiate injectors, more likely to be educated and employed, and more prone to non-injection use of heroin, crack/cocaine, and amphetamines, as well as heavy alcohol consumption. They were also more likely to report recent needle sharing (71% vs. 57%), sex with casual partners (57% vs. 31%), and men having sex with other men (33% vs. 9%; p < 0.01 for all). Furthermore, injecting in high-risk locations, such as a dealer’s place or at home were associated with higher HIV prevalence.

Addressing Stigma & Discrimination against PLHIV

Stigma and discrimination continue to hinder the uptake of HIV-related services despite the enactment of the HIV and AIDS (Prevention and Control) Act, 2017. The levels of acceptance and willingness to interact with individuals living with HIV remain low, with only marginal improvements over the years. HIV/AIDS-related stigma (H/A stigma) poses a significant barrier to effective prevention and treatment programs by discouraging individuals from accessing and adhering to essential services. Evidence shows that stigma is associated with increased HIV risk behaviors and poor adherence to treatment. For instance, individuals with presumed HIV-negative or unknown status who hold stigmatizing attitudes are more likely to engage in high-risk behaviors, as observed in studies from China. Among people living with HIV/AIDS, stigma and discrimination have been linked to non-disclosure of HIV status to sexual partners, increasing the risk of transmission, as seen in studies from South Africa and France.

Addressing these challenges requires rigorous research to delineate the role of social inequalities and overlapping stigmas, such as those related to homosexuality or migration, in perpetuating risk behaviors. Additionally, H/A stigma complicates the uptake of novel biomedical prevention interventions like pre-exposure prophylaxis (PrEP), HIV vaccines, and adult male circumcision. Fear of vaccine-induced HIV infection and concerns about being labeled as HIV-positive deter individuals from accepting these innovations. Overcoming stigma is critical to enhancing service uptake, improving public health outcomes, and achieving the broader goals of HIV prevention and control.

Addressing SRBs via Virtual Platforms

The widespread use of virtual platforms, including dating apps, has significantly influenced Sexual Risk Behaviors (SRBs), creating evolving patterns of risk-taking that warrant closer examination. Studies have highlighted the association between dating app use and increased risky sexual behaviors, as well as adverse sexual health outcomes.

For instance, a study among Italian youth revealed that active and former dating app users engaged in a higher number of sexual encounters—both protected and unprotected—compared to non-users. Active users were at greater risk, exhibiting higher rates of hook-ups, condomless sexual activity, and STIs. The ease of accessing casual sex partners and the intensity of app use, such as frequent access or prolonged years of usage, further amplified these risks, with intensive users more likely to engage in sexual activities on first dates and report STI diagnoses.

Demographic factors like gender, age, and sexual orientation further influenced these behaviors. Males were found less likely to engage in unprotected sex compared to females, while homosexual users were more inclined towards casual hook-ups. These nuances underline the complex interplay between individual characteristics and app usage in shaping SRBs.

In the Indian context, this evolving dynamic is further complicated by limited research exploring the relationship between dating app use and SRBs. Cultural stigma and shame surrounding discussions of sexual health hinder open conversations, which in turn prevents the creation of targeted interventions. The lack of robust data and societal taboos create barriers to understanding and addressing these behaviors effectively.

This trend poses challenges for traditional intervention models. Given the significant risks associated with drug use and its interplay with sexual health behaviors, tackling substance abuse and promoting healthy sexual practices through innovative digital strategies is an essential public health priority.

Way Forward

Expanding Testing Strategies and Preventative Interventions 

NACP V should prioritize enhancing the supply, accessibility, and affordability of PrEP for at-risk groups. Efforts must also focus on bridging the significant knowledge gap among the general population regarding these effective preventative medications. In addition to PrEP, NACP V can expand its preventative strategies by integrating other effective medications and tools. Vaccinations, such as those for HPV and hepatitis B, should be prioritized to prevent sexually transmitted infections and associated cancers.

The program can also explore innovative prevention options, such as long-acting injectable PrEP (e.g., Cabotegravir) for individuals who face challenges with adhering to daily oral medications. To enable widespread access and implementation, it is essential to include Cabotegravir in the National List of Essential Medicines (NLEM). Additionally, advancing the use of microbicides for localized protection during sexual activity would further strengthen HIV prevention strategies. 

Developing a habit of routine STD testing among at-risk populations is essential for early detection and prevention efforts. NACP V believes the comprehensive HIV Counselling and Testing Services (HCTS) models under NACP, including standalone centers, facility-integrated services, and community-based settings (CBS), provide a valuable platform to expand STI testing. Efforts should focus on introducing and scaling up cost-effective dual rapid test (RDT) kits that can detect both HIV and syphilis. The implementation of dual testing programs should be monitored and evaluated through real-time data analytics which will help identify service delivery gaps. This effort should aim to increase accessibility and coverage of testing.

