HIV care policy in India: A review of social security schemes.

Social protection schemes are available in India to mitigate the various challenges faced by people living with human immunodeficiency virus (PLWH) infection. The availability of the schemes should be uniform across the country and based on the rights of these people. We reviewed the schemes available in the high PLWH-burdened states of the country for the year 2019. We identified 83 social protection schemes for the PLWH in 13 representative states from different zones of India. The number of schemes was as low as two in the states of Mizoram and Telangana and 12 schemes in Rajasthan. Most of the schemes belong to the 'health' category (n = 26, 31.3%), nutrition (n = 14, 16.9%), financial aid (n = 12, 14.5%), insurance (n = 11, 13.5%), employment generation (n = 3, 3.6%), housing (n = 3, 3.6%), and legal support (n = 5, 6.0%). While health-related schemes are present in all the states, the distribution of the other social schemes varies widely across the states. The schemes commonly address the social safety of the children affected by human immunodeficiency virus (HIV), nutritional supplementation, direct financial assistance or subsidized services, and employment generation but vary considerably regarding the type and the number of services. We strongly recommend for evidence-based policy decision to provide uniform social schemes for PLWH. Copyright:

Introduction

Social protection is a set of public measures that society provides for its members to protect against social and economic distress. These social protection schemes are designed to reduce poverty, inequality, vulnerability, and multi-dimensional deprivation.[123] These schemes are often provided for social issues like unemployment, old age, benefits for family and children; or in various health conditions including maternity, and provision of health care.[45] Social protection can support the vulnerable section of the community like women and children by providing education, nutrition, and cash transfers, and thereby, protecting the families.[6] People living with HIV (PLWH) infection often face social discrimination and stigma across the world. Such discrimination and stigma render them susceptible to various social and physical harms besides their illness in different settings.[7891011] Thus, social protection is required to mitigate the various challenges faced by the PLWH and their families.[1213]

Globally, the burden of human immunodeficiency virus (HIV) and the incidence of new infection has been reduced steadily in the last two decades.[1415] India also showed a similar trend during this period. India’s fight with the HIV epidemic is more than three decades old. It is estimated that more than 37 million people were living with the HIV infection and acquired immunodeficiency syndrome (AIDS) globally by the end of 2018. India, with an estimated 2.1 million PLWH, has the third-largest HIV/AIDS epidemic in the world after South Africa and Mozambique[16] In India, the prevalence is highest among three northeastern states, namely Mizoram, Nagaland, and Manipur ranging between 1.2 and 2.3%. On the other hand, states like Maharashtra, Andhra Pradesh, and Karnataka bear the highest number of PLWH ranging between 0.27 million in Karnataka and 0.4 million in Maharashtra.[17] Nevertheless, alongside achieving the sustainable development goal (SDG) of lowering HIV incidence, India must focus on ensuring a healthy life for the PLWH.[1418]

Unfortunately, PLHW is often stigmatized and marginalized in India.[19] In some instances, stigma and discrimination marginalize PLWH and their households and exclude them from essential services.[7] This impact reaches far beyond the health sector which makes family members end up with poverty by reducing the productive members of the family, and on other hand, by increasing medical expenses for PLWH since HIV/AIDS needs lifetime drug treatment.[20] According to the HIV and AIDS (Prevention and Control) Act, 2017, Chapter VII, the central and the state governments are expected to take measures to facilitate the access of the welfare schemes to address the need of the PLWH. The act also states to take measures by the central government to take necessary action to provide adequate information about the disease and program-related communication to ensure the rights of the PLWH. Fortunately, the state and the central governments have taken measures to help the PLWH by designing many social benefit schemes. These schemes cover a wide range of services like financial aid, employment, food supplementation, travel concessions, insurance benefits, schemes for children, etc., However, the literature is inadequate to understand the kind of social schemes available, the entitlements of the schemes, and the state-level variations, if any. In this background, we have summarized the various social schemes available for the PLWH in India, and we examined the adequacy of the schemes based on the state-level burden of the PLWH.

