Comments on National AIDS POLICY

[Guest guest]

From

Maitreya & Dr Jayasree

maitreya@...; jayasree@...

To

Mr. J.V.R.Prasad Rao

Project Director

National AIDS Control Organization

India

Sub: Comments on National AIDS prevention and Control Policy

Sir,

After going through the initial niceties of the National policy on AIDS, we

come across:

(I)

3. The Objectives and Goals, in it the third paragraph (iii)”To create an

enabling socio-economic environment for prevention of HIV/AIDS, to provide

care and support to people living HIV/AIDS and to ensure

protection/promotion of their human rights including right to access health

care system, right to education, employment and privacy to mobilize support

of a large number of NGOs/CBOs for an enlarged community initiative for

prevention and alleviation of the HIV/AIDS problem”.

And again in the: 4. Strategy II. “To create an enabling socio-economic

environment so that all sections of population can protect themselves from the

infection and families and communities can provide care and support to people

living with HIV/AIDS” And yet again in the:

7.Implementation Strategy we come across 7.5 “As socially marginalized

sections like commercial sexworkers, injecting drug users, street children,

men having sex with men, etc. are not normally accessible through the

traditional Government machinery, involvement of NGOs and CBOs should be

secured to effectively reach these populations through a holistic approach

of targeted intervention programmes.

These programmes should aim at prevention and control of sexually transmitted

diseases, deliver relevant IEC messages which are in the local idiom and are

interactive in nature, promote condom use for effective prevention of the spread

of HIVE/AIDS and create an enabling environment that reduces vulnerability of

these groups.

NGOs and charitable organizations should also be actively involved in

organizing low cost care and support systems and outreach for people living

with HIV/AIDS”.

It is so nice we felt like crying!! With Prevention of Immoral Traffic Act

and Section 377 of IPC in force what these statements mean! We are working

in the field of AIDS, under Kerala AIDS Control Society (KSACS) for the last

five years among sexworkers and all the rest of the above mentioned

communities. We complained against police atrocities and arrests to all

possible and available authorities in India down from the Sub Inspectors of

local police stations to the Chief Justice of India. Nothing happened.

Instead things like this happened:

“On July 7,2001, police in Lucknow, UP raided the offices of two NGOs

(Bharosa Trust and Naz Foundation International) which were working on

HIV/AIDS issues, addressing themselves particularly to vulnerable

communities, including men who have sex with men (MSM) and male sex workers.

Employees of the organizations were arrested and charged with " propagating

and indulging in unnatural sex " under Section 377 of the Indian Penal Code

(IPC), read with Sections 120b (conspiracy) and 109 (abetment) of IPC.

They were also charged under Section 292 of the Indian Penal Code (sale of

obscene books), Section 3 and 4 of the Indecent Representation of Women

(Prohibition) Act, 1986 (prohibition of advertisements or publication

containing indecent representation of women), and Section 60 of the

Copyright Act, 1957 (remedies in the groundless threat of legal proceedings)

The offices of both NGOs were then sealed.

If this happened in Lucknow, Uttar Pradesh, see what happened to another NGO

in Karnataka and Maharashtra:

“It all started with VAMP the prostitutes' collective buying a piece of land

in the border town of Nippani in the Belgaum district of Karnataka state.

Since the collective had finally bought its own space the regular Monday

meetings shifted to Nippani. Women from seven districts of Western

Maharashtra and North Karnataka were to attend these meetings as they have

been doing for the past ten years in Sangli. Unfortunately from the second

meeting the local corporators decided that the women who attended these

meetings were defiling the `pure and sacred' space and they decided to put a

stop to these meetings.

They first threatened to kill the main leaders i.e. Meena Seshu and Shabana

Khazi if the meetings continued. When this did not happen they threatened to

break the vehicles that brought the women to the meetings and when we

refused to bow down to their wishes they pelted stones on the building in

the dead of the night. 25 to 30 boys with swords and thick bamboo sticks

beat up every man who dared to pass through the street and robbed them of

their gold and their money. The police turned a blind eye. On 18/2/2002 they

tried to break down the door to Shabana's rented room and but for her land

lord she would have been seriously injured if not dead by now. All this

because the terms laid down by them were not acceptable to the collective

and SANGRAM the NGO working with the women.”