Accelerating the Transition to Dolutegravir (DTG)-Based Regimen

The Dolutegravir (DTG)-based treatment regimen is a highly effective option for managing HIV, recommended by the World Health Organization (WHO) as preferred first-line and second-line ART. DTG offers numerous benefits, including rapid viral suppression, better tolerability with fewer side effects, and convenient once-daily dosing, improving adherence and patient outcomes. Its high genetic barrier to resistance ensures sustained effectiveness, even in challenging cases. India had initiated the transition to a DTG-based treatment regimen within the existing service delivery system in 2020. In 2022, NLEM was updated to include Dolutegravir along with its complementary drugs, Tenofovir and Lamivudine, recognizing their critical role in the effective management of HIV.

NACP should ensure a robust supply chain system to ensure the uninterrupted availability of fixed-dose combinations to prevent treatment gaps. With accurate forecasting and robust procurement mechanisms, it will help prevent shortages which will help in accelerated transition. Concerns such as weight gain and rare cases of hypersensitivity or hepatotoxicity to this regimen in special populations like reproductive women have to be dealt with immediately. Comprehensive training should be provided to healthcare providers who should be trained to manage DTG-specific challenges, including toxicity and drug interactions. Strengthening laboratory infrastructure and establishing comprehensive monitoring frameworks for viral load, CD4 counts, and metabolic parameters combined with leveraging digital tools for tracking outcomes, should help in enhancing oversight. 

Comprehensive Harm Reduction Strategies for IDUs 

To deal with the alarming prevalence of HIV among IDUs, NACP Phase V, efforts will focus on addressing this epidemic by expanding coverage based on p-MPSE data and local epidemiological insights. This expansion will include scaling up comprehensive harm reduction services, such as the needle-syringe exchange program (NSEP) and opioid substitution therapy (OST), through direct implementation and collaboration with the Ministry of Social Justice and Empowerment. 

As per the Sankalak: Status of National AIDS Response 2023 report, there are 1,543 targeted intervention sites across India. In contrast, there are only 277 NSEP sites. However, information regarding the consistent coverage and utilization of NSEP services remains limited. A recent systematic review and meta-analysis revealed that, on average, only 34 needles and syringes are distributed per IDUs annually in India. This falls significantly short of the World Health Organization (WHO) standards, which classify coverage as low (<100 needles per year), moderate (100–199 needles per year), or high (≥200 needles per year). To ensure adequate harm reduction, the distribution of needles and syringes must be substantially scaled up.

As of 2024, NACO estimates that only 23% of the active injecting drug user (IDU) population in India is receiving Opioid Substitution Therapy (OST). To enhance the reach and effectiveness of OST, it is imperative to expand its services to cover all districts across the country. The current network of 393 OST centers must be significantly increased to address the unmet need. Mobile outreach programs and establishing drop-in centers in high-prevalence areas to enhance accessibility will be an effective tool.

The introduction of alternative medication options, such as methadone, alongside the existing buprenorphine-based therapy, is crucial for improving treatment accessibility and outcomes. Methadone has significantly improved outcomes for opioid use disorder (OUD) in the U.S., reducing overdose deaths by up to 50% compared to untreated individuals. As a cornerstone of medication-assisted treatment (MAT), it decreases illicit opioid use, curbs the spread of HIV and hepatitis C among people who inject drugs, and enhances retention in treatment programs. According to Substance Abuse and Mental Health Services Administration (SAMHSA), as of 2020, nearly 400,000 individuals were enrolled in methadone maintenance therapy, reflecting its widespread efficacy.

Integrating these services into primary healthcare centers and ART clinics ensures a holistic care approach, addressing both HIV and co-infections like hepatitis and tuberculosis to reduce the burden of viral hepatitis-related illnesses among IDUs. 

Stigma Reduction and Inclusive Support Systems for HIV and STI Management

Eliminating stigma and discrimination should remain a top priority, with enhanced public awareness campaigns and the rigorous enforcement of the HIV and AIDS (Prevention and Control) Act, 2017. Education and sensitization workshops should be conducted in schools, hospitals and workplaces to address misconceptions and reduce stigma surrounding their HIV-positive peers. Additionally, counseling and therapy services should be expanded within both the private sector and NGOs to provide a wider range of options and accessible support for individuals seeking help with STIs. Strengthening community engagement and leveraging local partnerships can ensure the inclusivity and effectiveness of these programs. 

References

1. Government of India, Ministry of Health & Family Welfare, National AIDS Control Organization (2022). Strategy Document: National AIDS and STD Control Programme Phase-V (2021-26). https://naco.gov.in/sites/default/files/NACP_V_Strategy_Booklet.pdf
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About the Contributor– Arjun Brij is a Policy Researcher at the Impact and Policy Research Institute. 

Acknowledgment: This article was reviewed by IMPRI experts and other collaborators. 

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