HIV Sentinel

Surveillance 2012-13
A Technical Brief

India’s voice against AIDS

Department of AIDS Control
Ministry of Health & Family Welfare, Government of India
www.naco.gov.in
 HIV Sentinel
Surveillance 2012-13
A Technical Brief

India’s voice against AIDS

Department of AIDS Control
Ministry of Health & Family Welfare, Government of India
www.naco.gov.in
 CONTENT

FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Objectives of HIV Sentinel Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Important Applications of HIV Sentinel Surveillance data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Expansion of HIV Sentinel Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 Implementation Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3. Initiatives during HSS 2012-13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4. Overview of HIV Levels and Trends among General Population at National Level . . . 14
5. HIV Levels in General Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6. HIV Trends in General Population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
7. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ANNEXES
Annex 1: State-wise number of HSS sites, 2003-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Annex 2: Bilingual Data form for surveillance at ANC sites, HSS 2012-13 . . . . . . . . . . . . . . . . . . . . 31
Annex 3: SACS’s checklist for HSS 2012-13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Annex 4: Pre Surveillance Sentinel Site Evaluation Form, HSS 2012-13 . . . . . . . . . . . . . . . . . . . . . . 34
Annex 5: State-wise HIV prevalence among ANC clinic attendees, HSS 2003-2013 . . . . . . . . . . . . . 35
Annex 6: State-wise HIV prevalence among FSW, HSS 2003-2011 . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Annex 7: State-wise HIV prevalence among MSM, HSS 2003-2011 . . . . . . . . . . . . . . . . . . . . . . . . . 37
Annex 8: State-wise HIV prevalence among IDU, HSS 2003-2011 . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Annex 9: State-wise HIV prevalence among Single Male Migrants (SMM), Long Distance Truckers
(LDT) and Transgender (TG) sites, HSS 2003-2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
India has the largest and one of the best HIV surveillance systems in the world. HIV surveillance in India was started
in 1985 when the Indian Council of Medical Research initiated surveillance among blood donors and patients with
Sexually Transmitted Diseases. In 1998, the National AIDS Control Organisation (NACO) formalized Annual HSS in
the country and in subsequent years, Antenatal Clinic (ANC) sites in peri-urban and rural settings, and High Risk
Group surveillance sites were rapidly scaled up.
Concurrent with increase in the number of sentinel sites, there has been a renewed focus on improving sample
collection and processing and the quality of data collection and management. Standardized training modules have
been developed to streamline training across the country. Samples collected are tested at 117 State Reference
Laboratories with guidance and external quality assurance by 13 National Reference Laboratories. Quality of data
collection has been enhanced through rigorous monitoring and supervision of the HSS activities by officers and
epidemiologists from the State AIDS Control Societies, designated Regional Institutes, and Development Partners.
The introduction of web-based monitoring through the Strategic Information Management System for HSS 2012-13,
has facilitated real time monitoring and supervision of surveillance activities and enabled immediate corrective
action.
This technical brief highlights the key findings from HSS 2012-13 besides briefly presenting the methodology and
implementation mechanism. Declining trend continues to be noted in places where HIV was visible and
interventions were started earlier in the epidemic, while emerging pockets are observed in some low and very low
prevalence states.

This report is the collective effort of many teams. I would like to congratulate the field staff at all sentinel sites and
testing labs, the Project Directors and surveillance teams in the State AIDS Control Societies, staff of the Regional
Institutes and National Institutes, Central Team Members and State Surveillance Teams without whose efforts,
surveillance on such a mammoth scale would be impossible. I appreciate the technical support extended by the
WHO, CDC and UNAIDS in the planning, implementation and supervision of the 13th round of HSS. I commend Dr. S.
Venkatesh, Deputy Director General (Monitoring and Evaluation), Department of AIDS Control (DAC) and all
members of his team for successfully implementing HSS 2012-13 and bringing out this technical brief following the
highest possible standards.

As NACP-IV is being implemented, data from 13th round of HSS will be instrumental in district re-categorization and
subsequent decentralized evidence based planning and implementation. This data will be also used for estimating
key epidemiological parameters, such as HIV burden, new infections and deaths due to AIDS as well as need for ART
and PPTCT. It also provides information for prioritization of programme resources and evaluation of programme
impact. I am confident that all stakeholders will use the information provided in this technical brief to understand
the landscape of the HIV epidemic in India and to plan and implement evidence-based local responses to the
epidemic.

LOV VERMA
 ACRONYMS

AIDS Acquired Immuno-Deficiency Syndrome

AIIMS All India Institute of Medical Sciences, New Delhi
ANC Antenatal Clinic
CDC Centers for Disease Control and Prevention
CHC Community Health Center
CI Confidence Interval
CTM Central Team Member
DAC Department of AIDS Control
DBS Dried Blood Spot
DAPCU District AIDS Prevention and Control Unit
ELISA Enzyme-Linked Immunosorbent Assay
EQAS External Quality Assurance Scheme
FSW Female Sex Worker
HIV Human Immuno-deficiency Virus
HRG High Risk Group
HSS HIV Sentinel Surveillance
IBBS Integrated Biological and Behavioural Surveillance
ICMR Indian Council of Medical Research
IDU Injecting Drug Users
LDT Long Distance Truckers
M&E Monitoring and Evaluation
MSM Men who have Sex with Men
NACO National AIDS Control Organisation
NACP National AIDS Control Programme
NARI National AIDS Research Institute, Pune
NICED National Institute of Cholera and Enteric Diseases, Kolkata
NIE National Institute of Epidemiology, Chennai
NIHFW National Institute of Health and Family Welfare, New Delhi
NIMS National Institute of Medical Statistics, New Delhi
PGIMER Postgraduate Institute of Medical Education and Research, Chandigarh
RI Regional Institute
RIMS Regional Institute of Medical Sciences, Imphal
SACS State AIDS Control Society
SIMS Strategic Information Management System
SMM Single Male Migrant
SRL State Reference Laboratory
STD Sexually Transmitted Disease
TG Transgender
ToT Training of Trainers
UNAIDS Joint United Nations Programme on HIV/AIDS
UT Union Territory
WHO World Health Organisation

A Technical Brief iii

Executive Summary

1. India has one of the world's largest and most robust HIV Sentinel Surveillance (HSS) Systems. Since 1998
it has helped the national government to monitor the trends, levels and burden of HIV among different
population groups in the country and craft effective responses to control HIV/AIDS. It is implemented
across the country with support from two national institutes and six regional public health institutes of
India.

2. The 13th round of HSS was implemented during 2012-13 at 763 sites, including 750 Antenatal clinics
(ANC) Surveillance Sites, covering 556 districts across 34 States and Union Territories (UTs) in the country.
For High Risk Groups (HRGs) and Bridge Populations, a Nationwide Integrated Biological and Behavioral
Surveillance (IBBS) is being carried out as a strategic shift to strengthen the surveillance system among
these groups.

3. The methodology adopted during HSS was Consecutive Sampling with Unlinked Anonymous Testing.
Specimens were tested for HIV following the Two Test Protocol. A total of 2,95,246 ANC samples were
tested from 741 valid sites during HSS 2012-13.

4. The overall HIV prevalence among ANC clinic attendees, considered a proxy for prevalence among the
general population, continues to be low at 0.35% (90% CI: 0.33%-0.37%). The highest prevalence was
recorded in Nagaland (0.88%), followed by Mizoram (0.68%), Manipur (0.64%), Andhra Pradesh
(0.59%) and Karnataka (0.53%). Chhattisgarh (0.51%), Gujarat (0.50%), Maharashtra (0.40%), Delhi
(0.40%) and Punjab (0.37%) are other states which recorded HIV prevalence of more than the national
average. Bihar (0.33%), Rajasthan (0.32%) and Odisha (0.31%) recorded HIV prevalence slightly lower
than the country average.

5. Similar to the 12th round of HSS (2010-11), all states have shown less than 1% HIV prevalence among
ANC clinic attendees in this most recent 13th round (HSS 2012-13). However, on a site-wise analysis, it is
noted that overall, 80 sentinel sites have shown HIV prevalence of 1% or more among ANC clinic
attendees. Of these, 27 sites are in the moderate and low prevalence states of Arunachal Pradesh, Bihar,
Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Meghalaya, Odisha, Rajasthan, Uttar Pradesh,
Uttarakhand and West Bengal. Twelve sites across the country recorded a prevalence of 2% or more
including 3 sites, one each in the low prevalence states of Chattisgarh, Gujarat and Rajasthan.
6. Data from consistent sites has been analysed to interpret HIV trends. An overall decline in HIV prevalence
among ANC clinic attendees is noted at a national level as well as in the historically high prevalence states
in the south and northeast regions of the country. However, rising trends among ANC clinic attendees are
observed in some moderate and low prevalence states such as Chhattisgarh, Gujarat, Jharkhand, Odisha,
Punjab, Assam, Delhi, Haryana, Uttar Pradesh and Uttarakhand.

