Health and STD situation in India.

What do health reports say? What are the most widespread diseases, and how does sex work and prostitution fit into this picture?

Sexually Transmitted Diseases are a huge health challenge in India. STDs affect almost 6% of the sexually active adult population (between 15 and 49 years of age) every year.

The estimate of 6% translates to a whopping 3,00,00,000 people or 3 crores!

Although HIV is rather controlled, STDs like gonorrhea and syphilis are on the rise in high-risk groups. These groups include Men Who Have Sex with Men (MSM), Female Sex Workers (FSW), and Injecting Drug Users (IDU).

These groups account for about 20 to 30 per cent of the occurrence.  However, there are no accurate figures, as those quoted are older estimates by the Indian Council of Medical Research, ICMR.

The Indian authorities’ response to STDs has been through public health programmes that focused on sex workers.  These included encouraging the use of condoms, STD screening, treatment and testing under the Anti-retroviral Therapy (ART).

These measures remain the main drivers in India’s initiatives against STDs. That these programmes have immensely contributed to containing new infections is well documented, but social stigma, monitoring and considerable gaps in surveillance still exist. (National AIDS Control Organisation)

What official reports say

National Estimates

According to the National AIDS Control Organisation (NACO), the 2023/2024 estimates have placed adult HIV prevalence at around 0.20–0.22% nationally. This figure is in the range of approximately 23 to 25 lakhs, depending on the report/estimate round. In a vast country like India, the epidemic is diverse across different states/districts.

Key-population differences

Surveillance and TI Data available with NACO convey that the prevalence of HIV is more pronounced among female sex workers (FSWs) and other key populations when compared to the general population. (For instance, the Integrated Biological and Behavioural Surveillance/Targeted Intervention (IBBS/TI) and HIV Sentinel Surveillance (HSS) rounds have reported higher prevalence among FSWs in flash point districts. Programme documents show an average that is much higher than the general prevalence. Group-level and district-level characteristics are provided by the TI guidance and studies. (NACO)

Syndromic management & program approach

Due to the huge volume of syndromic cases and inadequate lab coverage, India’s national guidance sees syndromic management as the mainstay of regular STD services. The accent is on firming up lab diagnosis wherever possible, while simultaneously integrating STD services into wider sexual and reproductive health platforms. (NACO)

The most widespread STDs/STIs in India

Syphilis, Gonorrhoea, Chlamydia and Trichomoniasis together form the bulk of the sexually transmitted diseases in India.

• Syphilis (including congenital syphilis risk) - The most effective means to prevent congenital infections is through antenatal testing and prevention programmes. Therefore, NACO and National TB & STI guidance have prioritised syphilis screening in pregnancy to eradicate congenital syphilis.
• Gonorrhoea - Gonorrhoea is common in outpatient STD/STI clinics and is a focus of antimicrobial-resistance (AMR) surveillance. Microbiology studies conducted in India have indicated a high resistance historically to the earlier drugs like ciprofloxacin. Surveillance studies by ICMR/NARI and other academic papers have largely helped in guided the national treatment recommendations.
• Chlamydia & Trichomoniasis - Chlamydia & Trichomoniasis are often detected in clinic-based as well as targeted-population surveys. However, their actual numbers are ambiguous due to very limited routine screening other than the targeted programmes and antenatal services. (NACO) 

Sex work, prostitution, and the sexual-health landscape

• Targeted Interventions (TIs) - NACO and the State AIDS Control Societies operationalise India’s national HIV strategy. They employ Targeted Interventions that explicitly provide services for female sex workers (FSWs), male sex workers, MSM, hijra or transgender persons and IDUs. Targeted Interventions are in the form of condom distribution, community outreach, STI screening and treatment, HIV testing, and linkage to Anti-retroviral Therapy. Government records indicate considerable declines in incidence among the priority groups.
• Prevalence among sex workers - Programme data and IBBS rounds show that HIV prevalence among FSWs and other key populations is higher than in the general population. The extent of prevalence is varied and throws up different figures, varying by district. However, some flash point districts continue to show high prevalence, whereas other districts show highly reduced occurrence due to constant TI coverage.
• Law and policing context - Commercial sexual exploitation in India is addressed by a central criminal law. This law is in the form of the Immoral Traffic (Prevention) Act (ITPA), 1956. Under this act, activities connected with commercial sex (like brothel-keeping, procuring, trafficking and public solicitation) are criminalised, although the legal situation is rather complicated (selling sex itself is not framed the same way as many of the associated activities). Criminalisation of associated activities has led to determining how sex work is practised (for example, in secretive venues). This has, in turn, influenced sex workers’ access to health services and their willingness to engage with public programmes. (India Code)
• Stigma and enforcement - Social stigma, fear of arrest, moral policing, and social marginalisation decrease the acceptance of testing and routine STI/HIV care among sex workers and other key populations. This is noted even by the National Programme documents as well as civil-society analyses. As such, the NACO’s guidelines for TI are to encourage peer-to-peer outreach, legal aid linkages, and community mobilisation to expand access. (NACO)

Surveillance, antimicrobial resistance (AMR), and programmatic gaps

• Surveillance blind spots - The National guidelines clearly take stock of the limits of STI surveillance. Most of the data are clinic-based and not population-representative. Private-sector reporting is inadequate, and many incidents are managed analytically. This renders it rather difficult to get accurate national prevalence numbers. Therefore, the national guidance calls for reinforcing lab capacity and enhancing custom reporting. (NACO)
• AMR in gonorrhoea - NARI/ICMR-linked data and academic studies portray a very high resistance to older antimicrobials like ciprofloxacin, with cephalosporins (ceftriaxone) continuing to be effective in most collected data. Hence, the available data and the WHO regional surveillance have stipulated the need for aggressive and constant AMR monitoring.
• Syndromic management & the need for diagnostics -Syndromic measures allow for wider coverage but tend to miss out on infections that are asymptomatic, especially chlamydia. This makes AMR findings all the more difficult. Therefore, national-level documents highly recommend reinforcing diagnostics as well as regional referral labs alongside syndromic care. (NACO)