Well, don’t worry before you read what happened in Hyderabad, Andhra

Pradesh:

“Yesterday, i.e. on the 19thof February 2002 the police in Hyderabad raided

many public cruising areas of Hyderabad city and rounded up MSM from those

areas. In all 25 persons were taken into custody and thereafter made to sit

down on a public road so that they could be " exhibited " . Even as the public

saw all this, the arrested were repeatedly abused by police personnel and

some of them were physically assaulted. My sources reveal that it was

obvious that the intention of the police was to humiliate and violate the

dignity of those taken into custody. Of those taken into custody were five

outreach workers of Mithrudu. The outreach workers at the time of arrest had

identified that they work on HIV/AIDS, but the police ignored this fact.

Mithrudu is an organisation that works on HIV/AIDS intervention with MSM

under NACO policies and is funded by the Andhra Pradesh State AIDS Society

for running the MSM project.”

If you think that is too much, read what happened in Bangalore, Karnataka:

“We have been working with hijras, kothis, and homosexual/bisexual men from

the poor and non-English speaking backgrounds for the last 2 years. Recently

(1 month ago) we have started a drop-in/meeting space every Sunday from 3 p

m to 6 p.m in our office. Our office is in the Flat 13 (3rd Floor) of the

Royal Park' Apartments. There are only two residences (out of 16 flats) in

the 'Royal Park' apartments, which are situated on the first and second

floors. The rest are offices, which remain closed on Sundays. On the 17th of

March 2002 (Sunday) one of the residents, Mr. Ashok Kattimani an ex-MLC sent

for one of Sangama's office staff at 3:00 p.m who was present at the meeting

He stated that since there were families present in the building, we

shouldn't allow hijras (most people including Mr. Kattimani and Police don't

differentiate between kothis and hijras, at times they even call

gay/homosexual/bisexual men 'hijras') to come there. The Sub Inspector from

Commercial Street police station came with 3 plainclothes police men. They

took the details of Sangama's office, copies of registration documents and

aims and objectives of Sangama. The other policemen did a thorough search of the

office while the Inspector was speaking to two of us. The Inspector said

that hijras cannot have a meeting in the residential locality, which

according to him 'humiliated' the people. He advised us not to have the

Sunday meetings any more in the office and to have it in the out-skirts of

the city.

There is a pattern in these attacks as it is all done by the police or with

the aid of the police. There are innumerable incidents in our own state of

Kerala. There are more than 50 projects now under the Kerala State AIDS

Control Society and all of them faces similar problems from the police. The

sexworkers projects just limb through now.

While the Health department asks to train the sexworkers and drug abusers as

peer educators, the Home department arrests them, punish them and fine them. All

these made the projects ineffective and our pleas till now falls on deaf ears.

With all these how can NACO write with impunity about the enabling environment?

We never see NACO’s presence in any of these situations, except a personal

letter from you in the AIDS INDIA e-forum to Meena Seshu of SANGRAM (thanks) We,

NGOs would like to know how you will realize this proclaimed position in future.

(II)

Now in: 5. POLICY INITIATES you are talking in the last part of the first

paragraph “The challenge is to identify appropriate, locally relevant

interventions and experienced community based organizations to work with

poor and marginalized populations who are particularly vulnerable to HIV

infections. HIV/AIDS control programme however well planned and designed at

the central level remains ineffective unless they reach out where people

live, work, study and access health and other welfare services including

information services.”

Too true! But what is the practice of NACO thus far. In the state of Kerala,

the projects were initiated first directly by ODA, now known as DFID. Later

they formed the State Management Agency (SMA), run by Dalal Consultancy to

manage projects.

After two years the funding agency DFID, started funding

through NACO and a set of guidelines (later they became ironlines) were

released by NACO, which actually killed the projects. We were asked to

present projects, always giving upper hand to the ‘lessons learned’ before.

But on the third year NACO’s guideline came and suffocated the projects and

no one wanted any lessons learned. The upper limit of the Budget was fixed

and we were forced to cut all lessons learned and reschedule the whole

projects. From that day onwards we are all part of the government, doing our

‘quotas’.

Now when you talk about lessons learned it is such a mockery of

the whole episode. Now we, NGOs are just semi governments towing the lines

of the supposed to be autonomous AIDS Control Societies, dancing according

to the whims and fancies of the government staffs who have no concern or

knowledge to do anything.

Do you know sir; your guidelines killed all initiatives in the local level and

by saying all these you are adding insultto injury.