A Technical Brief | 1
7. This declining trend of the HIV epidemic in the country is also corroborated by a declining number of HSS
sites showing a prevalence of 1% or more. The number of surveillance sites among ANC has increased
from 476 sites in 2003, 626 in 2006 and finally to 750 sites in HSS 2012-13. However, in the same period,
the number of ANC HSS sites showing a prevalence of 1% or more has decreased from 140 in 2003 to 80 in
2012-13, consistent with a long term declining prevalence trend.

8. The HIV epidemic in the country continues to be heterogenic, especially in terms of its geographical
spread. The declining trend among ANC clients, considered as a proxy for general population, is consistent
with India's story of large scale implementation and high coverage during the National AIDS Control
Programme (NACP)-III. Preliminary findings from the 13th round of HSS strongly support the DAC's focus
on states like Punjab, Odisha, Gujarat, Chhattisgarh, Bihar, Uttar Pradesh, Jharkhand, Rajasthan etc
where the HIV epidemic has been recent and the overall burden is relatively low but are having pockets of
HIV. There is a need for better understanding of the drivers of epidemic in these states. In-depth
epidemiological investigation of observed emerging pockets will help the programme in its endeavor to
accelerate halting and reversing the HIV epidemic in NACP-IV.

9. The 13th round of HSS provides crucial evidence base for planning and implementation of programmatic
initiatives under NACP-IV. Data from HSS will be instrumental in district re-categorization and subsequent
decentralized evidence-based planning and implementation. The data will be used to estimate HIV
prevalence, incidence and burden, to serve as a baseline under NACP-IV and provide information for
prioritization of programme resources and evaluation of programme impact.

2 | HIV Sentinel Surveillance 2012-13

1. Introduction

The year 2012-13 marks the transition of the National AIDS Control Programme (NACP) from Phase III to Phase
IV. At this important juncture, the 13th round of HIV Sentinel Surveillance (HSS) was implemented in 556 districts
in 34 States and Union Territories (UTs) of India during January-April 2013. This report presents the findings of the
13th round of National HSS and shows prevalence levels and trends of the HIV epidemic from 2003 to 2012-13.
Though the 13th round of HSS was carried out at ANC and STD sites only, this report also includes data on HIV
prevalence among High Risk Groups (HRGs) and Bridge Populations from earlier rounds of HSS.
1.1 Objectives of HIV Sentinel Surveillance
• To understand the levels and trends of the HIV epidemic among the general population, bridge
populations as well as high risk groups in different states
• To understand the geographical spread of the HIV infection and to identify emerging pockets
• To provide information for prioritization of programme resources and evaluation of programme impact
• To estimate HIV Prevalence and HIV burden in the country
1.2 Important Applications of HIV Sentinel Surveillance data
• To estimate and project burden of HIV at state & national levels
• To support programme prioritization and resource allocation
• To assist in evaluation of programme impact
• Advocacy
1.3 Expansion of HIV Sentinel Surveillance
Over the past three decades, HIV Sentinel Surveillance in India has evolved significantly. While HIV surveillance,
for the first time, was initiated in India by the Indian Council of Medical Research (ICMR) as early as 1985,
sentinel surveillance was conducted by National AIDS Control Organisation (NACO) at 52 sites in selected cities
during 1993-94. In 1998, NACO formalized annual sentinel surveillance for HIV infection in the country with 176
sentinel sites (of which 92 were ANC sites).

The year 2003 witnessed the first major expansion of the surveillance network. There were several factors
responsible for this expansion. High levels of HIV were noted at urban ANC sites in high prevalence states; field
evidence indicated a likelihood of spread of HIV to the rural areas; and it became essential to address a potential
bias in the surveillance estimates due to the presence of sentinel sites only in urban areas. As a result, more than
200 rural ANC sentinel sites were established at the Community Health Center (CHC) level in most districts in high
prevalence states as well as in some districts in low prevalence states of North India. Overall, 354 districts had at
least one HSS site in 2003. In subsequent rounds, up to 2005, expansion continued mainly among high risk group
(HRG) sites.

A Technical Brief | 3
The year 2006 was the second and the most important milestone in the expansion of the HIV sentinel surveillance
network in India. It was decided that at least one sentinel site should be functional in every district of India, and
new sentinel sites were added among all risk groups in that year. As a result, the number of surveillance sites
increased from 703 in 2005 to 1,122 in 2006 including 8 surveillance sites for 15-24 year old pregnant women and
composite sites in places where it was difficult to establish stand-alone sites. In the same year, concurrent with
the expansion of surveillance network, the HSS implementation structure was strengthened with the involvement
of five leading public health institutions in the country as Regional Institutes (RI) for providing technical support,
guidance, monitoring and supervision for implementing HSS. Supervisory structures were further strengthened
with the constitution of Central and State Surveillance Teams comprising public health experts, epidemiologists
and microbiologists from several medical colleges and institutions.

During the subsequent three rounds of HSS, the focus has been on further expansion of surveillance among High
Risk Groups and Bridge Populations. These rounds also witnessed several key strategic improvements in the
implementation of HIV Sentinel Surveillance such as:
i. Undertaking thorough technical validation of new sentinel sites by Regional Institutes before including
the sites in surveillance and dropping poorly performing sites
ii. Introduction of Dried Blood Spot Method (DBS) of sample collection from HRG to overcome logistic
problems at HRG sites
iii. Introduction of Informed Assent/ Consent at High Risk Group sites to address ethical concerns
iv. Initiation of random sampling methods of recruitment, at HRG sites, taking advantage of the availability
of updated line lists of HRG at the Targeted Intervention(TI) projects
v. Standardization of training protocols across the states with uniform session plans and material and
adoption of a two–tier training plan with Training of Trainers (TOT) followed by training of site personnel
vi. Development of a four-tier supervisory structure – Central Team from national level, Regional Institutes,
State Surveillance Teams constituted by Regional Institutes and State AIDS Control Society (SACS)-
constituted teams

vii. Stronger focus on supportive-supervision & action-oriented monitoring

viii. Increased focus on quality in all aspects – quality of planning, quality of training, quality of
implementation and quality of supervision and feedback
ix. Decreasing the number of testing laboratories for ANC and STD samples and limiting them to well
performing laboratories with Enzyme-Linked Immunosorbent Assay (ELISA) facilities, to ensure better
quality of testing as well as close supervision

x. Development of a new web-based data management system to enhance data quality and to ensure real
time monitoring of surveillance activities

xi. Initiation of epidemiological investigation into unusual findings (sudden rise or decline in prevalence)
for understanding the reasons and making necessary corrections

4 | HIV Sentinel Surveillance 2012-13

The 13th round of HSS was implemented at 763 ANC and STD sites (750 ANC and 13 STD sites). Most of the STD
sites from the 12th round of HSS were phased out during HSS 2012-13. For High Risk Groups and Bridge
Populations, a National Integrated Biological and Behavioral Surveillance (IBBS) is being carried out as a
strategic shift to strengthen surveillance among these groups. The expansion of HSS sites in the country from
1998 to 2012-13 is summarized in Table 1.
As the expansion continued, the geographical distribution of surveillance sites changed from concentration in
high prevalence states to uniform distribution across the country. In 2003, 271 districts of the country had at least
one ANC surveillance site and half of them were in the southern and western regions of country. In 2006, 464
districts in country had at least one ANC surveillance site. During the 13th round of HSS implementation, 551
districts had at least one ANC surveillance site, 57% of them were in northern & eastern regions, 30% were in the
southern & western regions and the remaining 13% were in the north-eastern region of country. Figure 1a,1b
and 1c depicts the changing pattern of distribution of ANC surveillance sites in the country. The details on state
wise distribution of HSS sites for the years 2003, 2006, 2010-11 and 2012-13 are provided in Annex-1.

