Mizoram, a northeastern State of India bordering Myanmar, is home to several tribal clans under the ethnic group Mizo: Renthelei, Ralte, Paite, Lai, Hmar, Lusei, Mara, Thado and Kuki. Mizos also reside in the neighbouring northeastern States of Tripura, Assam, Manipur and Nagaland. The majority of Mizo outside India live across the border in the neighbouring Chin State and Sagaing Region of Myanmar. Globally, the HIV epidemic has been witnessing a declining trend, and a similar observation is evident from within India as well1. Inception of the National AIDS Control Programme in India and establishment of the National AIDS Research Institute (NARI), one of the premier organizations under the Indian Council of Medical Research (ICMR), in 1992 contributed in a big way to achieve such a feat2. Since then, HIV-targeted interventions (TIs) in the country have predominantly focused on these key population groups such as female sex workers (FSWs), men having sex with men (MSM), transgenders and people who inject drugs (PWID)3. Despite TI programmes since more than three decades and adoption of the ‘test and treat’ strategy some population groups yet remain unreached4. Some of the key population groups such as FSW and MSM are shifting from physical locations to virtual platforms5; hence, the need for innovative outreach intervention.
In recent times, annual upsurges in new HIV infections have been recorded in the northeastern States of Tripura, Arunachal Pradesh and the northern State of Chhattisgarh, which did not have a significant presence of HIV in the early years of the epidemic6. Importantly, Mizoram has been witnessing an increasing trend of HIV prevalence not only among PWID and FSWs but also among the general population7. The HIV prevalence among FSWs and PWID in this State, compared to the national averages, continues to be higher at 24.7 and 19.8 per cent, respectively, which are highest in the country8. Nearly a decade ago, the jail inmates in the State of Mizoram were mostly drug users9. The HIV prevalence among the prisoners in Mizoram has been recorded as high as 21 per cent10. On the other hand, the present adult HIV prevalence in Mizoram is 2.3 per cent, nearly ten folds higher than the national average6. The HIV prevalence among antenatal clinic attendees has also surpassed one per cent7.
The reasons behind the current situation of HIV in Mizoram are multiple, the commonly cited one being sharing of needles and syringes leading to nearly 39 per cent of the new HIV infections in Mizoram11. It is also on record that the proportion of regular sex partners of people living with HIV (PLHIV) undergoing HIV counselling and testing has been less than a third in Mizoram11.
The standalone integrated counselling and testing centres (ICTCs), and double the number of facility-based ICTCs including community-based screening sites, have been located across the State of Mizoram in line with the guidelines issued by the National AIDS Control Organization (NACO)12. In order to cater to the key population groups, TI sites have been established, which are concentrated mostly in Aizawl district13. Six centres across the Mizoram State deliver ART medications14. Despite such programmatic interventions, there is a rise in HIV incidence.
Against this backdrop, we conducted a rapid review of the HIV epidemic situation and responses in Mizoram, which, along with two other northeastern States of India, namely Manipur and Nagaland, documented the presence of HIV amongst PWID for the first time in India in 199015. The overall purpose of this review was to inform future interventions to halt and reverse the HIV epidemic in the State. In the process, the epidemic and responses in early 1990s were contrasted against the situation and mitigation measures of recent times.
Material & Methods
This review was conducted as a rapid assessment of evidence on policy and practices pertaining to HIV situation and responses in Mizoram. Being guided by the current understanding16, a systematic review-based strategy was deployed to search and critically appraise existing research where a ‘quick but not dirty’ approach was followed17. The systematic search of literature was conducted within a short span of eight weeks with a pragmatic mix of rigorous and explicit inquiry and thus being systematic, yet making concessions to the breadth or depth of the process by limiting particular aspects such as exhaustive assessment of the article/report quality unlike the usual practices18. This review was approved as a part of a larger study (NARI/EC Approved/20-21/409).