Methods

To identify the social schemes on HIV, we first identified the high-burdened states in different zones in India. The states in India are divided into six zones as it is given by National AIDS Control Organization (NACO) in the ‘India HIV estimates 2019 report.’[21] We selected two high-burdened states from each zone, except the South zone from which we purposively took three states. The states or union territories (UT) include Delhi, Rajasthan (North zone); Uttar Pradesh, Madhya Pradesh (Central zone); Maharashtra, Gujarat (West zone); Bihar, West Bengal (East zone); Mizoram, Manipur (Northeast zone); Andhra Pradesh, Tamil Nadu, and Telangana (South zone) [Figure 1].

Figure 1

Distribution of high PLWH-burdened states in India, 2019

To identify the social schemes available in each state, we applied to the ‘Right to Information’ (RTI) portal, India, asking for information on the current active social schemes available for PLWH. In reply, the RTI authority directed us to search through the official website of NACO and the State AIDS Prevention and Control Societies (SACS) sites. The NACO official website is managed by the Ministry of Health and Family Welfare (MoHFW), Government of India. The details of the state-specific schemes were taken from the office orders of various states. We considered the orders published between March 2017 and November 2019 for this review. After identifying the schemes from office orders of each chosen state, we retrieved the information about each scheme in terms of the beneficiaries and the entitlements from the office orders. We excluded those schemes which were mentioned in the SACS but were without any details on the benefits and entitlements. We created a word cloud for conceptual analysis for the most commonly occurring word in the entitlements of the social schemes. A geographical illustration was created in Q-GIS version 3.18 which is open software.

Results

Social protection schemes in India

From the 13 states we included for the analysis, we could identify a total of 119 schemes for the PLWH. The number of schemes was as low as two in the Mizoram state and as high as 25 schemes in the Tamil Nadu state [Table 1].

Table 1

Distribution of the social schemes for PLWH in India by states and category, 2019

	Number of PLWH-related schemes in each category								Total in state	Total PLWH in the state/UT in lakh*
	Health	Finance	Children	Nutrition	Insurance and social assistance	Employment	Housing	Legal
Delhi	4	1	1	0	0	0	0	0	6	0.4
Rajasthan	3	2	0	1	6	0	0	0	12	0.1
Madhya Pradesh	2	11	3	2	3	1	1	1	24	0.1
Uttar Pradesh	3	2	1	2	1	1	0	1	11	0.1
Bihar	1	2	0	1	0	1	0	1	6	0.2
West Bengal	2	1	0	1	0	0	0	0	4	0.1
Manipur	2	0	1	2	0	1	1	1	8	1.2
Mizoram	1	0	0	1	0	0	0	0	2	2.3
Maharashtra	1	0	0	2	0	0	1	0	4	0.4
Gujarat	2	1	5	1	0	0	0	0	9	0.2
Andhra Pradesh	2	1	0	1	1	0	0	0	5	0.7
Tamil Nadu	2	5	4	1	7	4	1	1	25	0.2
Telangana	2	1	0	0	0	0	0	0	3	0.5
Total in category	27	27	15	15	18	8	4	5	119	6.5

Distribution of the schemes under each category is shown in green, yellow, and red shades in a descending order. *10 lakh=1 million

We broadly divided the schemes into eight areas, namely health, finance, children, nutrition, insurance and social assistance, employment, housing, and law. We have summarized all the schemes in Appendix 1. Among all the schemes identified in each state, certain schemes are state-specific and some are central schemes. While most of the schemes belonged to the health category (n = 27, 22.6%) and finance (n = 27, 22.6%), the other major categories include insurance and social assistance (n = 18, 15.1%), nutrition (n = 15, 12.6%), and for children (n = 15, 12.6%) [Table 1]. The schemes for employment generation (n = 8, 6.7%), housing (n = 4, 3.3%), and legal support (n = 5, 4.2%) are low in numbers. While health-related schemes are present in all the states, the distribution of the other social schemes varies widely across the states.