Table 1: Expansion of HIV Sentinel Surveillance sites in India

Site Type 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008-09 2010 11 2012-13

STD 76 75 98 133 166 163 171 175 251 248 217 184 13

ANC 92 93 111 172 200 266 268 267 470 484 498 514 564

ANC (Rural) - - - - - 210 122 124 158 162 162 182 186

IDU 5 6 10 10 13 18 24 30 51 52 61 79 -

MSM - - 3 3 3 9 15 18 31 40 67 96 -

FSW 1 1 2 2 2 32 42 83 138 137 194 261 -

Migrant - - - - - - - 1 6 3 8 19 -

TG - - - - - - - 1 1 1 1 3 -

Truckers - - - - - - - - 15 7 7 20 -

TB 2 2 - - - - 7 4 - - - - -

Fisher-Folk/ - - - - - 1 - - 1 - - -
Seamen

Total 176 177 224 320 384 699 649 703 1122 1134 1215 1359 7631

1
IBBS is being implemented at 80 FSW domains, 68 MSM domains, 60 IDU domains, 15 TG domains, 35 Male Migrants domain at
destination districts and 16 domains of Married Female at high outmigration districts

A Technical Brief | 5
Figure 1a: Distribution of ANC HSS sites, HSS 2003

6 | HIV Sentinel Surveillance 2012-13

Figure 1b: Distribution of ANC HSS sites, HSS 2006

A Technical Brief | 7
Figure 1c: Distribution of ANC HSS sites, HSS 2012-13

8 | HIV Sentinel Surveillance 2012-13

1.4 Implementation Structure
HSS has a robust structure for planning, implementation and review at national, regional and state levels. The
structure and key functions of each agency involved are shown in figure 2 below.

Figure 2: Implementation Structure of HIV Sentinel Surveillance

NATIONAL AIDS CONTROL ORGANISATION

Technical Resource Group on Surveillance & Estimation

Nodal Agency: Policy, Strategy & Plan

NIHFW NIMS

Nodal Agency: Co-ordination, Nodal Agency: HIV Estimation

Supervision, Analysis and Documentation

CENTRAL TEAM REGIONAL INSTITUTIONS REFERENCE LABORATORIES

Supervision Quality Control on Testing Labs

North Zone Central Zone West Zone South Zone East Zone North East Zone
PGIMER AIIMS NARI NIE NICED RIMS
Chandigarh New Delhi Pune Chennai Kolkata Imphal
(5 States) (5 States) (7 States) (7 States) (6 States) (5 States)

Technical Validation of New Sites, Training, Monitoring, Supervision &

Data Entry; Technical Support & Guidance to SACS in Planning,
Implementation,Trouble-shooting & Analysis

STATE AIDS CONTROL SOCIETY STATE SURVEILLANCE TEAMS

Primary Implementing Agency in the State Training and Supervision

DAPCU Testing Laboratories

Coordination

Sentinel Sites

A Technical Brief | 9
2. Methodology

Complete details of the HSS methodology can be found in the HIV Sentinel Surveillance Operational
Guidelines available on the website of the Department of AIDS Control (DAC)2. Key elements of the HSS
methodology are summarized in Table 2.

Table 2: Snapshot of HSS methodology at ANC sites

Element Summary
Sentinel Site Antenatal clinic
Sample Size 400
Duration 3 months
Frequency Once in two years since 2008-09
Sampling Method Consecutive
Eligibility Criteria Pregnant Women, aged 15-49 years, attending the antenatal clinic for the first time during HSS period
Exclusion Criteria Already visited once at the ANC site during the current round of surveillance
Blood Specimen Serum
Testing Strategy Unlinked Anonymous
Testing Protocol Two Test Protocol

The data collection tool used in HSS 2012-13 at ANC Surveillance sites is given in Annex-2.

2
http://naco.gov.in/NACO/Quick_Links/Surveillance/

10 | HIV Sentinel Surveillance 2012-13

3. Initiatives during HSS 2012-13

In order to address the key issues identified in the implementation of HSS during previous rounds and to improve
the quality and timeliness of the surveillance process in the 13th round of HIV Sentnel surveillance 2012-13,
several new initiatives were implemented:

1. SACS Checklist for Preparatory Activities: This was developed to closely monitor the planning
process for HSS in each State (Annex 3). All the preparatory activities were broken down into specific
tasks with clear timelines and SACS were required to submit the completion status for each task. A
team of officers from NACO coordinated with state nodal persons on a day-to-day basis to ensure that
preparatory activities in all states were as per the timelines.

2. Pre-Surveillance Sentinel Site Evaluation (SSE): A pre-surveillance evaluation of ANC & STD
sentinel sites was carried out to identify human resource and infrastructure related issues at the
sentinel sites and necessary corrective action was taken at the identified sites before the initiation of
the surveillance. It also provided information on the background profile of the sites such as type of
facility, average OPD attendance, availability of HIV/AIDS services, distance of facilities from HSS labs
etc (Annex 4).

3. Standard Operational Manuals, Wall Charts and Bilingual Data Forms: These were
developed to simplify the HSS methodology for site level personnel and ensure uniform
implementation of the guidelines in all sentinel sites across the country. These were printed centrally
(including Hindi-English bilingual data forms) and distributed across the country.
4. Training under HSS 2012-13
Steps to improve quality of Training

I. A well-structured training programme was adopted to ensure that all personnel involved in HSS at
different levels were adequately and uniformly trained in their respective areas of responsibility.
II. The training agenda, curriculum and material, including planning and reporting formats were all
standardized and used in all states. Standard slide sets and training manuals, to be used in the
training of sentinel site personnel, were developed centrally to ensure uniformity.

III. Trainings were made interactive by including group work and an exercise on “Know Your Sentinel
Site”. This exercise helped participants in identifying the routine practices at their sites that could
affect the implementation of surveillance and recommended actions to address the same.

IV. Pre- and post-test assessments were done for each participant during site level training. Analysis
of these scores helped state teams to identify priority sites for supervisory visits.

V. Batch-wise training reports in standard formats were submitted at the end of each training.

A Technical Brief | 11
 Details of Trainings
I. Trainings started with two batches of a National Pre-Surveillance Meeting with around 90 personnel
from Regional Institutes and SACS to discuss the critical aspects of planning for HSS 2012-13 and
understand the system for supportive supervision through the online Strategic Information
Management System (SIMS) Application.

II. This was followed by 2-day Regional Trainings of Trainers (ToTs) organised by the Regional Institutes for
SACS officers & State Surveillance teams, comprising of public health experts and microbiologists.
These were aimed at creating state level master trainers and to plan for site-level trainings.
III. Subsequent to that, site level trainings (2 days per batch @ 8-10 sites per batch) were conducted in all
the states in multiple batches. Representatives from Regional institutes and NACO participated in the
trainings as observers to ensure that trainings were provided as per the protocol and all sessions were
covered as per the prescribed session plan.

IV. Separate trainings were organised for microbiologists & laboratory technicians from 117 ANC/STD
testing laboratories and 13 National Reference Laboratories on Surveillance testing protocols and
laboratory reporting mechanisms through the SIMS Application for HSS.

V. Overall, 40 central team members, 30 officers from six Regional Institutes, 95 SACS officers including
Surveillance, focal points, Epidemiologists and M&E officers, 280 State Surveillance Team (SST)
members, 260 laboratory personnel including microbiologists & laboratory technicians from the
designated testing laboratories, and over 3,000 sentinel site personnel including medical officers,
nurse/ counselors and laboratory technicians were trained under HSS 2012-13.
5. Laboratory System: For HSS 2012-13, the laboratory system was strengthened by limiting the testing of
specimens to designated State Reference Laboratories (SRLs). Real time monitoring of the quality of blood
specimens and laboratory processes was achieved through introduction of online reporting through the
SIMS Application for HSS. Efforts were made to standardize aspects of quality assurance in samples testing
under HSS as well as streamlining responses in case of discordant test results between the testing laboratory
and the reference laboratory, through the SIMS Application.

6. Supervisory Mechanisms for HSS 2012-13: Highest focus was given to supervision of all HSS activities
to ensure high quality of implementation and data collected during surveillance. Extensive mechanisms
were developed to set up a comprehensive supervisory system for HSS and to ensure that 100% of HSS sites
were visited within the first 15 days of start of sample collection. The principles adopted include action-
oriented supervision, real time monitoring & feedback, accountability for providing feedback & taking
action, and an integrated web-based system to enhance the reach & effectiveness of supervision.

a. SIMS Modules for web-based Supervision:

Specific modules were developed and made operational in the web-based SIMS for HSS in order to
facilitate real time monitoring of HSS 2012-13 activities.

I. Field Supervision was done through trained supervisors who visited the sentinel sites to monitor
the quality of recruitment of respondents and other site level procedures. Real time reporting of

12 | HIV Sentinel Surveillance 2012-13

 field supervision was done through the 'Supervisor Module' via a sub module 'Field Supervisory
Quick Feedback' and recommended follow-up actions were tracked through the 'Action Taken
Report' module in the same application. . The module was used extensively by all the supervisors
and helped in quick identification and resolution of issues in the field.
II. Data Supervision was done through Data Managers at Regional Institutes to monitor the quality of
data collection and transportation. It was done through the 'MIS' module in the SIMS Application
for HSS.
III. Laboratory Supervision was done through National and State Reference Laboratories to monitor
the quality of blood specimens, progress in laboratory processing and external quality assurance. It
was facilitated through the 'Lab Module' of SIMS.

