The number of female sex workers per 1,000 adult women in Karnataka stood at 8.34, placing it among the top five states on this metric.
Published Jun 07, 2025 | 7:00 AM ⚊ Updated Jun 07, 2025 | 7:00 AM
Synopsis: South India hosts a disproportionately large share of India’s key populations at risk of HIV, with Karnataka leading the nation in female sex workers, men who have sex with men, and hijra/transgender individuals, according to a new study. The findings highlight the necessity of sustained, focused public health efforts in the region.
Despite covering only a fraction of India’s landmass, the southern states account for a disproportionately large share of the country’s key populations at risk of HIV – namely, female sex workers (FSWs), men who have sex with men (MSM), hijra/transgender (H/TG) persons, and people who inject drugs (PWIDs).
This is according to a joint study conducted by the National AIDS Control Organization (NACO), the World Health Organization (WHO), the Indian Council of Medical Research (ICMR), and various other agencies.
The study, titled Programmatic Mapping and Population Size Estimation of Key Population in India: Method and Findings, highlights concentrated pockets of high-risk populations across Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana – placing South India at the centre of the country’s HIV response efforts.
Karnataka has emerged as the state with the highest number of FSWs in India, estimated at over 1.53 lakh. This figure accounts for more than 15 percent of the country’s total FSW population.
The state also topped national figures for MSM, with 45,630 individuals.
According to the study’s findings, Karnataka contributed 15.4 percent to both the national FSW and MSM populations.
The number of FSWs per 1,000 adult women in Karnataka stood at 8.34, placing it among the top five states on this metric. Arunachal Pradesh recorded the highest rate at 17.24 FSWs per 1,000 adult women, followed by Delhi at 15.46.
Additionally, Karnataka reported 10,926 H/TG individuals – the highest in the country – making it a vital region for gender-diverse health interventions. The state accounted for 11.35 percent of India’s total H/TG population, as per the study.
The research mapped approximately 20 percent of the country’s total FSW hotspots in Karnataka, the highest for any state. For MSM populations, Karnataka had around 15.6 percent of the total hotspots mapped nationally, again leading across states.
While Telangana ranks fifth in overall FSW population size – with 75,380 individuals accounting for 7.6 percent of the national total – it holds a unique and concerning distinction: the highest density of sex workers per hotspot in the country, with an average of 38 FSWs operating at each site.
This suggests a high level of congregation, which, if not addressed with targeted outreach and healthcare services, could heighten the risk of HIV transmission. Andhra Pradesh follows with 29 FSWs per hotspot, while Delhi, Meghalaya, and West Bengal each recorded 26 FSWs per hotspot.
The state’s high concentration patterns are not limited to FSWs. Telangana recorded approximately 50 MSM per hotspot – the highest nationally – followed by Delhi with 29 MSM per site. For H/TG populations as well, Telangana topped the chart with around 25 individuals per hotspot, followed closely by Delhi with 24.
Telangana also reported over 16,427 MSM and nearly 4,000 H/TG individuals, reflecting significant sub-populations that require tailored interventions, especially in urban areas such as Hyderabad.
The study mapped 568 network operators for FSWs in the state, indicating a substantial and organised network system.
Tamil Nadu stands out with an estimated 38,283 MSM, placing it among the top three states nationally and contributing 10.9 percent to the country’s total MSM population. The state accounted for approximately 9.1 percent of MSM hotspots mapped in the PMPSE study, making it the second-highest after Karnataka.
Kerala, despite its smaller geographic size, reported over 13,836 MSM, reinforcing the South’s significant representation in this category. These numbers reaffirm that sexual minorities in the region are both visible and vulnerable, underscoring the need for stigma-free healthcare services and robust legal protections.
Tamil Nadu also reported 60,725 FSWs, while Kerala recorded around 16,623 – indicating a consistent presence of solicitation hotspots, though with lower density than states like Telangana.
Tamil Nadu contributed approximately 6 percent of the total FSW hotspots nationally, and the study identified 372 network operators in the state.
In terms of H/TG populations, Tamil Nadu accounted for 9.57 percent of the national total, making it the fifth-largest contributor in this demographic.
Delhi, however, reported the highest concentration, with 2.75 H/TG individuals per 1,000 adult men, and contributed 18.61 percent of the national total. The study identified 59 network operators for H/TG individuals in Tamil Nadu.
With an estimated 1.19 lakh FSWs, 22,059 MSM, and 5,363 H/TG individuals, Andhra Pradesh remains firmly on India’s HIV map. The state accounts for 12 percent of the country’s total FSW population and 6.3 percent of the MSM population, according to the findings of the PMPSE study.