Appendix 1

Distribution of the social security schemes for PLWH by category, beneficiary, and entitlement, India, 2019

States (Incidence/1,000 population)	Scheme area	Names of the schemes	Beneficiaries and Entitlement
North zone
Delhi (0.15)	Health	Diagnosis	Provision of CT scan, MRI, ultrasound, blood test and other investigations at free of cost to all PLWH
		MITWA	Providing counseling and testing services at the doorstep and distributing free condoms to vulnerable population
		Treatment	Lifetime free ART and OI medications for PLWH
		Travel concession	Once a month 50% railway concession for PLWH to attend ART center
	Financial	Financial Assistance scheme	PLWH on ART- 2000/month Orphan children infected with HIV/AIDS- 4100/month Destitute children infected with HIV - 4100/month Orphan CABA - 3500/month Amount will be increased annually by 5%
	Children	Education	Free education to children affected/infected with HIV
Rajasthan (0.04)	Health	Travel concession	Concession of 75% in bus fare or 50% in train fare for PLWH to ART once in a month
		Treatment under Chief Minister relief fund	Free diagnosis, treatment, and medicine to PLWH
		Blood unit (RSBTC)	Free blood unit from blood bank to all PLWH
	Finance	Palanhar	For CABA, monthly INR 500 up to 5 years, INR 1000 if the child goes to school, and INR 2000 yearly subsidy for clothing
		Rajasthan Vidhwa pension yojana	INR 1500/month for widows with PLWH
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice.) Priority to PLWH in provisioning from the department of food and civil supplies
	Insurance and social assistance	Third gender	Inclusion of third gender in voter identity card
		Special cell	Anti-discrimination cell against third gender in colleges
		TG protection	Directive issued by the Rajasthan State Legal Service Authority to safeguard the rights of TGs
		Prioritizing transgender	For extending the benefits of social welfare schemes to all TGs
		Support to TGs	Liberalize and waive off fee in Higher Education Institutions for Transgender.
		Assistance to unemployed youth	Unemployed graduated youth (including TG) are provided with financial assistance from INR 3000/month to INR 3500/month
Central Zone
Uttar Pradesh (0.03)	Health	Blood and blood product component	Free blood and blood products (whole blood, fresh frozen plasma, packed red blood cells, cryoprecipitates, random donor blood concentrate) to PLWH.
		Treatment	Free baseline test, laboratory investigations for diagnosis and management of severe clinical conditions for PLWH Treatment without discrimination against PLWH
		Travel concession	Once a month 50% railway concession for PLWH to attend ART
	Finance	UP Vidhwa Pension Yojana	Financial assistance of INR 500/month to PLWH who are widows.
		Vivah Hetu Anudaan Yojana	Financial assistance of INR 20,000 at the age of marriage after 18 years and medical assistance of INR 10,000 to those who fall under BPL
	Children	Education	Provision of free education under the RTE Act to children infected and affected with HIV.
	Nutrition	ICDS	Double ration to children affected and infected with HIV/AIDS
		Antodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
	Insurance and social assistance	Aam Aadmi Bima Yojana	Premium of Rs. 200/year/member for a cover of INR 30,000 out of which 50% is subsidized from the social security fund.
	Employment aid	MNREGA	Priority in MNREGA job card to PLWH
	Law	Legal Aid	Provision of legal aid at free of cost by district bar association in Etawah, Mau, Deoria for PLWH if they come for their rights
Madhya Pradesh (0.04)	Health	Treatment	Free laboratory/diagnostic radiological investigation required for diagnosis and management of several clinical conditions and free ART to all PLWH.
		Support to pregnant women	Mobility support of INR 300/visit to pregnant women with HIV throughout pregnancy and up to 2 months after delivery
	Finance	IGNOAPS	Central contribution of Rs. 200/- per month per person after 60 years up to 79 years and Rs. 500/- per month per beneficiary from 80 years onward with additional Rs 300/- from state government
		IGNDPS	Disabled individuals having 80% or above disability, aging 18 years above will get Rs 300/month up to 80 years and Rs 500/month for above 80 years.
		IGNWPS	Monthly pension of Rs. 200 to widows in the age group of 40-59 years
		SSSPY	Rs 600/month to all old age, abandoned, and disabled people
		MSY	Loan amount of Rs 50,000/- to 10,00,000/- for self-employment of unemployed youth
		MYUY	Loan amount of Rs 10,00,000/- to 2 crores to set up an enterprise for new entrepreneurs
		MMSY	Cash incentive in two installments depending on the business needs of women
		Atal Pension Yojana	Fixed monthly pension between Rs 1000 to Rs 5000 post retirement for 5 years to those who registered the scheme
		MKVY	INR 51,000/- for marriage of daughters/widowed women/divorced women of needy families
		Ladli Lakshmi Yojana	INR 1,18,000/- in the name of girl child in five installments
		NFBS	INR 20,000/- in the event of death of a bread-winner in a household aged between 18 and 64 years
	Children	SSA	Universalization of school education to all children free of cost
		JSSK	Free drugs and consumables, free diagnostics, free blood wherever required, and free diet for 3 days during normal delivery, and 7 days for C-section to all institutional deliveries
		JSY	Mother’s package of Rs 1000 to 1400/- for institutional deliveries based on the area of delivery
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under the targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
		ICDS	Nutritional support to CABA
	Insurance and social assistance	PMJJBY	Rs 2 lakh cover in case of death of the policyholder with Rs. 330/- as an annual premium.
		Women policy	Inclusion of HIV/AIDS issue in the women policy Provision of benefits of various schemes for women infected and affected by AIDS.
		PMSBY	Insurance cover of Rs 2 lakh for accidental death and Rs 1 lakh for disability with only Rs 12 premium/annum
	Employment	MNREGA	Prioritizing PLWH in MNGRGA and 100 days guaranteed wage employment in a financial year
	Housing	PMAY	Home loan subsidy of 3% on the interest rate on a maximum loan amount of Rs 2 Lakh to PLWH