Overall, 80% of supervisors who visited the sentinel sites for supervision, reported on the 'Field
Supervisor Quick Feedback' format in SIMS and 52% of 'Action Taken Report' formats were
submitted by HSS focal persons from SACS and Regional Institutes. Laboratory reporting, through
the 'Lab module' was completed by 87% of SRLs
b. Integrated Monitoring and Supervision Plan

I. An integrated supervision plan for each state was developed by Regional Institutes, SACS and
NIHFW to avoid duplication in monitoring coverage, thereby facilitating maximum coverage of
surveillance sites by supervisors.

II. The first round of visits was primarily done by Regional Institutes, SACS & SST members. Central
team Members (CTM) visited priority sites identified through feedback from the first round of
visits. Subsequent visits were made based on priority with a target of making at least three visits
for each identified problematic site.
c. SMS-based Daily Reporting from Sentinel Sites

The 13th round of HSS 2012-13 piloted an approach of daily reporting of the number of samples
collected at each sentinel site through an SMS from a Registered Mobile Number to a central server. The
system automatically compiled and displayed site-wise data on an Excel format on real time basis.
Access to this web-based application was given to SACS, RIs, and DAC and it facilitated easy
identification of sites with poor performance and enabled initiation of corrective action at sites (i) that
initiated HSS late, (ii) where sample collection was too slow or too fast, (iii) where there were large gaps
in sample collection etc.

A Technical Brief | 13
4. Overview of HIV Levels and Trends among
General Population at National Level

Figure 3 depicts the overall HIV prevalence at national level among ANC clinic attendees from HSS 2012-13 and
HRG & bridge populations from the HSS 2010-11, based on valid sites. The HIV prevalence observed among ANC
clinic attendees, considered as a proxy for HIV prevalence in the general population, during 2012-13 was 0.35%
(90% CI: 0.33-0.37).

Figure 3: HIV Prevalence (%) among ANC Clients (2012-13) & other risk groups (2010-11), India

ANC (2012-13) 0.35

Migrants (2010-11) 0.99

Truckers (2010-11) 2.59

FSW (2010-11) 2.67

MSM (2010-11) 4.43

IDU (2010-11) 7.14

TG (2010-11) 8.82

Trends among different population groups at national as well as state level are derived using three year moving
averages of HIV prevalence at consistent sites from 2003 to 2013 for ANC and from 2003 to 2011 for HRGs and
bridge populations. At national level, a declining trend continues to be noted among ANC clinic attendees (Figure
4). A declining trend was also noted till 2010-11 among FSW & MSM; while a stable trend was recorded among
IDU. Data is inadequate to interpret trends among TG, migrants & truckers.

14 | HIV Sentinel Surveillance 2012-13

Figure 4: HIV Prevalence trend across different groups, India, 2010-113

12 1
0.9
10
0.8

ANC HIV Prevalence (%)

HRG HIV Prevalence (%)

0.7
8
0.6
6 0.5
0.4
4
0.3
0.2
2
0.1
0 0
03-05 04-06 05-07 06-08 07-10 09-12

IDU FSW MSM ANC

3
3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites

A Technical Brief | 15
5. HIV Levels in General Population

Under HIV Sentinel Surveillance, prevalence data from pregnant women at ANC clinics is considered as a
surrogate marker for prevalence among the general population. During HSS 2012-13, HSS was implemented at
750 ANC sentinel sites across the country. 741 sites achieved a valid sample size of 300 or more (minimum 75%
of target) and only data from valid sites is used for this analysis. Overall, 2,95,246 samples were collected at
these 741 valid sentinel sites.
Figure 5 shows state-wise HIV prevalence among ANC clinic attendees. Considerable differences continue to
exist in the prevalence rates across different geographical regions. As in HSS 2010-11, all states recorded less
than 1% prevalence among ANC clinic attendees during 2012-13 round. However 11 states recorded higher
prevalence than the national average including the four low/moderate prevalence states of Punjab (0.37%),
Delhi (0.40%), Gujarat (0.50%), and Chhattisgarh (0.51%). In terms of HIV prevalence, the three states having
the highest ANC prevalence were from the north-eastern region of country with Nagaland recording the highest
prevalence (0.88%) followed by Mizoram (0.68%) and Manipur (0.64%). HIV Prevalence higher than the
national average was also recorded in the states of Andhra Pradesh (0.59%), Karnataka (0.53%), Maharashtra
(0.40%) and Tamil Nadu (0.36%). Bihar (0.33%), Rajasthan (0.32%) and Odisha (0.31%) are states which
recorded prevalence slightly lower than the national average. Four UTs (Puducherry, Dadra and Nagar Haveli,
Chandigarh and Andaman & Nicobar Islands) recorded zero prevalence during the 13th round of HSS. Figure 6
shows the map of India where states are colour-coded according to four HIV prevalence categories.

16 | HIV Sentinel Surveillance 2012-13

Figure 5: HIV Prevalence (%) at ANC sites, India and States, 2012-13

Puducherry 0.00
D & N Haveli 0.00
Chandigarh 0.00
A & N Islands 0.00
Kerala 0.03
Himachal Pradesh 0.04
Jammu & Kashmir 0.07
Daman & Diu 0.13
Madhya Pradesh 0.14
Assam 0.16
Haryana 0.17
Tripura 0.19
Sikkim 0.19
West Bengal 0.19
Jharkhand 0.19
Uttar Pradesh 0.20
Goa 0.25
Arunachal Pradesh 0.26
Meghalaya 0.26
Uttarakhand 0.27
Odisha 0.31
Rajasthan 0.32
Bihar 0.33
India 0.35
Tamil Nadu 0.36
Punjab 0.37
Delhi 0.40
Maharashtra 0.40
Gujarat 0.50
Chhattisgarh 0.51
Karnataka 0.53
Andhra Pradesh 0.59
Manipur 0.64
Mizoram 0.68
Nagaland 0.88

A Technical Brief | 17
Figure 6: State-wise HIV Prevalence (%) among ANC Clinic attendees, HSS 2012-13

18 | HIV Sentinel Surveillance 2012-13

HIV prevalence among ANC clinic attendees at different sentinel sites shows the heterogeneous distribution of
the HIV epidemic and also the emerging pockets of HIV infection. Table 3 summarizes the distribution of pockets
of high HIV prevalence among ANC clinic attendees in India.
There were 80 sentinel sites, across 19 states, which recorded a prevalence of 1% or more during the 13th round of
HSS (Table 3). Of them, 51 (64%) were from the known high prevalent southern and north-eastern states of
Andhra Pradesh (16), Karnataka (9), Maharashtra (9), Tamil Nadu (9), Manipur (4), Nagaland (4), and Mizoram
(2). However, among the low/moderate prevalence states, Bihar, Chhattisgarh, Gujarat, Odisha, Rajasthan, and
Uttar Pradesh had 3 or more sites each with HIV Prevalence of 1% or more among ANC attendees in 2012-13. In
Bihar and Uttar Pradesh, the high prevalence sites were concentrated in northern Bihar and eastern part of Uttar
Pradesh. Sites with prevalence of 1% or more have also been observed in Jharkhand (1), West Bengal (1),
Arunachal Pradesh (1), Meghalaya (1), Madhya Pradesh (1) and Uttarakhand (1). Of the 80 sentinel sites which
recorded a prevalence of 1% or more, 12 sites showed prevalence of 2% or more.

Table 3: State-wise number of high prevalence ANC Surveillance sites in HSS 2012-13

State No. of Sites with ANC HIV No. of Sites with ANC HIV
prevalence of 1% or more prevalence of 2% or more
Andhra Pradesh 16 1
Arunachal Pradesh 1 -
Bihar 3 -
Chhattisgarh 4 1
Gujarat 3 1
Jharkhand 1 -
Karnataka 9 2
Madhya Pradesh 1 -
Maharashtra 9 -
Manipur 4 1
Meghalaya 1 -
Mizoram 2 1
Nagaland 4 2
Odisha 4 -
Rajasthan 4 1
Tamil Nadu 9 2
Uttar Pradesh 3 -
Uttarakhand 1 -
West Bengal 1 -
Total 80 12

There were also 172 sites across 155 districts in 25 states that showed moderate HIV prevalence of 0.50-0.99%
during HSS 2012-13. Figure 7 shows the map of India where districts are colour-coded into low (<0.5%),
moderate (0.50-0.99%) and high (> 1%) based on HIV prevalence recorded among ANC clinic attendees in HSS
2012-13. Overall, 37 districts in the country recorded a prevalence of 1% or more, 15 of them were form the
southern and Nnorth-eastern states of Andhra Pradesh (3), Karnataka (2), Manipur (2), Mizoram (2),Nagaland (3)
and Tamil Nadu (3).