(III)

In 5.1 Programme Management 5.1.2 you are mentioning about the AIDS Control

Societies “For smooth flow of funds to the programme and for grater

functional autonomy, the State Governments have already adopted the Society

model by forming State AIDS Control Societies with proper representation

from NGOs, experts in the field and organizations of people living with

HIV/AIDS. The societies are provided with adequate number of technical and

managerial personnel for effective management of the programme.”

In Kerala, this must be the joke of the century. We, NGOs have no knowledge

about who are all in the society, anyway none of us are represented nor any

PLWHAs. Moreover the so called Society acts exactly like any other

government institution; all that happened was the name ‘AIDS Cell’ changed

to AIDS Control Society. None of the staffs or the management changed and we

don’t feel any smooth flow of funds either.

Before, if the delay of funds happened was for three months now it is up to six

months. The director, who will be a secretary to government, will change anytime

and State AIDS Programme Officer (SAPO) is a retiring post for doctors and they

will change to the minimum of three times an year. Most of the times,

cardiologists, orthopaedicians, gynecologists, you name it, rarely a physician

of skin and STDs fill the post.

They will all be armed with moral agendas fed to them by their mothers to tackle

the AIDS scenario. We, the poor NGOs will be scandalous culprits spreading ideas

of ‘free sex’, by promoting condoms.

After the initial battle the SAPO gathers some understanding and gets the

hang the things, but then he/she will be out of the post either retired or

transferred. When you talk of experts sitting with NGOs and PLWHAs, which

country are you talking about?

Please reconstitute the AIDS Control Societies with adequate representation

not only from NGOs and PLWHAs but also representatives from all the target

groups, like sexworkers, MSMs, truck drivers etc. for effective management

of the programmes. And also make sure that those who will be in charge of

the SACs must have training in sexuality and AIDS prevention before they

step into the position. Again they should remain there at least for a period

of minimum five years.

(IV)

In 5.2 advocacy and Social Mobilization 5.2.2 you rightly say that, “There

is still a serious information gap about the causes of spread of the disease

even among a large number of medical and paramedical personnel both within

the Government and outside. This occasionally leads to discrimination of

HIV/AIDS infected persons in hospitals, dispensaries, workplaces and the

community at large.”

But if you go even to the medical college hospital in Thiruvananthapuram,

you will find this discrimination exists. In the top part of the diagnostic

file or paper, they will write in block letters about the HIV status of the

patient, which effectively leads to discrimination at all levels of

treatment inside and outside of the hospital.

If you question about this the medical community will say that it is for

precautionary measures they write this. As anyone can see that by universal

precaution anyone can prevent the HIV virus, it is unnecessary to do this. But

the doctors do this with impunity.

We request the NACO to step into this and prevent this discriminatory practice

by the doctors. NACO should ask organizations like IMA to instruct the doctors

to desist from this practice. Right now the personnel of the KSACS show their

inability to do anything.

(V)

In 5.2.3 “In educational institutions AIDS education should be imparted

through curricular and extracurricular approach. The programme of AIDS

education in schools and the ‘Universities Talk AIDS’ (UTA) programme should

have universal applicability throughout the country in order to mobilize

large sections of the student community to bring in awareness among

themselves and as peer educators to the rest of the community”.

Read this with 4. Strategy (iv)”reinforcing the traditional Indian moral values

among youth and other impressionable groups of population.”

May we ask you “Are you going to teach Ram’s values or his father’s;

Panchali’s or Krishna’s?

We seriously doubt the intention of writing such a sentence in strategy; we

presume that the persons who drafted the policies have to appease the

‘traditional’ party which is in power.

Which tradition are you talking about? There are umpteenth traditions in India.

But we suspect that you are mentioning about the moral traditions of the

colonial powers of the n era. ‘One man one woman’ paradigm is nothing to

do with any of the Indian traditions and if you are going to insist on it, the

idea of ‘safe sex’ will look like a sacrilege.

So how are you going to teach it? Don’t fool yourself. If NACO is going to hide

behind this hypocritical moral skirt, woe to this country. Keeping sexuality and

sexual knowledge under the carpet and talking nonsense about traditions

definitely will kill youth and old alike of this country.

It needs a sexual revolution in this country, in the sense of being responsible

to one’s sexual activities, which alone will prevent AIDS. All this talk of

traditions will create secrecy, insecurity and hypocrisy, which are the root

cause of unsafe sexual practices. So throw away the last strategy, (keep it, if

necessary, to humor the blockheads in power, but never practice it) and teach

‘safe sexual practices’ in the curriculum or otherwise.