	Law	Legal Aid	Free and competent legal aid to PLWH
East zone
Bihar (0.07)	Health	Travel support	Once a month INR 100 as travel expense for PLWH to attend ART
	Finance	Pension scheme	Financial assistance of INR 1500/month to PLWH
		Parvarish yojana	Financial assistance of INR 900/- per month to CABA aged 0-6 years and INR 1000/month for children aged 6-18 years.
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
	Employment	MNREGA	Prioritizing PLWH in MNGRGA and 100 days guaranteed wage employment in a financial year
	Law	Legal Aid	Legal aid to PLWH without any charges if they come for their rights
West Bengal (0.04)	Health	Treatment	Free diagnosis, investigation, and medicine to PLWH. No denial of treatment to PLWH by doctor or nursing officer.
		Travel concession	Free road travel pass or 50% concession in railway fare to ART once in a month for all PLWH
	Finance	Manabik pension scheme	Financial assistance of INR 1000/month to PLWH.
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
North-East Zone
Manipur (0.34)	Health	Travel support	Free transportation of PLWH and accompanying person once in a month to ART (by bus three persons/trip, by minibus two persons/trip and by maxi cab one person/trip)
		Treatment	Free investigations and treatment to PLWH
	Children	Resolution of Manipur Baptist Convention	Health care and special exemption to CABA in all the mission schools.
	Nutrition	ICDS	Double ration to CABA
		Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
	Employment	MNREGA job card	Priority in MNREGA job card to PLWH.
	Housing	Indira Awas Yojana	Pucca and sustainable houses to PLWH.
	Law	Legal Aid	Legal aid to PLWH without any charges.
Mizoram (1.18)	Health	Travel support	Free transport for ART once a month by road or 50% concession by train to all PLWH.
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
West Zone
Maharashtra (0.07)	Health	Travel support	50% concession by train for ART once a month to all PLWH
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
		Nutrition support	Nutritional support to CABA
	Housing	GR Sanjay Gandhi Niradhar yojana	INR 600/month to a single beneficiary and INR 900/month if there are two or more beneficiaries in the family
Gujarat (0.05)	Health	Jatan project	Travel reimbursement to PLWH/CABA and their caretaker with INR 100/- for loss of wage
		Medical assistance	Financial assistance of INR 500 to PLWH
	Finance	Tabibi Sahay	Financial assistance of INR 500/month to PLWH.
	Children	Palanhar Yojana	For CABA, INR 500/month up to 5 years. INR 1000/month if the child goes to school and INR 2000/year subsidy for clothing
		Leave provision in schools	Provision of special leave from school for ART and OI treatment
		Scholarship	An annual scholarship of INR 2000 to INR 16000 to CABA
		Special Care Home	Special care home for CABA
		Palak mata pita yojana	INR 3000/month to the foster parents or close relative of orphan CABA.
	Nutrition	Antyodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
South Zone
Andhra Pradesh (0.05)	Health	Travel scheme	Free bus/boat pass or 50% railway concession to all PLWH to attend ART center once in a month
		Treatment	Free ART medications to all PLWH
	Finance	YSR pension kanuka	INR 2250/month for all PLWH
	Nutritional aid	Antodaya Anna Yojana	35 kg of rice under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
	Insurance and social assistance	Destigmatization	Replacement of cause of death from ‘HIV/AIDS’ to ‘Immune-deficiency’ in the death certificate.
Tamil Nadu (0.04)	Health	Travel support	Free bus/train pass to all PLWH to attend ART center twice a month
		Nikshay Poshan Yojana	INR 500 per month of TB treatment and up to Rs 1000 as an advance to TB-positive PLWH
	Financial	OVC project	INR 2000 to INR 10000/year to the single/double orphan CABA between 5 and 18 years
		Widow pension	Rs 400/month to all widows living with HIV
		ART pension	Rs 1000/month to PLWH on ART
		APY	A monthly pension amount starting from 1,000/- up to 5,000/- every month after their retirement at the age of 60
		Loans	Cow loan, vehicle loan (TAHDCO), loan for small businesses (Mudra) for PLWH
	Children	SSA	Universalization of school education to all children at free of cost
		ICDS	Double ration to CABA
		ICPS	Well-being of children in different circumstances, as well as the reduction of vulnerability to situations
		Cradle baby scheme	PLWH could anonymously give their newborn babies to the state. The state would take care of the babies.
	Nutrition	Antodaya Anna Yojana	35 kg of food grains under targeted PDS to PLWH in subsidized price. (INR 2/kg for wheat and INR 3/kg for rice)
	Insurance and social assistance	Transgender Welfare Board	For non-discrimination against third gender, TG card, TG pension, TG loan, and TG grant.
		PMJAY	Health insurance coverage of Rs 5 lakhs per PLWH family per year
		PMSBY	Insurance cover of Rs 2 lakhs for accidental death and Rs 1 lakh for disability with only Rs 12 premium/annum
		Thalikku Thangam	Four grams of gold and cash of up to Rs 50,000 to degree or diploma completed financially backward HIV women for marriage
		AABY	Disability, accidental death, and natural death cover provided for PLWH
		RSBY	Health insurance for the enrolled BPL families including families having PLWH
		Others	Zero balance bank account, post office account, Aadhaar card, ration card, voter Id, passport, PAN card, and issue of certificates like income, death, widow, destitute, caste, residence, marriage , etc., to PLWH
	Employment	CDF	Subsidy for a maximum of Rs. 20,000/- per individual for starting any income-generating activity
		MNREGA	Prioritizing PLWH in MNGRGA and 100 days guaranteed wage employment in a financial year
		SJSRY	Revolving fund support to self-help groups and their federations
		Others	Job skill training, government employment scheme, government website for private jobs, etc.
	Housing	CMSPGHS	Rural housing benefit to PLWH with an area of 300 square feet at a unit cost of Rs. 2.10 lakh
	Law	Legal aid	Free legal aid to PLWH
Telangana (0.08)	Health	Treatment	Free ART medications to all PLWH
		Ayurdavan	Voice message alerts to PLWH if they miss due date to collect ART
	Financial	Asara pension	Monthly pension of INR 2016 for all PLWH.