A Technical Brief | 19
Figure 7: District-wise HIV Prevalence (%) among ANC clinic attendees, HSS 2012-13, India

20 | HIV Sentinel Surveillance 2012-13

There has also been a decline in the number of sites showing a prevalence of 1% or more during the years 2003-
13, despite a continuous increase in number of surveillance sites as well as establishment of high prevalence sites
in traditionally high prevalence states. In the year 2003, more than one third (34%) of ANC surveillance sites, out
of a total of 416 valid sites, showed a prevalence of 1% or more and 128 (91%) of them were in the six high
prevalence states of Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. In the 2006
HSS round, of the total 566 valid ANC sites, 26% recorded a prevalence of 1% or more,and 121 (81%) of these
high prevalence sites were in six high prevalence states. In contrast, during the 13th round of surveillance in
2012-13, only 11% of the total 741 valid sites recorded a prevalence of 1% or more, while 51 (64%) of them were
from the six high prevalence states. Figure 8 depicts the changing pattern of ANC HSS sites across different HIV
prevalence categories in the country.
Figure 8: Year wise distribution of sites in different HIV prevalence (%) categories
among ANC clinic attendees, HSS 2003-13

489
400
384
296 362
183 119 152

93 108 87 125 122

123 183 172
140 146 141 145 115 133 84 80

2003 2004 2005 2006 2007 2008 2010-11 2012-13

(N=416) (N=373) (N=380) (N=566) (N=600) (N=639) (N=667) (N=741)

>=1% 0.50%-0.99% <0.50%

The changes in prevalence category at the site level, discussed above, is also evident from Figure 9 which
highlights not only the declining number of districts with more than 1% prevalence in country, but also the
emerging pockets in states having a low/moderate epidemic.
Table 4 shows districts with at least one ANC site showing HIV prevalence of 1% or more among ANC clinic
attendees in 3 out of 6 rounds of HSS, i.e from HSS 2005 to HSS 2012-13. During this period, there were 312 sites
across 214 districts which recorded a prevalence of 1% or more at least once. However, there were 109 sites in 83
districts across 11 states where 1% or more HIV prevalence among ANC clients was recorded for at least three
rounds of ANC surveillance since 2005. While most of them (100) are in high prevalence states from the southern
and north-east regions, there are other states which have traditionally not been considered as high prevalent,
that have districts in this category, e.g. Bihar (Patna), Gujarat (Mehsana & Surat), Mizoram (Aizwal & Champhai),
Odisha (Ganjam, Anugul & Cuttack), and West Bengal (Kolkata). These pockets with a mature epidemic require
sustained high-intensity prevention interventions.

A Technical Brief | 21
Table 4: State-wise districts with ANC sites showing 1% or more HIV prevalence
in at least 3 out of last 6 rounds of HSS (HSS 2005 to HSS 2012-13)

State Districts with ANC sites showing 1% or more HIV prevalence in

at least 3 out of last 6 rounds of HSS (HSS 2005 to HSS 2012-13)

Andhra Pradesh 21-Adilabad, Anantapur, Chittoor, Cuddapah, East Godavari, Guntur, Hyderabad,
Karimnagar, Khammam, Krishna, Kurnool, Mahbubnagar, Medak, Nalgonda, Nellore,
Nizamabad, Prakasam, Visakhapatnam, Vizianagram, Warangal, West Godavari

Bihar 1-Patna

Gujarat 2-Mehsana, Surat

Karnataka 19-Bagalkot, Bangalore, Belgaum, Bellary, Bijapur, Chamrajnagar, Chikmagalur,

Davangere, Dharwad, Gulbarga, Hassan, Kodagu, Kolar, Koppal, Mandya, Mysore,
Ramanagram, Shimoga, Tumkur

Maharashtra 17-Mumbai, Mumbai (Suburban), Ahmadnagar, Amravati, Bhandara, Chandrapur,

Dhule, Jalgaon, Kolhapur, Latur, Nanded, Osmanabad, Sangli, Satara, Solapur,
Thane, Yavatmal

Manipur 5-Chandel, Churachandpur, Imphal East, Imphal West, Ukhrul

Mizoram 2-Aizawl, Champai

Nagaland 5-Dimapur, Kohima, Phek, Tuensang, Zunheboto

Odisha 3-Anugul, Cutttack, Ganjam

Tamil Nadu 7-Coimbatore, Erode, Karur, Namakkal, Perambalur, Salem, Tiruchirapalli

West Bengal 1-Kolkata

22 | HIV Sentinel Surveillance 2012-13

 Figure 9: District wise HIV prevalence (%) among ANC clinic attendees, HSS 2003, 2006 and 2012-13

HSS 2003 HSS 2006

HSS 2012-2013

A Technical Brief | 23
HIV Sentinel Surveillance 2012-13: A Technical Brief

Department of AIDS Control

6. HIV Trends in General Population

At the national level as well as in the traditionally high prevalence states, the HIV trend continued to decline
among ANC clinic attendees. A declining trend was also noted in the low prevalence states of Goa, Kerala,
Madhya Pradesh and West Bengal. However, some low prevalence states in west, north and east India have
demonstrated a stable to rising trend. A rising trend was observed in the moderate/low prevalence states of
Chhattisgarh, Delhi, Gujarat, Jharkhand, Odisha and Punjab. A rising trend was also observed among some very
low prevalence state like Assam, Haryana, Uttar Pradesh and Uttarakhand. A long term stable trend was noted in
the states of Bihar, Himachal Pradesh and Rajasthan.(Figures 10 to 15)

Figure 10: Region wise trends in ANC HIV Prevalence4

1.60

1.40
ANC HIV Prevalence (%)

1.20
1.00
0.80
0.60
0.40
0.20
0.00
03-05 04-06 05-07 06-08 07-10 09-12
India HP-South-4 HP-NE-3 LP-North-10

Figure 11: State wise trends in ANC HIV Prevalence based on consistent sites5
1.80
1.60
ANC HIV Prevalence (%)

1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
03-05 04-06 05-07 06-08 07-10 09-12
AP KR MH MN MZ MU NG TN
4
3-yr moving averages based on consistent sites; India – 385; HP-South-4 (Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra) – 233,
HP-NE-3 (Manipur, Nagaland, Mizoram) – 31, LP-North-10 (Assam, Chhattisgarh, Delhi, Gujarat, Haryana, Odisha, Jharkhand, Punjab,
Uttarakhand, Uttar Pradesh) – 60
5
3-yr moving averages based on consistent sites; AP (Andhra Pradesh)-44; KR (Karnataka)-54; MH (Maharashtra excluding Mumbai)-66
(2003); MN (Manipur)-14 (2003); MZ (Mizoram)-4 (2003); MU (Mumbai)-6 (2003); NG (Nagaland)-13 (2003); TN (Tamil Nadu)-63 (2003)

A Technical Brief | 24
Figure 12: State wise trends in ANC HIV Prevalence based on consistent sites6

1.00
0.90
0.80
ANC HIV Prevalence (%)

0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
03-05 04-06 05-07 06-08 07-10 09-12
GO KE MP WB

Figure 13: State wise trends in ANC HIV Prevalence based on consistent sites7

0.80

0.70
ANC HIV Prevalence (%)

0.60

0.50

0.40

0.30

0.20

0.10

0.00
03-05 04-06 05-07 06-08 07-10 09-12

CH GU JH OR

6
3-yr moving averages based on consistent sites; GO (Goa)-2; KE (Kerala)-4; MP (Madhya Pradesh)-13; WB (West Bengal)-7
7
3-yr moving averages based on consistent sites; CH (Chhattisgarh)-5, GU (Gujarat)-8, JH (Jharkhand)-5, OR (Odisha)-5, RJ (Rajasthan)-5

25 | HIV Sentinel Surveillance 2012-13

Figure 14: State wise trends in ANC HIV Prevalence based on consistent sites8

0.40

0.35

0.30
ANC HIV Prevalence (%)

0.25

0.20

0.15

0.10

0.05

0.00
03-05 04-06 05-07 06-08 07-10 09-12

AS HR UK UP DE PU

Figure 15: State wise trends in ANC HIV Prevalence based on consistent sites9

0.60

0.50
ANC HIV Prevalence (%)

0.40

0.30

0.20

0.10

0.00
03 - 05 04 - 06 05 - 07 06 - 08 07 - 10 09 - 12

BI HP RJ

8
3-yr moving averages based on consistent sites; AS (Assam)-3; HR(Haryana)-4, UK (Uttarakhand)-3, UP (Uttar Pradesh)- 17; DE (Delhi)-
4, PU (Punjab)-6
9
3-yr moving averages based on consistent sites; BI(Bihar)-7; HP(Himachal Pradesh)-6, RJ (Rajasthan)-5