Search strategy: Articles published in peer-reviewed journals and reports under grey literature were included in the current review. The bibliographic databases, namely PubMed, Embase and Cochrane Library, were searched for accessing published literature. Simultaneously, different development partners and stakeholders such as Family Health International (FHI-360), Centre for Disease Control (CDC), International Training and Education Centre for Health (ITECH), Joint United Nations Programme on HIV/AIDS (UNAIDS) and North East Technical Support Unit (NETSU) were contacted to access reports not available through the aforementioned searches.
Three broad domains were considered under our search strategy: ‘HIV/AIDS’, ‘target population/key population’ and ‘intervention activities, community engagement and geographical space/centres/institutions/stakeholders in Mizoram’ to reflect upon various aspects of HIV epidemic in the State. Keywords representing each of these domains were carefully selected following detailed discussions with subject experts and members of the investigation team from the ICMR-National AIDS Research Institute, Pune. Finally, the selected keywords were strung together using boolean operators to effectively search the PubMed database. Similar strategies were used to search the other two databases, namely Embase and Cochrane Library. No time restriction was applied while navigating through published literature. Reports obtained from various development partners and stakeholders constituted grey literature and were juxtaposed alongside the information synthesized from peer-reviewed articles gleaned through database search.
Data screening: Publications identified through bibliographic database searches and the internet were de-duplicated and then screened initially by title and abstract for their relevance. Subsequently, full texts of the articles were downloaded and assessed for their eligibility for inclusion. The flow of work is explained by the schema presented in Fig. 1. Bibliographies were managed and screened using web-based Rayyan (https://www.rayyan.ai/), a tool to conduct systematic reviews.
Twenty four articles were accessed by searching databases: PubMed, Embase and Cochrane. After title, abstract and full-text screening conducted independently by two authors, 11 of them were selected for data synthesis. Any discrepancy, pertaining to screening of an article and its inclusion in data synthesis, was resolved by the two authors jointly. In case of further discrepancy and conflict, resolution was achieved with the help of research supervisor. In addition, we accessed six relevant records from Google Scholar. Table depicts the overview of the articles.
With efforts to access grey literature, we could obtain seven reports from various stakeholders who worked or are currently working for the cause of HIV in Mizoram. Moreover, we included four dissertations/theses that were relevant to our review.
Synthesis: Evidence synthesis followed a descriptive approach to characterize the attributes extracted from peer-reviewed articles and reports under grey literature. The evidence was grouped into major themes, and this required an iterative process of referring back to the original studies and reading and re-reading them to be able to capture the context and the findings. The unpublished reports and interactions held with the stakeholders further contributed to the construction of this review.
Retrieved articles and reports: The systematic search revealed that the published articles on the topic of HIV epidemic and responses in Mizoram were limited. However, by reaching out to various experts and stakeholders, ultimately we were able to compile 28 source materials comprising articles, reports and dissertations contributing to the current review.
HIV and the youths in Mizoram: Three studies focused on the youths in Mizoram; early initiation of drug use was highlighted in these investigations. The reasons for such initiation were cited as increase in nuclear families (as opposed to the tradition tribal culture of commune-based living and support), poor self-esteem, advertisements promoting smoking and alcohol use and peer pressure19-21. Most of the youths in this investigation reportedly initiated drugs, especially heroin, during adolescence and a few were even inducted in such a practice at an early phase of life during 7-12 yr of age19. Drug use by children and adolescents led to absenteeism from schools, while among college-going youths, it interfered with their academic performances. The association of drug use with vulnerability to HIV also emerged as a concern19.
Kenyon20 evaluated the data on circumcision prevalence and sexual practices generated through the National Family Health Survey 2015 and examined their association with HIV prevalence. Individuals belonging to the age group of 15-49 yr and representing general population had more than one per cent HIV prevalence in the State of Mizoram and it was further documented that about a fifth reported high-risk sexual practice. Men reportedly had a greater number of sexual partners compared to women. Only 2.9 per cent of the respondents in this study reported using condoms during their last sexual act.
