GUWAHATI: Assam’s battle against HIV is entering a disturbing new phase, with injecting drug use emerging as an increasingly important driver of new infections even as the state continues its aggressive crackdown on narcotics. Data from the National AIDS Control Organisation (NACO), under the Union Ministry of Health and Family Welfare, show a sharp rise in the state’s HIV burden and a changing pattern of transmission.
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According to NACO’s India HIV Estimation 2025: Technical Report, Assam had an estimated 33,148 people living with HIV (PLHIV), with an adult HIV prevalence of 0.13 per cent. The latest estimate places Assam among the states with a substantial HIV burden despite its prevalence remaining below the national average.
The worrying part is not simply the number of people living with HIV, but the changing character of the epidemic. Injecting drug use, which accounted for a relatively small proportion of new detections in the earlier period cited in the state data, has become increasingly prominent in the recent pattern of infection. The figures cited in the state-level data indicate that the share of new detections associated with injecting drug use rose from around 8.5 per cent in 2020-21 to roughly 60-65 per cent during 2023-25.
That represents a fundamental shift in the public-health challenge facing Assam. Heterosexual contact continues to be the most commonly reported mode of HIV transmission overall, but the increasing contribution of injecting drug use means that Assam is confronting a transmission network that can spread infection rapidly through shared needles and syringes.
The development is particularly significant because Assam is the geographical gateway to much of the Northeast. Guwahati is a major transport and commercial hub, while the state is connected by road and rail to several states and international borders. Population movement, drug trafficking routes and the availability of injectable narcotics have created conditions in which a health crisis can move far beyond the people who initially inject drugs.
The largest concentrations of HIV cases are being reported from urban and transit centres, including Kamrup Metropolitan, which covers Guwahati, as well as Cachar, Nagaon and Dibrugarh.
These areas combine large populations, significant mobility and extensive transport networks, making them particularly important for HIV surveillance and prevention.
The numbers also raise questions about the trajectory of the epidemic. Assam’s adult HIV prevalence remains around 0.13 per cent, below the national estimate of 0.20 per cent, but the absolute number of people living with HIV has risen substantially. NACO’s latest estimates place the state’s total PLHIV figure at 33,148, including an estimated 32,533 adults and 615 children.
In other words, Assam’s problem is not necessarily that it has the highest prevalence in India. It is that a relatively low overall prevalence is coexisting with a rapidly expanding absolute caseload and a changing pattern of transmission.
The state has also recorded progress in identifying people living with HIV. The proportion of people who know their HIV status — the first “95” under the global 95-95-95 treatment targets — has increased substantially in recent years. The figures cited in the state data show awareness rising from around 52 per cent in 2022-23 to about 91 per cent in 2025-26.
That improvement matters because people who know their status are more likely to enter treatment and care. NACO states that antiretroviral therapy can suppress HIV replication, restore immune function and reduce the progression of HIV-related disease. ART is available free of cost through the public health system.
But knowing one’s status is only one part of the battle. The bigger challenge is preventing new infections, particularly among populations exposed to injecting drug use.
Assam is not alone in facing that challenge. The problem is particularly stark in Arunachal Pradesh, where injecting drug use has reportedly accounted for a very large share of new HIV detections. The state had only a relatively small HIV caseload earlier in the decade, but the estimated number of people living with HIV has risen to around 2,630.
Adult HIV prevalence in Arunachal Pradesh has also increased substantially from its 2010 level. Papum Pare and the Itanagar Capital Region, along with Namsai, have emerged as important concentrations of cases.
The contrasting patterns across the Northeast demonstrate why the region cannot be treated as a single HIV epidemic.
Nagaland and Manipur, for example, experienced significant HIV transmission through injecting drug use during earlier phases of the epidemic. The pattern has since changed, with heterosexual transmission accounting for a greater proportion of new infections.
