Reaching the unreached: Smart targeting of HIV interventions in India to benefit the most vulnerable populations

Challenge

Despite significant reductions in HIV-AIDS since the start of the National AIDS Control Programme (NACP) in 1992, India still had one of the biggest HIV epidemics in the world. The HIV epidemic in India was characterized by concentrated epidemics among key populations (KPs). This highly diverse and heterogeneous epidemic was driven primarily by sex work, unprotected sex among men who have sex with men (MSM), and injected drug use. India’s prevention program was built around targeted interventions (TIs) and a peer-based behavioral change program. India sought to leverage the TIs to achieve UNAIDS’s 90-90-90 targets (90 percent of HIV-infected individuals diagnosed, 90 percent of those diagnosed to be on anti-retroviral therapy (ART), and 90 percent of people on ART to achieve sustained virologic suppression), and end AIDS by 2030. The peer-based approach engages targeted communities to deliver interventions using peers from the key populations.  However, the program faced considerable impediments. The TIs followed an outdated model focused on stable groups with lower risk and vulnerability. This hampered efforts to reach new and hard-to-reach groups of KPs with higher risk profiles. Moreover, there was inadequate linkage with antiretroviral therapy, and treatment targets were not met.

Approach

With World Bank support, in 2018 the NACP’s strategies were revamped to make interventions more effective, in particular by improving the program’s targeting of vulnerable populations. One key innovation was the Differentiated Prevention Model (DPM), which involved segmenting the KPs into five categories, or risk groups. Services were then prioritized for those with higher risk and vulnerability such as new KPs. Recognizing the challenges that KPs faced in accessing HIV services, a Peer Navigation initiative was started in which “role model peers” supported members of KPs throughout HIV diagnosis, treatment, and care. Another innovation—the Differentiated Care Model—was introduced to customize treatment services for patients to reduce the frequency of visits to the hospital and cut waiting times. 

Results

The revamp of the TI strategy helped significantly increase coverage for people with HIV, especially among new and previously hidden groups. The NACSP substantially surpassed its initial targets, and the changes also resulted in significant behavior change.

• The NACSP core indicators on condom use increased from baseline (2013) to end-line (2020): from 80 percent to 96 percent among female sex workers (FSW), and from 45 percent to 85 percent among MSM.
• Safe drug injection increased from 45 percent to 88 percent among people who injected drugs.
• The new strategy also helped link those with HIV to treatment and the number of people receiving HIV treatment in India rose from 1.05 million in 2017 to 1.38 million in 2020.

 It also supported efforts to build global knowledge for the peer-led approach to addressing HIV cases.  

Bank Group Contribution

The World Bank has helped to fund India’s National AIDS Control Program (NACP) for three decades through International Development Association (IDA) credits totaling $807 million. Given the concentrated nature of India’s HIV epidemic, the focus of World Bank support has been on evidence-based prevention interventions for key affected groups. The World Bank brought global experience to the program and helped share the good practices of the India program with other countries around the world.

Partners

The achievement of NACSPs development objectives was a result of exceptional collaboration between the World Bank and the other key development partners such as WHO, UNAIDS, USAID and CDC. The Joint Implementation Review Missions (JIRM) was one of the best practices that emerged from this collaboration.

Looking Ahead

The fifth phase of the NACP from 2022-2027 will provide an opportunity to bring in new ideas and test fresh approaches to ensure that India achieves its 90-90-90 target by 2030.