Awareness programmes conducted through multi-media channels such as television, distribution of leaflets for creating awareness and competitions organized among youths through music and sports aimed towards dissemination of information on HIV/AIDS across all eight districts of Mizoram21. Red Ribbon Clubs and churches belonging to different denominations were engaged by the United Nations Office on Drugs and Crime in such awareness initiatives21. Forty two church leaders across eight denominations attended these discussion sessions on HIV from October 2009 to March 2010. Nuances around HIV testing and vulnerabilities of individuals engaged in same-sex sex to HIV across Mizoram constituted part of these intervention discourses. This reportedly had a positive influence on the youths; some of them volunteered for HIV testing and encouraged their peers to get tested as well. The report of this advocacy campaign underlined the importance of the engagement of church leaders and coordination between different denominations to help address issues around HIV in Mizoram21.
HIV transmission, co-infections, substance use and social studies: Most of the studies retrieved during the current review focused on injection drug use practices in Mizoram. Biswas et al22 highlighted that in the National Integrated Biological and Behavioural Survey (IBBS) conducted by the NACO in 2014-2015, Mizoram featured as the only State where 65 per cent of the drug users were <20 yr old. The most commonly used drug was heroin, locally known as ‘number 4’. In Mizoram, young PWID, belonging to the age group of 18-24 yr, reported injecting drugs in groups at less frequented public places such as graveyards, abandoned buildings and lonely riverside. Some of the shooting galleries were also reportedly used for sex work, reflecting upon HIV transmission through drug–sex interface. Medhi et al23 highlighted the issue of injecting drug users not getting enrolled in the Needle–Syringe Exchange Programme (NSEP) due to stigma and discrimination experienced by them. Studies24,25 further revealed the existing disconnect between awareness about safe injection practices among PWID and sharing of needles and syringes by a considerable proportion of them. This was consequently associated with the rise of HIV infection as well as hepatitis B and C co-infections in them. Synthetic opioid injection such as dextropropoxyphene use was reported in these studies, particularly at the time of crackdown on heroin smuggling.
Factors associated with HIV and co-infections of hepatitis C and B virus among young PWID,26 were injection of multiple drugs rather than a single one, having been an injection drug user (greater than five years) and sharing of needles and syringes. Early 1990s24-26 witnessed stabilization of HIV prevalence in Mizoram between six and 10 per cent among PWID, while the neighbouring State of Manipur witnessed a rapid rise from one to 16 per cent and finally 64 to 80 per cent during the same period among PWID. Later studies27,42 (personal communication) identified the progression of HIV epidemic in the general population of Mizoram in the early 2000s. The authors underlined the need to address macro-social and development issues as well as existing sociocultural and religious practices for the development of effective interventions The folklore-based community sensitization activities with the engagement of community leaders and youths were suggested as helpful strategies.
In the dissertation 2010, from the department of Social Work, Mizoram University, Fambawl defined broken families as those experiencing a marital breakdown or those where respondents had remarried. The most common reason for marital discord and divorce was addiction to smoking and alcohol followed by domestic violence28. Another dissertation from the same department by Vanlalhriati29 in the year 2013 focused on injection drug users in K-Ward, Synod Rescue Home and Tawngtai Bethel Camp Centre in Aizawl district. The most common reasons revealed through this study for re-use of injection equipment were non-availability of sterile syringes and needles (73%) and stigma associated with accessing them (11%). Further, some of the injection drug users reportedly (8%) were engaged in high-risk sexual practices such as unprotected sex with multiple sexual partners. While peer influence and broken family were identified as factors responsible for youths getting into drug use, self-discipline and family support were identified as important for success of de-addiction initiatives29.