A Technical Brief | 26
7. Conclusion

HSS 2012-13 was implemented in 556 districts of country in 34 States and UTs. In 2012-13, all the states recorded
an overall prevalence of less than 1% among ANC clinic attendees, considered as a proxy for general population,
with a national average of 0.35% (90% CI: 0.33%-0.37%). Also, long term declining trend for the country as well
as in the known high prevalence states has been evident during this round also. It is worth noting that, despite
significant increase in the number of surveillance sites, the total number of surveillance sites recording HIV
prevalence of 1% or more has consistently been on a decline. Only 80 sites (11% of total 741 valid sites) showed a
prevalence of 1% or more during HSS 2012-13, significantly lower than the 133 sites (21% of total 639 valid sites)
in 2008-09, 145 sites ( 26% of 566 valid sites )in 2006 and 140 sites (36% of total 416 valid sites) in 2003. All these
facts corroborate the impact of Evidence based, Comprehensive, Integrated, Intense and Sustained responses to
HIV epidemic in country.

However, the challenges remain. While there been a long term significant decline in all traditionally high
prevalence states, Nagaland and Mizoram have shown a comparatively high overall prevalence at a state level on
a year to year basic (2010-11 and 2012-13). Besides, there are 100 sites in states of Andhra Pradesh, Karnataka,
Maharashtra, Manipur, Nagaland and Tamil Nadu that recorded HIV prevalence of 1% or more in at least three
rounds of the last six rounds of HSS. This point to the fact that the Department needs to sustain its interventions in
these traditionally high prevalence states to consolidate the gains made.
The current trend of HIV epidemic and responses in India include traditionally low/moderate prevalence states. A
long term increasing trend has been again highlighted during 13th round in states of Assam, Chhattisgarh, Delhi,
Gujarat, Haryana, Jharkhand, Odisha, Punjab, Uttarakhand and Uttar Pradesh. Bihar has also recorded a higher
prevalence on a year to year basis (2010-11 and 2012-13). All of these states have been appropriately given high
priority in NACP-IV. Further, just as the transmission dynamics and patterns of vulnerability in high prevalence
states were understood and addressed, thereby controlling the rise of HIV in these states, the programme is giving
equal importance to understand the transmission dynamics and patterns of vulnerability (like migration) in these
states for further customization of response to the epidemic in these states.
For the past 15 years, HIV Sentinel Surveillance has continued to provide evidence on the levels and trends of HIV
in India. With each round of HSS, the pieces of the puzzle come closer together, providing a clearer picture of the
HIV epidemic in the country. HSS, along with other key data from surveys and programs has facilitated vital
program prioritization exercises such as district re-categorization, estimations and projections, including
incidence and prevalence. Armed with enhanced understanding of the epidemic, Department of AIDS Control has
targeted its response to districts demonstrating vulnerability to HIV transmission and spread. The Department of
AIDS Control is committed to using data to continually improve and evolve its response to India's HIV epidemic,
till the epidemic is fully controlled and reversed.

27 | HIV Sentinel Surveillance 2012-13

Annexes
 Annex 1: State-wise number of HSS sites, 2003-12

State No of district with any No. of districts with ANC No of districts No. of ANC HSS Sites No of HRGs &
HSS site HSS Sites with HRGs & Bridge Population
Bridge population HSS sites
HSS sites
2003 2006 2010-11 2012-13 2003 2006 2010-11 2012-13 2003 2006 2010-11 2003 2006 2010-11 2012-13 2003 2006 2010-11
A & N Islands 3 3 3 3 3 3 3 3 1 1 1 4 3 4 4 3 2 1
Andhra Pr. 23 23 23 23 23 23 23 23 11 12 22 43 44 63 64 15 19 31
Arunachal Pr. 5 10 11 11 2 5 6 8 3 7 7 3 5 6 8 3 9 12

29 | HIV Sentinel Surveillance 2012-13

Assam 9 23 25 24 4 15 19 24 5 16 19 7 15 20 25 7 23 30
Bihar 11 36 34 27 7 23 23 27 8 28 25 7 23 23 29 10 38 38
Chandigarh 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 4 7 7
Chhattisgarh 8 16 17 16 5 15 16 16 3 6 6 8 19 18 18 3 10 9
D & N Haveli 1 1 1 1 1 1 1 1 - - 2 1 1 1 0 0 0
Daman & Diu 2 2 2 2 2 2 2 2 - - - 4 2 2 2 0 0 0
Delhi 8 9 9 5 4 5 5 5 6 8 8 4 5 5 5 7 16 15
Goa 2 2 2 2 2 1 2 2 2 2 2 4 2 3 3 3 3 4
Gujarat 14 25 26 26 10 25 25 26 8 11 15 16 25 25 28 8 16 28
Haryana 9 19 20 15 4 12 12 15 5 12 14 7 12 12 16 5 18 28
Himachal Pr. 12 12 11 7 7 8 7 7 5 6 7 14 10 8 8 6 10 13
J&K 3 14 14 14 3 14 14 14 2 6 5 5 16 15 15 3 9 9
Jharkhand 8 17 19 19 7 12 12 19 3 11 14 12 16 15 21 3 19 26
Karnataka 28 28 30 30 28 28 30 30 7 7 24 54 54 60 62 10 14 38
Kerala 8 14 14 10 4 6 10 10 4 14 14 7 6 10 10 7 19 23
 Cont...
State No of district with any No. of districts with ANC No of districts No. of ANC HSS Sites No of HRGs &
HSS site HSS Sites with HRGs & Bridge Population
Bridge population HSS sites
HSS sites
2003 2006 2010-11 2012-13 2003 2006 2010-11 2012-13 2003 2006 2010-11 2003 2006 2010-11 2012-13 2003 2006 2010-11
Lakshadweep 1 1 - - 1 1 - - 1 1 - 1 2 - - 1 1 0

Madhya Pr. 23 45 44 47 15 36 37 47 10 15 15 26 36 37 47 10 16 20

Maharashtra 35 35 35 35 35 35 35 35 11 15 20 70 73 75 75 15 29 38
Manipur 9 9 9 9 9 9 9 9 4 5 9 14 14 14 14 7 10 18
Meghalaya 2 6 6 7 2 6 6 7 1 2 2 2 7 7 8 3 4 4
Mizoram 4 8 8 8 3 3 8 8 2 8 5 5 4 9 9 4 12 9
Nagaland 8 11 11 11 8 11 11 11 6 8 8 12 19 19 13 7 10 12
Odisha 9 30 30 30 5 23 30 30 7 18 20 5 23 32 32 8 22 31
Puducherry 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 3 8 8
Punjab 8 18 19 13 6 11 13 13 3 9 12 10 11 13 13 4 14 23
Rajasthan 12 32 31 33 6 25 28 33 7 21 17 12 25 28 35 8 23 20

Sikkim 1 3 3 3 1 2 2 3 1 2 2 3 3 3 4 1 3 4

Tamil Nadu 30 30 31 32 29 30 31 32 13 18 27 53 64 68 72 15 26 53
Tripura 2 4 4 5 1 1 1 3 2 4 4 1 2 2 4 2 8 12

Uttar Pradesh 31 69 69 55 19 51 55 55 17 31 35 30 62 65 65 19 37 50

Uttarakhand 7 11 12 12 3 7 7 12 4 7 9 6 9 9 15 4 7 11
West Bengal 13 19 19 18 9 12 18 18 8 14 16 18 13 22 22 15 32 38

India 352 588 595 556 271 464 504 551 173 328 387 476 628 696 750 223 494 663

A Technical Brief | 30
Annex 2: Bilingual Data form for surveillance at ANC sites, HSS 2012-13