(VI)

In 5.3 Participation of NGOs/CBOs in 5.3.2 ii. “Extending their

participation to new areas like provision of medical facilities including

home-based care, opening of community care centres, etc. apart from the

conventional areas of awareness, counseling and targeted interventions among

risk groups.”

We are working under the KSACS for the last five years, in a targeted

intervention project. This intervention forced us to expand into related

fields as a natural corollary. When you do an awareness campaign, you will

come across people with high risk behavior. So naturally you will have to do

intervention activities if you are serious about your words. Then care and

support comes in toe to the previous ones. Right now we are doing awareness

programmes, condom distribution, VCTC counseling and community training.

We have identified more than 30 HIV positive people who need immediate

attention and care. So this decision to expand into other areas will do well

to the projects. But is there a tacit understanding that one organization

should have only one project? We felt that way last year when we talked with

the authorities in the KSACS. But we hope this decision would change it and

help the NGOs to address all the related problems.

(VII)

In 5.5 Use of Condoms as a HIV/AIDS Prevention Measure in 5.5.2 “The

Government has adopted a conscious policy of use of condoms through the

social marketing and community-based distribution system. The social

marketing strategy has helped in increasing the use of condoms in the

country at large.”

In this section there is no mention of introducing the female condoms, which

is a must in our understanding after all these years. The gender power

relations keep the women, whether they are sexworkers or housewives at

greater risk. When we teach women about the problem of HIV, all they

experience is fear and powerlessness.

The women, except the street based sexworkers, generally has no negotiating

power in sexual activities and asking your intimate partner to use ‘safe

methods’ is neither ‘womanly’ nor ‘trustworthy’. This keeps them silent even

when they know they are at risk.

In this context, except empowering them to negotiate, which is a long time

strategy, giving female condoms is the only way out (it could also be

empowering in a different sense). We should immediately, take steps to

popularize the use of these condoms. Even if the cost of production is high

it won’t be more costly than treating an HIV+ person. We are not elaborating

on these as we have talked on this many times before.

We have another suggestion about the Government brand, “Nirodh”. When you

are talking about social marketing now, the use of condoms in the previous

family planning strategy was to distribute free of cost through the PHCs.

This has made it to fallen into disrepute. The condoms, as we all know, are

made with the same quality control but the wrappers and looks give a cheap

look. This has created an impression of substandardness to Nirodh. Right now

people are reluctant to use it. We can do one thing; we can stop naming

these condoms as Nirodh, but name it differently and then do social

marketing. Or we can take it and put them into colourful wrappers and market

it in the context of preventing AIDS, an AIDS prevention special. This is

will help immensely the projects as there is no provision for condom

purchasing in the projects and as they are now forced to get condoms from

the PHCs to be distributed among high risk communities.

(VIII)

In 5.7 Counseling “All hospitals, HIV testing centres, blood banks, STDs

Clinics and organizations formed by PLWHAs should have counseling services

manned by trained and professional counselors.”

The counseling with high risk group and HIV+ people needs special skill,

which is never imparted to the counselors in these projects or in VCT

centres. ‘Safe sex = Abstinence or Condom use’ is the usual knowledge. This

won’t work with high risk group or positive people. We should train these

counselors in other safe sex practices with deep knowledge in sexuality.

The silence on different sexual practices won’t help and we should stand on the

pleasure principle and then safety rather than on procreation and safety.

There is a gulf between procreational sex and recreational sex both in

attitude and approach.

High risk must mean unsafe sex and not sex for pleasure. Only when you

understand this difference the approach to sexual practices also differ. Keeping

this in mind the counselors should be taught to impart knowledge in safe sex

practices other than just condom use, so that the people can lead a healthy

sexual life without guilt.

(IX)

In 5.8 Care and Support for People Living with HIV/AIDS (PLWHAs) in 5.8.8.

“Although, HIV/AIDS still defies a cure, infection can no longer be equated

with imminent death. Advances in management of opportunistic infections, and

the development of effective anti-retroviral therapies mean that the illness

associated with HIV infection can be treated.

People Living With HIV/AIDS can now live longer and better quality of

lives.”…”But ante-retroviral therapies are not supported by the Govt. in the

programme because of their prohibitive costs on account of indefinite period of

treatment and other supportive investigations required for monitoring the

progress of the disease.”

We are in agreement with what you say in the first part, but the message

that AIDS is treatable but not curable, like diabetes should be high lighted

When you say that the drugs are of prohibitive cost even in the standards

of developed countries, you are hiding a truth that India is producing the

cheapest drugs to treat AIDS in the world.