Vulnerability of women to HIV: The dissertation by Sailo30 reported that most of the female injection drug users (FIDUs) engaged in sex work before attaining the age of 18 yr. Majority of them reportedly entered into sex work because of financial constraints and operated from streets. Substance use in any form was reported before transactional sex act, and this often resulted in inability of women to negotiate condom use with their clients. More than half of these respondents reported injecting drugs. Most of the female sex workers reported migrating to the capital city of Aizawl from other districts before getting into sex work. Some of the women also reported their native place being in Myanmar revealing the porous nature of the international border. In-depth analysis of primary data from the National IBBS highlighted that most of the non-home-based sex workers were younger compared to their home-based counterparts in Mizoram31. The report by the NETSU based on IBBS 2014-2015 revealed that the consistent condom use among FSWs was lower compared to the national average (Report on The Epidemiology of HIV in Mizoram; Unpublished report shared by NETSU, personal communication).
Issues pertaining to FIDU in Champhai, an eastern district of Mizoram bordering Myanmar, were explored recently through a qualitative investigation. The participants in this assessment reported discrimination from healthcare workers while accessing sterile needles and syringes under NSEP. This was in contrast with the experience of their male counterparts. This study further highlighted the lack of interministeral coordination and non-availability of opioid substitution therapy (OST)32.
HIV and prisoners: The feasibility of intensified case detection initiative for HIV and tuberculosis among inmates of Central Jail, Aizawl, was studied in the year 201933; 738 inmates were screened for HIV and tuberculosis over a period of four months. Sharing of needles was reported by injection drug users both inside and outside of prisons, with men being more involved. Male prison inmates also reported having multiple sexual partners compared to the female inmates, and condom use was reported by only half of them. Among the inmates who undertook an HIV test, 9.5 per cent were newly detected as having HIV during the study period. Of these only 34 per cent were linked with HIV care and treatment services, while others were released from prison and the outcome of a few could not be traced.
Role of community leaders in HIV response: The United Nations Development Programme supported an exploratory study during 2010 to examine the attitude of church members towards HIV/AIDS, across six different Christian denominations in Mizoram. Most of the respondents were in 14-20 yr age bracket and were aware about sexual route being the most common mode of HIV transmission. They mentioned that issues around HIV and AIDS were not openly discussed in the churches although church leaders were expected to play important role in the dissemination of information on this issue34 (personal communication). In a mixed-method study35,36, in-depth interviews and focus group discussions were conducted in Aizawl engaging Presbyterian church leaders, pastors, women, youths and men. Despite expressing willingness to discuss HIV related issues, the church leaders were hesitant to do so with local youths. However, they felt that the involvement of churches would play a key role in improving the HIV situation in Mizoram. Homosexuality was viewed as a taboo, and most of the church leaders were resistant to accept such a sexual orientation. In addition, 80 per cent of the church leaders felt that homosexuals deserved to get HIV, while nearly 65 per cent of the church leaders supported NSEP37. This contrasted with advocacy efforts around condom use35,36; a few church leaders acknowledged the role of condoms in HIV prevention38.
The programme ‘Friends on Friday’ was conducted among church leaders, local networks of PLHIV and youths at Grace Home (hospice care), Aizawl, during 2011-201236. Sensitization on HIV, dealing with stigma and discrimination and condom demonstration were carried out as intervention activities under this programme. The results of this innovative intervention were encouraging36. Another study conducted by Ralte39, aiming to understand the relationship between the State and the civil societies in Mizoram, underlined that the Young Mizo Association (YMA) and church leaders were strong influencers in the community. Noticeably on different occasions, YMA and church raised strong resentment towards alcohol and substance users and even organized repressive and discriminatory measures against them.
Service-related challenges: The Centre for Peace and Development, an NGO, in the district of Aizawl, Mizoram, documented prevailing myths and misconceptions around HIV across different population groups in 2006 and brought them to the notice of the State AIDS Control Society (SACS)40. A few NGO leaders highlighted the lack of advocacy around HIV prevention and care services. Concerns about the way privacy and confidentiality of patients were handled by the hospital staff were also flagged. Recommendations emerging from this work included innovative measures for communication, introduction of mobile blood testing facility and installation of condom vending machines40.
