Integrated and Enhanced Surveillance and Epidemiology in India: Advancing the National HIV and Sexually Transmitted Infection Response

The National AIDS and STD Control Programme-Phase V (NACP-V), implemented by the Government of India, aims to reduce annual new HIV infections and AIDS-related deaths by 80% against the 2010 baseline.[1] Key objectives also include eliminating HIV/AIDS-related stigma, achieving dual elimination of vertical transmission, and ensuring universal access to high-quality sexually transmitted infection (STI) services for vulnerable and at-risk populations. The National AIDS Control Organisation (NACO) has developed the Integrated and Enhanced Surveillance and Epidemiology (IESE) framework to monitor the magnitude and direction of HIV, STIs, and related comorbidities, providing critical data to inform evidence-led planning and implementation.[2] Through the IESE framework, NACO seeks to strengthen surveillance systems, enhance data analysis, and promote informed decision-making to effectively address the evolving HIV epidemic and related health challenges in India. The IESE framework has evolved from traditional HIV Sentinel Surveillance (HSS) to meet contemporary public health needs, driven by the 2030 Sustainable Development Goals (SDGs).[3] Fully domestically funded and institutionalized, this system encompasses HIV, STIs, and related morbidities like hepatitis, informing an integrated response through empirical data tracking progress on impact indicators through mortality and incidence surveillance. Size estimation of key populations in physical and virtual spaces, integrated bio-behavioral surveillance surveys of critical biomarkers and behaviors among key population as well as among people living with HIV, and programmatic case-based surveillance to identify emerging locations and populations in need of response are key components of this surveillance system. The IESE framework incorporates ethical principles, community ownership, data triangulation, programmatic synergy, institutional collaboration, and data-driven action to ensure effective disease surveillance and response. Since the 1st year of NACP-V (2021–2022), NACO has conducted a comprehensive range of activities within the IESE framework, elucidating key aspects of disease surveillance for effective program planning, implementation, as well as impact assessment. The technical rigor for the implementation has been ensured through nine government public health institutes, called as regional institutes, engaged by NACO to provide technical support for IESE activities. The outcome illustrates the framework’s multifaceted approach, emphasizing epidemiological insights, innovative methodologies, and strategic recommendations. By disseminating the valuable experiences, lessons learned, and best practices in public health surveillance, IESE aims to augment informed policy decisions enhancing program effectiveness. While there has been extensive evidence on the magnitude, direction, and determinants of HIV under the NACP, the same cannot be said for other STIs. STIs are of significant public health concern due to their prevalence, potential complications, and epidemiological synergy with HIV.[4] In areas where HIV is not well established, high STI prevalence serves as an early warning sign for HIV-related risk behaviors. Moreover, the presence of an STI in a sexual partner can increase the risk of HIV acquisition from an infected partner. The WHO in its global health sector strategy on STIs (2016–2021) has linked STI surveillance to report the progress on four SDGs on neonatal and under-5 mortality (SDG 3.2), ending of AIDS epidemic (SDG 3.3), universal access to sexual and reproductive health (SDG 3.7), and universal health coverage including vaccines for all (SDG 3.8).[5] Accordingly, STI surveillance among different population groups is a core component of IESE. STI surveillance under the IESE framework focuses on syphilis, Neisseria gonorrhoeae (NG), and Chlamydia trachomatis (CT). Syphilis testing has been included in antenatal clinic (ANC) attendee and prison population surveillance for a long time.[6] Under the IESE framework, the reverse testing algorithm has been employed for ANC and prison HSS not only to strengthen the interpretations of findings but also to inform the disease burden estimations. However, STI surveillance poses distinct challenges, particularly for NG and CT. These include stringent laboratory requirements, complexities in sample storage and transportation, and limited availability of licensed test kits for pooled sample testing. The unavailability of test kits across platforms and their high costs exacerbates these challenges. Tailoring the STI surveillance implementation framework to the existing program capacity for testing samples for NG/CT will be a key operationalization of STI surveillance under NACP. A key next step in bolstering HIV and STI surveillance under IESE will be to enhance the use of routine data collected via the NACP’s IT-enabled information management system, strengthening overall care for HIV beneficiaries. The HIV-ALERT system, a numerator-based surveillance mechanism institutionalized under IESE, systematically identifies geographic hotspots and population groups that need intensified programmatic responses and epidemiological investigations. By expanding HIV-ALERT to establish case surveillance systems that leverage routinely reported individual-level data and artificial intelligence, IESE can not only detect epidemics but also predict them at the most granular level, informing targeted public health actions. As India endeavors to achieve the 2030 SDG, it is crucial to provide integrated comprehensive care through frontline workers across prevention, early detection, treatment initiation, and retention for HIV and STIs. The program shall leverage the Ayushman Arogya Mandir (AAM) initiatives to enhance its efforts. By incorporating HIV care services within the AAM framework, the program will ensure universal access to health care for individuals at risk of or infected by HIV and STIs. This collaboration can facilitate holistic care addressing physical, mental, and emotional well-being, promoting equity and inclusivity. Additionally, the AAM’s emphasis on preventive, promotive, and curative care can boost the program’s outreach and uptake, particularly in rural and hard-to-reach areas. Capacity building, test kit provision, integration of reporting information systems, and data confidentiality management – given the provisions of the HIV and AIDS (Prevention and Control) Act, 2017 – are potential challenges that need to be addressed while leveraging the reach of AAM initiatives. It is also important to align surveillance systems with the Digital India initiatives. A robust, technology-driven surveillance system will strengthen real-time monitoring of the epidemic’s dynamics. By utilizing advanced analytics, artificial intelligence, and data science, the program can forecast trends, identify hotspots, and pinpoint vulnerable populations, enabling tailored interventions. Synergies between NACP and various Government of India initiatives will expedite progress toward the SDG target of ending the AIDS epidemic as a public health threat by 2030 while reinforcing India’s commitment to universal health coverage and sustainable development. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.