In fact in the pretext of cost we deny anti-retroviral drugs to healthy people.

If we put enough efforts we can definitely bring down the cost. Moreover we

don’t have to wait for the drug price to come down; we could very well produce

it. It is only a matter of will. Even the agreements in TRIPS can be violated in

context of life saving situations, as Brazil did.

We do find enough money to produce Atom bombs and buy billions of dollars

worth of arms and ammunitions every month. We are spending daily thirty

million rupees to keep the bleak, barren snow clad mountain of Saichen (god

alone knows why we need such a place) and you are sermonizing about the

prohibitive cost.

We can’t allow the ‘enemies of India’ to kill Indians but we can allow poverty

and disease to do it. Strange is the logic of patriotism and nationalism when it

comes to saving people. India is trying to be the Asian Giant in military power

and there is no dearth of provision for that. So it is only a matter of priority

but not of cost.

Probably the riots in Gujarat can be explained also in terms that we are saving

the minority community from AIDS by killing them before the virus strike. All

these ‘life saving’ activities of making bombs and missiles thrive while

there is no money for drugs and basic amenities.

(X)

In 5.10 HIV and Injecting Drug Use “ The problem of HIV/AIDS has added an

new dimension as sharing of injection equipment for narcotic drug use is one

of the most efficient routes of HIV transmission and is considered to be

much more risky than unprotected sexual contact.”….”An appropriate Needle

Exchange Programme with proper supervision by trained doctors/counselors,

etc. will be required.”

We were clamoring for such a decision for the last five years, after our

encounter with the drug addicts of Thiruvananthapuram and adjacent places.

The then officials in charge kept a safe distance from taking a decision of

needle exchange. The tragedy with the Govt. machinery is that they learn

only when it is too late to learn. If such a decision could be taken four or

five years back we could have saved thousands of life. Here again it is the

moral issue of whether we are promoting drug abuse by the needle exchange

that determines decisions rather than the safety of people’s lives. But

better late than never. We do welcome the decision to start an appropriate

needle exchange programme.

(XI)

In 5.14 Bilateral and International ation …“Government will promote

mutual information sharing with these countries and the neighboring

countries in the South Asia region on their national AIDS control plans.

Cross country issues like drug use, labor migration, trafficking among women

& children, etc. could be the common ground for regional cooperation among

the neighboring countries.”

Now the real joke starts. With the Indian army staying alert on the Line of

Control between Pakistan and India, talking cooperation with neighboring

countries is the height of it. We are building fences around Bangladesh; we

have strained relations with China, Nepal and Sri Lanka and yet we talk of

cooperation. We are building armies to fight these countries and what kind

of cooperation do we seek from them. “Of course we have to conclude all

these policies in such a bombastic note, don’t take it seriously.” Yes, yes,

we are sorry!

(XII)

Now for the crowning point 7. Implementation Strategy 7.1 “The success of

any implementation strategy for the prevention and control of HIV/AIDS would

depend largely on the commitment of the political, administrative and

community leaders and their sensitization on the potential risks and

consequences of a widespread HIV/AIDS epidemic in the country. “

Of course we see these sensitization talks from ministers who want to test

all foreigners and in the bill brought in the Goa assembly for compulsory

testing of couples before marriages. Two years back we heard of a minister

of Thailand walking around with a garland of condoms to sensitize the public

But not here in India, our political masters will walk with garlands of

bullets in the land of Buddha and Gandhi rather than this ‘shameful’ talk of

AIDS.

Now Buddha smiles only when the Atom bomb bursts. If we have

commitment from the political leaders and community leaders, do you think we

will have issues of Ayodhya and Babri Masjith and riots in Gujarat? We don’t

know what to make of these things. Anyway like you, we are crossing our

fingers for the impossible to happen. Let us hope that at least the minimum

of this policy statement will happen in the near future.

Before concluding, we have to point out that there is a grey area of

addressing the problem of children being used in sexual activities. Usually

it is called child abuse and suppressed at all costs. But there are many

children making a living out of doing sexual services and they are at great

risk. But we can’t address them like sexworkers, we can’t teach them safe

sex, we can’t treat them like adults. But they are there with all the risks

of an adult sexworker. What we should do with them? Please clarify.

Love

Maitreya & Dr Jayasree

E-mail: maitreya@...; jayasree@...

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