A rapid assessment conducted across five northeastern States, namely Assam, Meghalaya, Manipur, Nagaland and Mizoram in the early 2000s, mapped the vulnerability of key population groups and local youths to HIV infection. Poverty and lack of access to sterile syringes and needles in rural areas of Mizoram were identified as factors associated with HIV risk in this investigation; opposition faced by HIV intervention workers from local activist groups was another highlight41 (personal communication). A monograph published in 2006 also narrated about inhibitory forces making dents in the ongoing HIV prevention and care services in the community and underlined the need for reducing stigma and discrimination faced by PLHIV in Mizoram42.
A spatiotemporal analysis of all healthcare services, such as sub-district/sub-divisional hospitals, community health centres, primary health centres and sub-centres in Mizoram, revealed glaring differences in their geographical distribution across the districts; while Mamit, Serchhip, Kolasib and Saiha were better-served districts, the remaining four, namely Aizawl, Lawngtlai, Champhai and Lunglei, were poorly catered43. The report from NETSU highlighted the disruption in programme interventions, especially in 2015. This affected both the quantity and quality of HIV prevention and care services; the supply of the sterile needles and syringes became irregular leading to a surge in unsafe injection practices among PWID and consequent rise in the HIV epidemic (Report on The Epidemiology of HIV in Mizoram; unpublished report shared by NETSU, personal communication). Under the project ‘Sunrise’ in 2019, FHI-360, an international NGO, conducted a scoping exercise to characterize the prevailing services and identify existing gaps, barriers and challenges. Key population groups in three districts - Mamit, Lunglei and Kolasib in Mizoram - were in focus. The study revealed that the key populations remained distanced from service outlets - reasons being non-availability of OST, condoms, antiretroviral treatment (ART), fear of being recognized by known people while accessing NSEP, difficult access to the services, stigma and discrimination and non-availability of CD4 cell count and viral load testing facility at ART centres. Despite HIV awareness, there was some reluctance among the community leaders to accept the key population groups in the State and acknowledge their specific needs (FHI 360. Scoping Report for Three Districts in Mizoram; unpublished report shared by FHI-360, personal communication).
Due to the rising HIV/AIDS scenario in Mizoram, FHI-360 in collaboration with the Mizoram SACS implemented a mentoring model during April 2015-September 2020 to enhance the capacity for strategic intervention and introduce innovations for improving HIV intervention coverage. Innovative service delivery outlets for needle–syringe exchange such as grocery shops, volunteer homes and public bathrooms as satellite vending sites were introduced. Community-based screening for HIV among the key population groups was also introduced through camp approach and this reportedly increased HIV test uptake. Importantly, satellite OST centres helped linking more PWID to HIV prevention and care services. This programme was successful in drafting and implementation of a revamped and revised TI strategy and development of an integrated AIDS action plan for Mizoram (Project Sunrise End of Project Report FHI 360 & NACO. Report shared by FHI-360; personal communication).
This rapid review, with its focus on HIV situation and responses in the State of Mizoram, has synthesized evidence from 28 source materials comprising articles, reports and dissertations. Various issues pertaining to the HIV epidemic in the State, including socio-economic vulnerabilities and measures taken to address them, have been highlighted. We may have missed some of the grey literature, which is a limitation of the study. However, the present synthesis lends valuable public health insight for future programme planning and mitigating the impact of HIV in Mizoram (Fig. 2).
Despite scarcity of published literature, this review has been able to trace the HIV epidemic in Mizoram since early 1990s to the recent times. Moreover, it delved upon the vulnerabilities of key population groups and general population including youths to HIV. Intervention projects, which successfully addressed the challenges on ground through innovation, were showcased.
Almost all the studies retrieved under this review focused on key population groups except a few that dealt with HIV in youths. Therefore, looking back and critically examining the innovative community awareness campaigns with behaviour change communication among the youths such as Red Ribbon Clubs merit immediate attention. Usage of social media platforms as means of behaviour change, dispelling myths around HIV and increasing access to prevention and care services repeatedly featured as key considerations under successful intervention initiatives. In addition, the role of YMA should be strengthened not only to help create awareness around HIV and other sexually transmitted diseases but also to create an enabling rather than stigmatizing environment. Examples can be drawn from other countries in this regard such as sub-Saharan Africa where youths played a critical and positive role in HIV programme44.