31 | HIV Sentinel Surveillance 2012-13

Annex 3: SACS’s checklist for HSS 2012-13

S.N Activity To be Status Remarks

completed by
1. Background Activity
1.1 Filling of DD (MES) if position is vacant
1.2 Intimation to NACO on DD (MES)-Focal person for HSS 2012-13
2. Finalization of ANC and STD surveillance sites
2.1 Validation of new sites in consultation with Regional Institutes
2.2 Submission of composite sites details to NACO
2.3 Sentinel site evaluation of ANC/STD Sites
2.4 Release of budget to Sentinel Sites
3. Procurement
3.1 Estimation for procurement of consumables
3.2 Process initiated and Tenders issued
3.3 Purchase order issued
3.4 Consumables received at SACS
3.5 Site-wise packing of consumables
3.6 Consumables reached sites
4. Testing lab preparation for HSS ANC/STD sites
4.1 Submission of contact details of lab personnel to NACO
4.2 Submission of details of ELISA/RAPID tests done at ANC/STD testing labs to NACO
4.3 Submission of details of Sentinel Site - Testing Lab linkages to NACO
4.4 Release of budget to Testing Lab
4.5 Consumables reached Testing labs
5. Training of SACS team, SSTs and ANC/STD surveillance site personnel
5.1 Finalisation of SST members in consultation with RIs
5.2 Participation of SACS in National Pre-Surveillance Meeting
5.3 Participation of SACS in Regional Pre-Surveillance Planning Meeting & TOT
5.4 Preparation of training plan including identification of training site
@ 3 days per batch (10-12 sites per batch)
5.5 Communication to the sentinel sites about training dates and location
5.6 `Preparation of Training Kits (Operational Manual, Technical guideline, Session
wise presentation, data forms, Sample Transport sheet, Date Form transport
sheet, Site codes, sub site codes, site-Testing lab linkage sheet etc)
5.7 Training of sentinel sites
6. Orientation/ Sensitization meetings at SACS involving NRHM officials & district authorities
6.1 Letter to key officials from NRHM at state and district level on HSS
and support required

A Technical Brief | 32
 Cont...
S.N Activity To be Status Remarks
completed by
6.2 Sensitization of state level NRHM leadership and officials on HSS
and support required during routine state level meeting or as a
separate meeting, as appropriate in each state
6.3 Sensitization of district level NRHM/DMHOs/CMOs on HSS and support
required during site level training or routine district level meeting
7. Development of monitoring plan
7.1 Constitution of state and district level monitoring team
7.2 Development of integrated monitoring plan to ensure first visit to
every sentinel site in first 15 days of start of HSS by SACS/SST
team/RI/Central Team
8. Printing and Supply of Documents
8.1 Translation of Bi-lingual Data Forms to Local Language
8.2 Printing of Bi-lingual Data Forms
8.3 Bi-lingual Data Forms reached Sentinel Sites
8.4 Printing of Stickers with Site Details/ Preparation of Stamps with
Site Details
8.5 Stickers/ Stamps with Site Details reached Sentinel Sites
8.6 Operational Manuals/ Wall Charts supplied by NACO reached
Sentinel Sites
9. Commencement of HSS 2012-13 Implementation
9.1 Data of Initiation of HSS 2012-13 at ANC/STD sites

33 | HIV Sentinel Surveillance 2012-13

Annex 4: Pre Surveillance Sentinel Site Evaluation Form, HSS 2012-13

A Technical Brief | 34
Annex 5: State-wise HIV prevalence among ANC clinic attendees, HSS 2003-2013

State 2003 2004 2005 2006 2007 2008-09 2010-11 2012-13

A & N Islands 0.45 0.00 0.00 0.17 0.25 0.06 0.13 0.00
Andhra Pradesh 1.45 1.70 1.67 1.41 1.07 1.22 0.76 0.59

Arunachal Pr. 0.00 0.20 0.46 0.27 0.00 0.46 0.21 0.26
Assam 0.00 0.14 0.00 0.04 0.11 0.13 0.09 0.16
Bihar 0.11 0.22 0.38 0.36 0.34 0.30 0.17 0.33
Chandigarh 0.22 0.50 0.00 0.25 0.25 0.25 0.00 0.00
Chhattisgarh 0.76 0.00 0.32 0.31 0.29 0.41 0.43 0.51
D & N Haveli 0.13 0.00 0.25 0.00 0.50 0.00 0.00 0.00
Daman & Diu 0.27 0.38 0.13 0.00 0.13 0.38 0.13 0.13
Delhi 0.13 0.31 0.31 0.10 0.20 0.20 0.30 0.40
Goa 0.48 1.13 0.00 0.50 0.18 0.68 0.33 0.25
Gujarat 0.38 0.19 0.38 0.55 0.34 0.44 0.46 0.50
Haryana 0.27 0.00 0.19 0.17 0.16 0.15 0.19 0.17
Himachal Pradesh 0.25 0.25 0.22 0.06 0.13 0.51 0.04 0.04
Jammu & Kashmir 0.00 0.08 0.00 0.04 0.05 0.00 0.06 0.07
Jharkhand 0.08 0.05 0.14 0.13 0.13 0.38 0.45 0.19
Karnataka 1.43 1.52 1.49 1.12 0.86 0.89 0.69 0.53
Kerala 0.09 0.42 0.32 0.21 0.46 0.21 0.13 0.03
Madhya Pradesh 0.42 0.38 0.27 0.26 0.25 0.26 0.32 0.14
Maharashtra 1.15 0.97 1.07 0.87 0.76 0.61 0.42 0.40
Manipur 1.34 1.66 1.30 1.39 1.31 0.54 0.78 0.64
Meghalaya 0.35 0.00 0.00 0.09 0.00 0.04 0.05 0.26
Mizoram 1.70 1.50 0.81 0.94 0.85 0.72 0.40 0.68
Nagaland 1.69 1.85 1.97 1.36 1.10 1.14 0.66 0.88
Odisha 0.00 0.50 0.60 0.55 0.23 0.73 0.43 0.31
Puducherry 0.13 0.25 0.25 0.25 0.00 0.25 0.13 0.00
Punjab 0.13 0.44 0.25 0.20 0.12 0.31 0.26 0.37
Rajasthan 0.15 0.23 0.50 0.29 0.19 0.19 0.38 0.32
Sikkim 0.21 0.00 0.25 0.10 0.09 0.00 0.09 0.19
Tamil Nadu 0.83 0.81 0.54 0.54 0.58 0.35 0.38 0.36
Tripura 0.00 0.25 0.00 0.42 0.25 0.00 0.00 0.19
Uttar Pradesh 0.22 0.44 0.1 0.25 0.08 0.18 0.21 0.20
Uttarakhand 0.06 0.00 0.00 0.11 0.06 0.22 0.25 0.27
West Bengal 0.46 0.43 0.89 0.38 0.40 0.17 0.13 0.19
India 0.80 0.95 0.90 0.60 0.49 0.49 0.40 0.35
Note:- (1) Based on valid sites (75% of target achieved) (2) No HSS site in Lakshadweep during HSS 2010-11 and
2012-13 (3) All figures in percentage (4) Figures from HSS 2012-13 are provisional.

35 | HIV Sentinel Surveillance 2012-13

Annex 6: State-wise HIV prevalence among FSW, HSS 2003-2011

State 2003 2004 2005 2006 2007 2008-09 2010-11

A & N Islands - 0.50 0.40 - - - -
Andhra Pradesh 20.00 16.97 12.97 7.32 9.74 11.14 6.86
Arunachal Pradesh - - - 0.00 - 0.00 0.28
Assam 0.00 0.00 0.76 0.46 0.44 0.80 0.46
Bihar 4.80 0.20 2.24 1.68 3.40 2.98 2.30
Chandigarh 0.60 0.80 0.67 0.67 0.40 0.82 0.00
Chhattisgarh - - - 1.57 1.43 - 2.73
D & N Haveli - - - - - - -
Daman & Diu - - - - - - -
Delhi 1.61 4.60 3.15 2.80 3.15 2.17 0.70
Goa 30.15 - - - - 6.40 2.70
Gujarat - 9.20 8.13 6.40 6.53 3.74 1.62
Haryana - - 2.00 1.19 0.91 1.55 0.48
Himachal Pradesh 0.00 0.80 0.00 0.66 0.87 0.55 0.53
Jammu & Kashmir - - - 0.00 - 0.00 0.00
Jharkhand - 0.00 0.80 0.88 1.09 0.94 0.82
Karnataka 14.40 21.60 18.39 8.64 5.30 14.40 5.10
Kerala 1.94 - - 0.32 0.87 1.46 0.73
Madhya Pradesh - - 1.82 1.07 0.67 - 0.93
Maharashtra 54.29 41.69 23.62 19.57 17.91 10.77 6.89
Manipur 12.80 12.40 10.00 11.60 13.07 10.87 2.80
Meghalaya - - - - - - -
Mizoram - 13.69 14.00 10.40 7.20 9.20 -
Nagaland 4.40 4.44 10.80 16.40 8.91 14.06 3.21
Odisha - 5.18 2.60 1.00 0.80 2.40 2.07
Puducherry - 1.94 0.28 1.44 1.30 - 1.21
Punjab 0.00 - - 1.36 0.65 0.97 0.85
Rajasthan 3.92 2.31 3.72 2.55 4.16 3.58 1.28
Sikkim - - - - 0.00 0.44 0.00
Tamil Nadu 8.80 4.00 5.49 4.62 4.68 6.22 2.69
Tripura - - - - - - 0.21
Uttar Pradesh 6.60 8.00 3.50 1.52 0.78 1.03 0.62
Uttarakhand - - - - - - 0.44
West Bengal 6.47 4.11 6.80 6.12 5.92 4.12 2.04
India 10.33 9.43 8.44 4.90 5.06 4.94 2.67