I: Inclusive scheme; E: Exclusive scheme. Expansion of abbreviations (In alphabetical order): AABY- Aam Aadmi Bima Yojana, ART- Anti-retroviral therapy, BPL - Below Poverty Line, CABA- Children affected by HIV/AIDS, CDF - Collector’s Discretionary Fund, CMSPGHS- Chief Minister’s Solar Powered Green House Scheme, FSW- Female sex workers, ICDS- Integrated Child- Development Scheme, ICPS- Integrated Child Protection Scheme, IGNDPS - Indira Gandhi National Disability Pension Scheme, IGNOAPS- Indira Gandhi National Old Age- Pension Scheme, IGNWPS- Indira Gandhi National Vidhwa Pension Scheme, MITWA- Mobile Integrated Testing & Wellness Access, MMSY - Mukyamantri Mahila- Swasaktikaran Yojana, MSY - Mukyamantri Swarojgar Yojana, MYUY - Mukyamantri Yuva Udyami Yojana, MNREGAMahatma Gandhi National Rural Employment- Guarantee Act, NFBS - National family benefit scheme, OI - Opportunistic Infections, PDS- Public Distribution System, PLWH- People Living with HIV, PMGAY - Pradan Mantri Awas Yojana, PMJAY- Pradhan Mantri Jan Arogya Yojana, PMJJBY - Pradhan Mantri Jeevan Jyoti Bima Yojana, PMSBY - Pradan Mantri Suraksha Bima Yojana, RSBTC- Rajasthan State Blood Transfusion Council, RSBY - Rashtriya Swasthya Bhima Yojana, RTE- Right to education, SSA - Sarva Siksha Abhiyan, SSSPY - Samagra Samajik Suraksha Pension Yojana, TG- Trans gender