Mizoram shares its border with adjacent countries and States, and the issue of migration has been a concern for past many years. This revolves around illegal migration across the international border and movement from the neighbouring States of Manipur45. The vulnerability of migrant women to HIV due to poverty, engagement in unsafe injecting practices and sex work is on record30 and needs to be addressed from the perspective of rights of migrants to health.
Stock-outs and non-availability of sterile syringes and needles, condoms and OST have been identified as other core concerns. The policymakers and programme personnel46 therefore need to ensure uninterrupted services related to HIV prevention and care. Examples of community-led interventions from other parts of India with active engagement of underserved population groups such as sex workers and PWID in programme planning, implementation and monitoring47,48 could be drawn upon in this regard. However, adapting such approaches to the local sociocultural, religious and policy context would remain crucial.
High HIV prevalence among incarcerated population in Mizoram is another issue of great public health urgency10; which might not have featured as a priority during the initial phase of epidemic management planning in the northeastern States of India. It is important to note that among those prisoners who were detected with HIV; linkage to care and preventive services could be traced only in one-third of them. Strengthening of such linkages therefore appears crucial33. Noticeably, Scotland and Australia reported extensive injecting drug use among the prisoners49,50 and Switzerland was the first country to introduce the NSEP in prisons and this was soon followed by others51. In India, the operational guidelines52 are drafted and examining their implementation at State level is urgent.
As religious leaders have strong influences in Mizoram, lessons from the past such as ‘Friends on Friday’ should be re-examined for their relevance in today’s Mizo society38. Further, it would be important to draw sustainable action plans with such influencers in the community with a focus on macro-social and structural interventions53,54 to bend the rising curve of HIV infections downwards in Mizoram. Noticeably, examples are available from Kenya where church leaders were an integral part of HIV containment programme55. Taboo around homosexuality remains yet another unaddressed issue in Mizoram, as literature focussing on MSM population are spare and more evidence need to be generated around effective HIV prevention in them. Active engagement of faith-based organizations56 across religious denominations, civil societies, prison authorities as well as community-based organizations by the Mizoram State AIDS Control Society would be critical in overcoming such obstacles. This rapid review has critically examined HIV scenario and responses in Mizoram which will help inform future intervention planning.
Overall, this review identified key determinants of rising HIV infection in Mizoram. Drawing upon good practice examples from the past, it has also been able to glean out core considerations for future intervention planning where active community engagement will play a critical role. Supportive policies and practices against stigma and discrimination, especially towards MSM, PWID (male and female), FSWs and PLHIV, would facilitate better linkages between HIV prevention and treatment services and key population groups. Furthermore, new innovative interventions such as HIV self-test and linking newly identified PLHIV with treatment services will add required momentum to the ongoing HIV control programme. Importantly, in recent times, HIV self-test is gaining popularity and acceptance among various population groups including youths in other parts of India57-59. Macro-social and structural interventions along with strategic HIV risk communication, ensuring uninterrupted availability of testing and treatment services across the State of Mizoram appear crucial.
Secondary data access declaration: All the grey literature and unpublished reports which have been cited in the text can be made available through appropriate request to the corresponding author.
Acknowledgment: Authors acknowledge the help of stakeholders and development partners: Ms Nandini Kapoor-Dhingra from UNAIDS-India; Drs Bitra George, FHI-360; Melissa Nyendak, CDC; Anwar Parvez Sayed, Sampath Kumar, Technical Advisor (prevention), I-TECH India; and Mr Pankaj Kumar Choudhury, NETSU, in accessing unpublished reports from where we pulled out information for the present review along with the systematic search.
Financial support & sponsorship: None.
Conflicts of Interest: None.
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