Drugs and HIV in India’s Northeast: An Uneven Epidemic

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A map of India’s Human Immunodeficiency Virus (HIV) epidemic looks reassuring until the eye drifts to the top-right corner. Nationally, 2023 India HIV Estimates put adult prevalence (15-49 years) at 0.2 percent, with a little over 2.54 million people living with HIV and new infections down by roughly 44 percent since 2010. Acquired Immunodeficiency Syndrome or AIDS related deaths have also seen a decline by roughly 79 percent in the same time frame. This smooth national curve, however, conceals a very different reality in the Northeast. States such as Mizoram, Nagaland, and Manipur sit at the top of the country’s prevalence table, with adult rates of around 2.7, 1.3, and 1.0 percent, respectively, several times the Indian average. Mizoram alone has recorded over 32,000 HIV-positive cases and more than 5,500 deaths over the last three decades.

Geography does much of the explaining. India’s Northeastern states form a narrow corridor abutting Myanmar and the wider Golden Triangle, one of the world’s most notorious regions for opium poppy cultivation and, increasingly, synthetic drug production. The same hillsides that support maize and shifting cultivation also sustain poppy fields; by scoring the poppy’s seed capsule, farmers extract opium latex, which is refined into heroin and moved along long-standing narcotics routes into and through the region. Recent campaigns against drugs in Manipur, Assam, and neighbouring states have led to highly publicised seizures. Customs and enforcement agencies report hundreds of kilogrammes of methamphetamine tablets, heroin, and cannabis intercepted in the Northeast in 2024-25 alone, with Narcotic Drugs and Psychotropic Substances Act (NDPS) cases rising in parallel. For World AIDS Day (December 1), the immediate test for India is whether the energy poured into a war on drugs can be matched by a sustained effort to protect the people who live in the shadow of these economies.

HIV Hits India’s Northeast Harder

HIV is a retrovirus that targets the body’s immune system, slowly impairing its ability to resist common infections. Eventually, if the virus is not diagnosed and treated with antiretroviral therapy (ART), the immune system will be compromised to such an extent that the patients will develop serious, often life-threatening infections and cancers. This advanced stage is known as AIDS, and it is defined not by the presence of the virus alone, but by the damage it has done to the body’s defences. In policy terms, this distinction matters since HIV can now be managed as a chronic condition with timely treatment, while AIDS signals that the health system has failed to diagnose, initiate treatment, or retain individuals in care.

The Northeast is not an isolated anomaly but part of a broader pattern in which drug-affected border and transit states carry a disproportionate HIV burden.

These distinctions look abstract until we map them onto states. Table 1 shows how sharply the Northeast diverges from the national picture. Against an all-India adult HIV prevalence of 0.2 percent, Mizoram stands at 2.73 percent (around 13.6 times the national average), Nagaland at 1.37 percent (nearly seven times), and Manipur at 0.87 percent (more than four times). Meghalaya (0.43 percent) and Tripura (0.37 percent) sit roughly twice the national average, while Arunachal Pradesh (0.25 percent) is modestly higher than that. Only Assam (0.13 percent) and Sikkim (0.11 percent) fall below the national average. Punjab, included here as a non-Northeastern comparator with a long history of injecting drug use, has an adult prevalence of 0.42 percent, similar to Meghalaya and above Tripura. It underlines that the Northeast is not an isolated anomaly but part of a broader pattern in which drug-affected border and transit states carry a disproportionate HIV burden.

Table 1: Where HIV hits hardest: adult prevalence and new infections in select Indian states

Source: HIV Estimates 2023 Factsheet, National AIDS Control Organisation (NACO); Collated by Author

*Adult Prevalence applies to Ages 15-49.

*PLHIV is People Living with HIV.

As Table 2 shows, between 2010 and 2023, India as a whole saw annual new infections fall by about 44 percent and AIDS-related deaths by roughly 79 percent. Manipur, Mizoram, and Nagaland broadly mirror or slightly lag this pattern: deaths fell steeply by about 69-78 percent in all three. Assam and Meghalaya sit in a more mixed middle. At the other end of the spectrum lie Arunachal Pradesh and Tripura, where new infections have risen by roughly 470 and 524 percent, respectively, and deaths by 214 and 300 percent. Some of this surge likely reflects the system seeing more of what already existed, as India’s 2023 HIV estimates lean heavily on routine programme data and expanded testing. In states such as Arunachal Pradesh, Tripura, and Punjab, the model had to be recalibrated because the number of people already on ART exceeded older survey-based estimates, a strong indication that earlier rounds were undercounting infections. At the same time, NACP-V (National AIDS and STD Control Programme Phase V) has pushed community-based screening and targeted testing in high-incidence Northeastern districts, so better reporting and more active case-finding may almost certainly be inflating the percentage jumps.