Despite a legacy of strong HIV prevention programmes, the latest data indicate that Andhra Pradesh continues to be a frontline region, requiring sustained surveillance and public health support.
The state accounted for around 8 percent of the total FSW hotspots mapped nationally, making it the second-highest after Karnataka.
Notably, Andhra Pradesh also recorded one of the highest average numbers of FSWs per network operator and reported 29 FSWs per hotspot – the second-highest density in the country, after Telangana. The study mapped 148 network operators for FSWs in the state.
For the H/TG population, Andhra Pradesh recorded an average of 20 individuals per hotspot – tied with Maharashtra for the second-highest concentration nationally.
The landscape of PWIDs presents a markedly different regional pattern compared to other key populations, with northern and north-eastern states carrying the heaviest burden.
Punjab leads with 15.6 percent of India’s total PWID population, followed by Uttar Pradesh at 12.3 percent, Delhi at 11.3 percent, Assam at 9.1 percent, and Manipur at 8.7 percent.
Concentration rates reveal an even more alarming trend. Mizoram recorded the highest rate at 31.29 PWIDs per 1,000 adult men, followed by Manipur at 28.68 and Nagaland at 27.32.
These figures in the north-eastern states are significantly higher than the national average and far exceed those seen in southern India.
In contrast, South Indian states reported comparatively lower PWID numbers. Karnataka recorded 4,330 individuals, Kerala had 3,276, and Tamil Nadu registered just 891 in this category. Nevertheless, their presence remains notable in urban slums and industrial belts, where access to harm-reduction services remains inconsistent.
Delhi reported the highest density of PWIDs per hotspot at 25, followed by Chandigarh with 23 and Assam with 22 – underscoring the urban concentration of injection drug use.
The study estimated a total of 9,95,499 FSWs, 3,51,020 MSM, 2,88,717 PWIDs, and 96,193 H/TG individuals across India. The southern states’ dominance in three of these four categories underscores the region’s pivotal role in the country’s HIV prevention strategy.
Karnataka, Andhra Pradesh, and Telangana together contributed approximately 35 percent of India’s total FSW population. Meanwhile, Karnataka, Tamil Nadu, and Andhra Pradesh accounted for about 32.6 percent of the national MSM population.
In the H/TG category, Karnataka and Tamil Nadu ranked among the top five states nationally.
The study also found that around 14 percent of FSWs, 7 percent of MSM, and 8 percent of H/TG individuals were estimated to operate exclusively through network operators, highlighting the growing role of organised networks in sex work, particularly in the South.
Among FSWs, nearly two-thirds of all network operators were concentrated in just three states: Delhi (27 percent), Karnataka (25 percent), and Maharashtra (12 percent). This distribution suggests the presence of well-structured, coordinated systems in these regions.
For MSM populations, Maharashtra led with 383 network operators, followed by Karnataka with 198, indicating significant organisational presence facilitating connections and support systems in these states.
The north-eastern states’ prominence in PWID populations is also reflected in their network operations: Punjab had 162 network operators, Jammu & Kashmir 133, and Assam 105.
While southern states dominate in absolute numbers, several northern and western regions reveal concerning concentration rates. Delhi, which ranks fourth in total FSW numbers with 8.9 percent of the national population, reported the second-highest rate at 15.46 FSWs per 1,000 adult women. The national capital also accounted for 27 percent of all network operators for FSWs – an indicator of its complex and sizeable sex work infrastructure.
Goa, despite its smaller population, recorded a high rate of 11.67 FSWs per 1,000 adult women, while Chandigarh showed 10.10 per 1,000 – pointing to intensified vulnerabilities in smaller urban centres and union territories.
Maharashtra, contributing 9.6 percent to India’s total FSW population, ranked third nationally in absolute terms. It also accounted for 12 percent of all network operators for FSWs, underlining its significance in the national HIV response.
Despite a relatively low overall adult HIV prevalence of 0.20 percent in 2023, the burden among key populations remains significantly higher. The study observed that HIV prevalence among these groups in 2021 ranged from 1.85 percent to 9.03 percent – approximately 9 to 43 times higher than the national adult average.
Specifically, prevalence was recorded at 1.85 percent among FSWs, 3.26 percent among MSM, 3.78 percent among H/TG persons, and 9.03 percent among PWIDs. These figures underline the ongoing vulnerability of key populations and the urgency of targeted, sustained interventions.
The concentration of high-risk groups in South India – especially the high-density patterns observed in Telangana and the large absolute numbers reported in Karnataka – signals a pressing need for focused public health resources in the region. The community-led PMPSE study has provided updated and granular size estimates, offering a critical evidence base for designing and deploying interventions more effectively.