Nagaland continues to have one of the highest adult HIV prevalence rates in India, at around 1.37 per cent. The state has an estimated 23,731 people living with HIV. Yet there has also been progress, with new HIV infections and AIDS-related deaths substantially lower than their 2010 levels.
Manipur, meanwhile, has an estimated 23,463 people living with HIV and an adult prevalence of around 0.81-0.87 per cent. New infections have fallen significantly since 2010, while AIDS-related deaths have also declined.
The difference between these states and Assam is important. The Northeast does not have one uniform HIV pattern. Some states are dealing with the continuing consequences of epidemics driven heavily by injecting drug use, while others are seeing a greater share of new infections through heterosexual transmission.
Mizoram remains the most heavily affected state in terms of adult HIV prevalence. Its prevalence is estimated at around 2.73 per cent, considerably higher than Assam’s 0.13 per cent. Yet even Mizoram has recorded declines in new infections.
Tripura presents another warning. Adult HIV prevalence has risen from around 0.05 per cent in 2010 to approximately 0.37 per cent in 2023. Between April 2007 and May 2024, 828 HIV-positive students were registered at ART centres in the state, with 47 reported deaths.
Sikkim remains at the other end of the spectrum, with an estimated 533 people living with HIV and an adult prevalence of approximately 0.11 per cent.
The regional figures underline a larger reality: the Northeast’s HIV epidemic is changing rather than disappearing.
Dr S.I. Ahmed, Chairman and Medical Director of the AIDS Prevention Society, said Mizoram, Nagaland and Manipur continue to have among the highest adult HIV prevalence rates in the country, alongside states such as Andhra Pradesh, Telangana and Karnataka.
He also pointed to the rise in infections in states such as Tripura and Meghalaya.
“Factors such as socio-economic disparities, drug abuse, high-risk behaviours, and limited healthcare access have contributed to the rapid spread of HIV/AIDS in the region. Despite efforts from governmental and non-governmental organisations, several barriers persist in combating the epidemic,” Dr Ahmed said.
Birendra Kumar Barman, Member of the Pharmacy Council of India and president of the Advance Pharmacy Practitioners of Assam, said drug use had become a central concern in the region’s HIV response.
“The root of the rise of HIV/AIDS cases in the Northeast is drugs. Now, drug use has spread among teenagers and young people across all sections of society, from the elite to the working class.
The use of single syringe has also gone up among them. The situation is beyond the control of the parents. At the present situation, drugs have become more popular among the young people than liquor,” Barman said.
He said drug use had also spread among sections of the labour force and alleged that supply networks targeting young people and workers had expanded into what he described as a “big racket”.
“At a time when the younger generations of other countries are busy working with AI technology, our younger generations have to battle with HIV/AIDS. Who can protect them,” Barman said.
His comments point towards the difficult intersection between drug enforcement and public health.
Assam has launched one of the country’s more visible anti-narcotics campaigns in recent years. The state government has repeatedly highlighted the seizure of large quantities of narcotics and the arrest of thousands of people under the Narcotic Drugs and Psychotropic Substances Act.
Official figures show that drugs worth more than Rs 3,200 crore have been seized in Assam since 2021, while tens of thousands of people have been arrested in connection with drug-related cases.
The scale of the seizures is enormous. In 2025 alone, authorities reported recovering heroin, ganja, psychotropic tablets, cough syrup, opium and morphine in substantial quantities. The figures provide a clear indication that Assam remains an important market and transit corridor for narcotics.
Yet there is a glaring contradiction at the heart of the crisis.
The government is seizing more drugs than ever before, making thousands of arrests and registering thousands of cases. At the same time, drug-linked HIV transmission is becoming increasingly prominent.
The two sets of numbers do not necessarily prove that the anti-drug campaign has failed. Drug seizures and arrests indicate that enforcement agencies are intercepting narcotics and pursuing suspected traffickers. But they also demonstrate the scale of the problem that remains.