Table 2: New HIV infections fall in some states and surge in others: changing HIV and AIDS deaths (2010-2023)

Source: HIV Estimates 2023 Factsheet, National AIDS Control Organisation (NACO); Collated by Author

The pattern that emerges is of older epicentres and newer frontiers. In Manipur, Mizoram, and Nagaland, sustained investment in testing and antiretroviral therapy appears to have driven deaths down decisively and pushed new infections onto a downward or gently declining path, even as overall prevalence remains high because large cohorts of PLHIV survive longer. By contrast, states such as Tripura, Arunachal Pradesh, and — outside the region, Punjab — look more like emerging or resurgent hotspots, where HIV has moved faster than the health system’s ability to diagnose and treat, producing simultaneous rises in infections and deaths from a low base. India’s push to end AIDS is being pulled in opposite directions: mature programmes in some high-burden states are clearly working to save lives, while newer clusters of risk in others signal that prevention, harm reduction, and treatment coverage have not yet caught up with changing drug and sexual networks.

India’s push to end AIDS is being pulled in opposite directions: mature programmes in some high-burden states are clearly working to save lives, while newer clusters of risk in others signal that prevention, harm reduction, and treatment coverage have not yet caught up with changing drug and sexual networks.

As recent data underlines, this is no longer a purely “needle” epidemic, even though drugs remain central to the story. In Mizoram, unsafe sexual practices now account for roughly two-thirds of HIV infections, with about 30 percent still linked to intravenous drug use (IDU) and shared needles. Assam reflects the mirror image: new figures from the Assam State AIDS Control Society suggest that injecting drug use has overtaken heterosexual contact as the dominant route, accounting for around 65 percent of new HIV infections in 2023-24.

Figure 1: New HIV infections fall in some states and surge in others: changing HIV and AIDS deaths (2010-2023)

Source: HIV Estimates 2023 Factsheet, National AIDS Control Organisation (NACO); Visualised by Author

If Table 2 captures how new infections and deaths have shifted, Figure 1 shows how those pressures have accumulated over time. While India’s adult HIV prevalence declines, several Northeastern states move in the opposite direction. Mizoram climbs steadily from 1.79 to 2.73 percent. Meghalaya and Tripura show similar upward trajectories from low starting points, roughly tripling or more over the same period, and Arunachal Pradesh rises more than sixfold, from 0.04 to 0.25 percent. Assam, Sikkim, and — outside the region, Punjab — display slower but persistent increases, with Punjab’s prevalence more than doubling to 0.42 percent by 2023. Only Manipur and, in a different way, Nagaland resemble the national curve. Taken together, Figure 1 shows an India where the overall line bends downwards, even as several Northeastern states trace their own rising paths.

Harm Reduction and the Border Challenge

Even as Northeastern states continue to report adult HIV prevalence rates far above the national average, it is clear that enforcement-led approaches alone may be insufficient. Recent crackdowns have yielded massive narcotics seizures, but this has not translated into commensurate declines in HIV infections. A coordinated narcotics-control framework that brings together the home, health, and finance ministries; narcotics agencies; the Ministry of Development of the North Eastern Region; and state governments under a shared health-security agenda will be essential if enforcement gains are to translate into fewer infections. A broader public health strategy is needed. Strengthening harm reduction must be central and include expanding opioid substitution therapy (OST) coverage and integrating HIV services with tuberculosis and hepatitis programmes. Unsafe injecting practices are one of the major drivers of the region’s HIV epidemic; tackling that risk at its source will save lives and contain the virus. In parallel, scaling up community-led outreach and care is crucial. The Northeast’s strong tradition of local community solidarity means that non-governmental organisations, youth groups, churches, and peer networks are well placed to reach hidden high-risk populations. Empowering these groups with funding and training can sustain prevention efforts, reduce stigma, and ensure that those most vulnerable are not left behind.

Unsafe injecting practices are one of the major drivers of the region’s HIV epidemic; tackling that risk at its source will save lives and contain the virus.

A complementary priority should be building sustained health capacity and surveillance in border districts. The region’s frontier areas need robust clinics, mobile health units, and real-time disease monitoring. This investment would enable the early detection of HIV outbreaks and faster responses, especially in areas along drug transit routes. Finally, policymakers should frame border public health as a national security and resilience issue. The drug and HIV twin crises in the Northeast are threats to India’s broader stability. Treating epidemic control in these border states as part of the national security agenda will help marshal greater political will and resources. Such a reframing encourages an integrated approach, one that couples law enforcement with health outreach, thereby strengthening India’s overall health resilience while addressing the Northeast’s HIV challenge head-on.

K.S. Uplabdh Gopal is an Associate Fellow with the Health Initiative at the Observer Research Foundation.

• Healthcare
• India
• adult hiv prevalence in india
• drug menace in north east
• hiv cases in india
• hiv cases in north east india
• hiv positive cases in india
• world aids day 2025

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