We found a wide variation in the distribution of the schemes when compared with the state-specific total burden of the PLWH. Mizoram though has a high burden (2.32 lakh PLWH) of PLWH—only two schemes were available [Table 1]. On the contrary, having half the burden of the PLWH, Manipur has eight schemes available for the PLWH. Madhya Pradesh and Tamil Nadu have the highest number of schemes available, despite having a low burden when compared with the other states included in the analysis. A similar status was noticed for states like Uttar Pradesh and Rajasthan. We selectively analyzed the distribution of the major four scheme areas, viz. finance, nutrition, insurance and social assistance, and employment [Figure 2].

Figure 2

Distribution of benefits under the various social schemes for PLWH by states, India, 2019. Footnotes for Figure 2: Financial benefits are categorized into a big circle (>2000 INR), medium circle (1001–2000 INR), and small circle (≤1000 INR). For benefits under other schemes, the square box indicates the presence of benefit under a scheme. The colors are indicative of different benefits

The financial schemes vary widely between the states. While direct financial schemes are available for many groups in Tamil Nadu and Madhya Pradesh, it is not the same for the other states. Notably, we could not identify any financial support schemes for any PLWH group in Manipur, Mizoram, and Maharashtra. Foodgrains are provided at subsidized rates to the PLWH in all states, except in Delhi and Telangana [Figure 2, Appendix 1]. Areas like insurance, women empowerment, destigmatization, and vocational training for livelihood generation are scanty for the PLWH.

Qualitative analysis of the entitlements of the schemes shows that the schemes commonly address the social safety of the children affected by HIV, nutritional supplementation, direct financial assistance or subsidized services, and employment generation [Figure 3]. A handful of schemes addresses the need of the women including the widow, education for children, and pension for the elderly PLWH.

Figure 3

Qualitative analysis of the major provisions in the social security schemes for the PLWH in India, 2019.

Discussion

In the present review, we have summarized the various social schemes available for the PLWH in the Indian context. We have shown that India has a unique approach to addressing the social issues faced by the PLWH through various schemes run by the government. We have summarized the type of schemes, beneficiaries, and their entitlements in various states with a high HIV burden. Our finding also indicates the variation in the distribution of the social schemes in terms of the states and the type of schemes.