A drug seizure removes one consignment. An arrest removes one alleged participant from a network. Neither necessarily addresses the person who is already dependent on drugs, the syringe being shared, the untreated addiction behind the behaviour or the HIV infection that may already have entered a community.
That distinction is crucial.
NACO’s HIV prevention programme recognises injecting drug users as a key population requiring targeted interventions. Such interventions include needle-and-syringe programmes, opioid substitution therapy, HIV testing and counselling, and linkages to antiretroviral treatment. NACO’s own programme data show that these services are an established component of India’s HIV response.
The challenge, therefore, is not simply to stop drugs from entering Assam. It is also to ensure that people who are already injecting drugs can be reached before HIV spreads further through their networks.
This is where the traditional enforcement approach meets its limits.
Police action can disrupt trafficking. It cannot, by itself, treat addiction.
Seizures can remove narcotics from circulation. They cannot diagnose HIV.
Arrests can dismantle portions of a supply chain. They cannot ensure that an HIV-positive person starts or remains on ART.
That is why Assam’s HIV response has to operate alongside, rather than behind, its anti-drug campaign.
NACO itself describes HIV as more than a health issue, noting that its occurrence is influenced by socioeconomic factors and requires a multisectoral response involving government departments, civil society and other institutions.
The scale of the Northeast’s HIV burden makes the challenge even more urgent.
The number of people living with HIV across the eight northeastern states has risen substantially, although the situation varies sharply between states. Mizoram continues to carry the region’s highest prevalence, while Assam has the largest estimated absolute caseload among the eight states according to the figures cited in the latest estimates.
The human cost is equally significant.
Between 2020 and 2024, HIV-related causes claimed thousands of lives across the Northeast. Manipur recorded the highest number of deaths, followed by Assam.
Behind every number is a person who has to live with a lifelong infection, and often with the stigma attached to it.
That stigma remains a major obstacle. People living with HIV can face discrimination at workplaces, in families and in communities. NACO itself recognises that HIV can compound problems such as job insecurity, poor healthcare access, nutritional vulnerability, social exclusion and economic hardship.
For Assam, the challenge is therefore much larger than increasing the number of tests or ART centres.
It is about reaching the people who are most vulnerable before they become infected.
It is about making needle-and-syringe services accessible to people who inject drugs.
It is about expanding rehabilitation and addiction-treatment services.
It is about ensuring that young people have access to accurate information before experimentation turns into dependence.
It is about ensuring that those who test positive are immediately linked to treatment and remain there.
And it is about recognising that a person who uses drugs is not simply an offender in an enforcement file but also a potential patient in a public-health system.
The latest figures should therefore force a rethink of how Assam measures its success in the war against drugs.
The value of narcotics seized is an important enforcement indicator. The number of arrests is another. The number of cases registered is another.
But none of these numbers tells the complete story.
The more important public-health indicators are whether fewer people are beginning to inject drugs, whether needle sharing is declining, whether HIV infections among people who inject drugs are falling, whether infected people are being diagnosed early and whether those on ART are achieving viral suppression.
Assam has demonstrated that it can wage an aggressive campaign against the drug trade. The growing HIV burden now demands that the state demonstrate an equally determined campaign against the health consequences of drug use.
The warning is already visible in the data.
Assam’s estimated PLHIV count has climbed to more than 33,000, while injecting drug use is becoming increasingly prominent among new HIV detections. The state is simultaneously confronting a massive narcotics problem, with drugs worth thousands of crores seized and tens of thousands of people arrested.
These are not separate stories anymore.
They are two sides of the same crisis.
The drug war is being fought on the streets, at checkpoints, in police stations and in courtrooms. The HIV battle is being fought in hospitals, ART centres, rehabilitation facilities and among communities that often remain invisible.
Unless those two battles are fought together, Assam risks winning the statistics of drug seizures while losing the far more important battle of preventing new HIV infections.
The needle, in that sense, has become more than a symbol of drug dependence. It is now a warning about the next public-health crisis Assam cannot afford to ignore.