Note:- (1) Based on valid sites (75% of target achieved) (2) No HSS site in Lakshadweep (3) All figures in percentage

A Technical Brief | 36
Annex 7: State-wise HIV prevalence among MSM, HSS 2003-2011

State 2003 2004 2005 2006 2007 2008-09 2010-11

A & N Islands 1.25 - - - - - -
Andhra Pradesh 13.20 16.00 6.45 10.25 17.04 23.60 10.14
Arunachal Pradesh - - - - - - -
Assam - - - 0.78 2.78 0.41 1.40
Bihar 1.60 1.60 0.40 0.30 0.00 1.64 4.20
Chandigarh - 1.36 1.60 4.80 3.60 2.79 0.40
Chhattisgarh - - - - - - 14.98
D & N Haveli - - - - - - -
Daman & Diu - - - - - - -
Delhi 27.42 6.67 20.40 12.27 11.73 7.87 5.34
Goa 9.09 1.68 4.90 4.80 7.93 6.40 4.53
Gujarat - 6.80 10.67 11.20 8.40 5.48 3.00
Haryana - - - 0.00 5.39 3.20 3.05
Himachal Pradesh - - - 0.44 0.00 0.40 1.23
Jammu & Kashmir - - - - - - -
Jharkhand - - - - - 2.00 0.40
Karnataka 10.80 10.00 11.61 19.20 17.60 12.52 5.36
Kerala - 0.89 3.20 0.64 0.96 0.75 0.36
Madhya Pradesh - - - - - - 7.94
Maharashtra 18.80 11.20 10.40 15.60 11.80 11.90 9.91
Manipur 29.20 14.00 15.60 10.40 16.40 17.21 10.53
Meghalaya - - - - - - -
Mizoram - - - - - - -
Nagaland - - - - - - 13.58
Odisha - - - - 7.37 4.19 3.79
Puducherry - 5.22 5.60 2.47 2.00 - 1.21
Punjab - - - 4.80 1.22 3.00 2.18
Rajasthan - - - 0.00 - - -
Sikkim - - - - - - -
Tamil Nadu 4.20 6.80 6.20 5.60 6.60 5.24 2.41
Tripura - - - - - - -
Uttar Pradesh - - - - 0.40 4.07 1.56
Uttarakhand - - - - - - -
West Bengal - 1.33 0.54 6.60 5.61 4.90 5.09
India 8.47 7.47 8.74 6.41 7.41 7.30 4.43
Note:- (1) Based on valid sites (75% of target achieved) (2) No HSS site in Lakshadweep (3) All figures in percentage

37 | HIV Sentinel Surveillance 2012-13

Annex 8: State-wise HIV prevalence among IDU, HSS 2003-2011

State 2003 2004 2005 2006 2007 2008-09 2010-11

A & N Islands - - - - - - -
Andhra Pradesh - - - - 3.71 6.90 3.05
Arunachal Pradesh - - - 0.00 0.00 0.23 0.24
Assam 5.56 4.48 7.86 2.86 2.14 3.64 1.46
Bihar - - - 0.20 0.60 5.47 4.54
Chandigarh - 4.80 9.20 17.60 8.64 13.60 7.20
Chhattisgarh - - - - - - 0.42
D & N Haveli - - - - - - -
Daman & Diu - - - - - - -
Delhi 14.40 17.60 22.80 10.00 10.10 18.60 18.27
Goa - - - - - - -
Gujarat - - - - - - 1.60
Haryana - - - 0.00 0.80 2.00 0.80
Himachal Pradesh - - - - - 0.65 4.89
Jammu & Kashmir 0.00 0.00 0.00 2.50 - 0.00 0.00
Jharkhand - - - 0.40 - 1.65 2.02
Karnataka 2.80 0.00 - 3.60 2.00 2.00 0.00
Kerala - 2.58 5.19 9.57 7.85 3.04 4.95
Madhya Pradesh - - - - - - 5.13
Maharashtra 22.89 29.20 12.80 20.40 24.40 20.00 14.17
Manipur 24.47 21.00 24.10 19.80 17.90 28.65 12.89
Meghalaya 0.00 0.00 0.00 3.33 4.17 - 6.44
Mizoram 6.40 6.80 4.80 3.05 7.53 5.28 12.01
Nagaland 8.43 3.22 4.51 2.39 1.91 3.17 2.21
Odisha - - - 10.40 7.33 7.20 7.16
Puducherry - - - - - - -
Punjab - - - 13.80 13.79 26.36 21.10
Rajasthan - - - - - - -
Sikkim - - 0.48 0.20 0.47 1.45 0.00
Tamil Nadu 63.81 39.92 18.00 24.20 16.80 9.48 -
Tripura - - 10.92 0.00 0.00 0.42 0.45
Uttar Pradesh - - - 4.63 1.29 2.46 2.03
Uttarakhand - - - - - - 4.33
West Bengal 2.61 3.83 7.41 4.64 7.76 6.90 2.72
India 13.15 11.16 10.16 6.92 7.23 9.19 7.14
Note:- (1) Based on valid sites (75% of target achieved) (2) No HSS site in Lakshadweep (3) All figures in percentage

A Technical Brief | 38
Annex 9: State-wise HIV prevalence among Single Male Migrants (SMM),
Long Distance Truckers (LDT) and Transgender (TG) sites, HSS 2003-2011

SMM LDT TG
State
2005 2006 2007 2009 2011 2006 2007 2009 2011 2006 2007 2009 2011
A & N Islands - - - - - - - - - - - - -
Andhra Pradesh - - - - - - - - 3.20 - - - -
Arunachal Pradesh - - - - - - - - - - - - -
Assam - - - - - - - - - - - - -
Bihar - - - - - - - - - - - - -
Chandigarh - - - - - - - - - - - - -
Chhattisgarh - - - - - - - - - - - - -
D & N Haveli 0.00 - - - - - - - - - - - -
Daman & Diu - - - - - - - - - - - - -
Delhi - - - - - - - - - - - - -
Goa - - - - - - - - - - - - -
Gujarat - - - 1.80 0.67 - - - 3.09 - - - -
Haryana - - - - 1.33 - - - - - - - -
Himachal Pradesh - - 0.00 0.00 0.00 - 0.40 - - - - - -
Jammu &Kashmir - - - - - - - - - - - - -
Jharkhand - - - - - - - - 1.20 - - - -
Karnataka - - - - 0.00 - - - 3.20 - - - -
Kerala - - - - 0.00 2.40 3.60 0.80 0.00 - - - -
Madhya Pradesh - - - - - - - - 2.47 - - - -
Maharashtra - 2.40 1.60 3.00 1.07 - - - 1.61 29.60 42.21 16.40 18.80
Manipur - - - - - - - - - - - - -
Meghalaya - - - - - - - - - - - - -
Mizoram - - - 0.80 1.22 - - - - - - - -
Nagaland - - - - - - - - - - - - -
Odisha - 1.44 - 3.60 3.20 2.73 - - - - - - -
Puducherry - - - - - - - - - - - - -
Punjab - - - - 1.20 1.07 - - - - - - -
Rajasthan - - - - - - - - - - - - -
Sikkim - - - - - - - - - - - - -
Tamil Nadu - - - - 0.80 - - - 2.01 - - - 3.82
Tripura - - - - - - - - - - - - -
Uttar Pradesh - - - - - - - - - - - - -
Uttarakhand - - - - - - - - - - - - -
West Bengal - - 9.27 2.42 1.61 2.72 2.72 1.75 3.71 - - - -
India 0.00 1.60 3.61 2.17 0.99 2.37 2.87 1.57 2.59 29.60 42.21 16.40 8.82

Note:- (1) Based on valid sites (75% of target achieved) (2) No HSS site in Lakshadweep (3) All figures in percentage

39 | HIV Sentinel Surveillance 2012-13

N OT E S
N OT E S
 India’s voice against AIDS
Department of AIDS Control
Ministry of Health & Family Welfare, Government of India
www.naco.gov.in