The main purpose of the social protection for the PLWH is poverty alleviation, care, and support.[22] Besides, the social support helps the PLWH to adhere to antiretroviral therapy (ART) in the long run.[2324] Evidence suggests that social schemes in the form of conditional cash transfer, financial incentives, transportation assistance, food assistance, entrepreneurial training also help in the retention of the PLWH in care and reduce the overall mortality.[24] Fortunately, our analysis indicates that all the states in the country provide direct benefits for health. However, for the other types of schemes, we noticed a wide disparity among the states. While states like Tamil Nadu, Madhya Pradesh, Uttar Pradesh, and Manipur have schemes under most of the categories, the same is not true for the other states. For example, Mizoram provides only two types of schemes and Telangana only three types of schemes for the PLWH.

Employment- and housing-related schemes are considerably low in number throughout these states. Homelessness not only increases the chance of the spread of HIV from the infected person to the at-risk homeless individuals,[23] but also increases the chance of other risk behaviors like substance use, and poor adherence to the ARTs.[2526] Employment schemes can improve adherence to ART and empower the affected person and the family to combat poverty, vulnerability, and food insecurity.[12] If coupled with direct financial assistance schemes, the benefits can further improve. Financial assistance is directly associated with a better treatment outcome.[2728] Moreover, cash transfer helps in the education of the children, health, and nutrition.[6] Unfortunately, our analysis identified that there are two states where neither direct finance nor employment benefits are available for the PLWH.

Our finding indicates that only 6 out of 13 states have a total of 15 schemes for children with HIV or children whose parents are infected with HIV. Moreover, Gujarat itself has five schemes for these children. The same interstate disparity was noticed for fiancé- and insurance-related schemes. While high-burden states like Manipur and Mizoram do not have insurance schemes for PLWH, Rajasthan has six insurance schemes despite having a low burden compared to the two northeast states. Madhya Pradesh alone contributes more than 40% of the financial schemes despite having a low PLWH compared to the other states. Fortunately, except for two states, the other states have at least one or two nutritional schemes to support the PLWH. High-quality evidence suggests that food assistance for PLWH has multiple implications including retention in care, improvement in adherence to ART, reduction in morbidity, and opportunistic infection and reduction of the overall mortality.[24] Finally, PLWH needs to understand the rights and opportunities they have.[29] Human rights interventions often enable positive PLWH-related outcomes.[30] We found that a majority of the states do not have a direct provision for legal support to the PLWH. The absence of such assistance may aggravate poverty and poor HIV-related outcomes.

We have identified the social protection schemes for the PLWH by a manual search of the NACO official website and SACS site. There is a potential chance that we have missed out on a few of the schemes available for the PLWH. To reduce this information bias, two authors independently looked for the schemes and a third author has compiled the schemes to reduce the under-reporting. Also, we could not analyze in detail the quantity and quality of the schemes. However, we have provided an exhaustive benefit of each program, state-wise.

Conclusion and Recommendations

Our review has summarized the various social protection schemes for PLWH available in the high-burdened states in India. The number and variation in the schemes indicate that the country has an enormous scope to safeguard the marginalized PLWH group. However, the schemes vary considerably across the states in terms of the type of services and the number of services. We trust that such a document will help the stakeholders as well as the PLWH to understand the state-specific need of the PLWH and revise the entitlements of the PLWH. Also, we strongly recommend multicentric studies to identify the need of this vulnerable group to develop an evidence-based policy decision on the availability of social schemes for this group. Finally, the primary care physicians involved in HIV care should be aware of the various schemes available for the PLWH. Thus, primary care physicians can integrate medical care with social care to get a better HIV care outcome.

Key messages

India provides many social security schemes for people living with HIV (PLWH).

The number and types of schemes vary considerably between the states.

High-grade evidence is required to understand the utilization of these schemes and the further needs of this vulnerable group.

Ethics committee clearance

We have obtained the institutional ethics committee clearance for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.