Debate, dithering and deadly AIDS

[Guest guest]

Opinion: News Analysis. Debate, dithering and deadly AIDS

BILL GATES opened the gates — literally — to another of those

perennial debates on HIV/AIDS in India. Ever since the first case was

registered in Chennai in 1986, controversy of one kind or another has

surrounded the subject. There have been constant contestations about

the number of infected people, accusations and counter-accusations about

the use/misuse of funds and incidents of persecution and harassment of

non-governmental organisations working on HIV/AIDS-related sexual

education programmes. In the process, the important issues about what can and

should be done, regardless of the numbers affected, and also how the gaping

holes in the country's health delivery system can be plugged, have been

forgotten.

The announcement by the Microsoft chief of a $100-million grant for

HIV/AIDS last week came on the heels of a controversial statement

made by the U.S. Ambassador, Blackwill. The American diplomat quoted

from a report prepared by the National Intelligence Council, which advises

the U.S. Central Intelligence Agency, predicting that by 2010 there would 25

million people afflicted with AIDS in India. This set off a predictable

flurry of denials led by the Minister of State for Health, Shatrughan Sinha,

who claimed that such statements contributed to unnecessary panic.

How important are the numbers? According to the National AIDS Control

Organisation (NACO), the nodal agency that coordinates all AIDS control

and prevention activities in the country, an estimated 3.8 million people

are known to have HIV/AIDS. The accuracy of this figure has often been

questioned. Projections based on existing data and trends are even

more problematic, particularly for a disease such as HIV/AIDS that has

defied many predictions during the last two decades. In 1991, for instance,

according to conservative projections, India was supposed to have 12

million HIV/AIDS cases by 2000. The figure commonly accepted today is four

million.

The problem of calculating numbers lies in the system of data collection.

Says Ravi Duggal of the Centre for Enquiry into Health and Allied Themes

(CEHAT): " The existing data is based on reported cases from Government hospitals

and ante-natal clinics. But the majority of people use private

health facilities. Such cases are never reported. In any case, unless

you conduct an epidemiological study, there is no accurate way of

arriving at the numbers. " Yet, regardless of the actual numbers of infected

people, it is evident that the disease is spreading. States such as Karnataka

and Andhra Pradesh have shown a distinct rise in the number of HIV/AIDS

cases.

There is also an increase in the number of women being registered.

NACO estimates that about 89 per cent of the reported cases occur in the

sexually active and economically productive age group of 15-44 years and one

in every four cases reported is a woman.

Meena Seshu of Sangram, who was recently given a special award for

her work with commercial sex workers in Sangli, Maharashtra, by the

international group, Human Rights Watch, says, " the Indian Government

clings to the idea that the epidemic is limited to `high-risk groups' — sex

workers, drug users, truck drivers and so on — and that targeting them

with information about HIV transmission and condoms is the best

strategy to contain the epidemic further. But this analysis no longer reflects

the reality of AIDS, at least for some Indian States where the epidemic

is in the general population. In these States, women who have sex only with

their husbands may be the group at highest risk of HIV transmission. The

long-standing subordination of women and girls in Indian society

takes on lethal dimensions with the rapid spread of HIV/AIDS. "

Shilpa Merchant of Population Services International (PSI), Mumbai,

says that there has been a noticeable transition of infection in Mumbai

from the high-risk groups to the general population. Most alarming, she says,

is the number of young couples who are now coming for counselling because the

husband has found he is HIV-positive. Many of these young men admit

their initiation into sex took place through a sex worker and that they had

no knowledge about safe sex. " It is scary, " she says. However, Government

surveys suggest that the intensive information and surveillance

programmes targeting " high-risk " groups have yielded some positive results. The

Behavioural Surveillance Survey (BSS) carried out by the Central

Government in 2000-01 revealed that overall awareness about HIV/AIDS among

people in the reproductive age group (15-49 years) was 76.1 per cent, higher

among men than among women and also better known in cities than in villages.

However, only around one-third of rural women in Bihar, Gujarat, Uttar Pradesh,

Madhya Pradesh and West Bengal were aware of the disease. Surveys have also

indicated an increase in condom use, crucial as almost 90 per cent of cases of

infection are through sexualcontact.

The Government has also had some success in plugging the blood

transfusion route to HIV/AIDS. Following a 1996 Supreme Court ruling, unlicensed

blood banks and professional blood donors have been phased out. As a result,

the incidence of HIV/AIDS through infected blood has declined from eight per

cent a decade back to four per cent. Most of the funds allocated for

HIV/AIDS continue to be used for prevention. Treatment of those

already infected is still very minimal, given the treatment costs. Although

Indian drug companies have pioneered lower cost drugs, and countries such as

South Africa and Brazil have turned to them, India is still not in a

position to offer treatment. The minimum cost for a year of treatment is Rs.

25,000.

Unless detected at a very early stage, there is no guarantee that the

anti-retroviral drugs will either restrain or reverse the disease.

Thus, none of the Government programmes have factored in the treatment

costs so far.

The absence of treatment is now emerging as a major concern, says Dr.

Duggal. This is true, he says, even of programmes to treat tuberculosis

and malaria. The treatment budgets are adequate to cover only 25 to 30

per cent of the cases. As a result, people do not get the full course of

treatment leading to drug resistance and relapses. The same could happen if

patients with HIV/AIDS are treated with inadequate budgets to support effective

treatment.

Furthermore, there are few facilities for people who do wish to be

treated or can muster the resources. Private hospitals and clinics continue to

display lack of knowledge and sensitivity towards HIV/AIDS patients.

And care and counselling centres run by NGOs are few and far between. Ms.

Seshu says, " persons with HIV/AIDS continue to face abuse and

discrimination in the health care system, and, unless they are rich, they can

hardly hope for the basics of treatment of opportunistic infections, let alone

anti-retroviral medicines. It is a sad irony that India is one of the

biggest producers of the drugs that have transformed the lives of

people with AIDS in wealthy countries, but for millions of Indians access to

these medicines is a distant dream. "

So is it a question of resources? If you add up the sums committed

by various agencies ranging from the World Bank to USAID and bilateral

agencies, millions of dollars have been promised for the AIDS

prevention and control programmes. In Maharashtra, which has over half the

reported HIV/AIDS cases in the country, USAID launched a special, seven-year

$41.5-million programme last year. But K. Vaidyanathan, who runs the

project, says the issue is not resources but our ability to use these

resources. " There is no dearth of money, " he says, " but a dearth of

good projects " . In the last six months, they have received 400

applications from NGOs for funding but only 20 have been selected as being

capable of fulfilling project requirements. Mr. Vaidyanathan says that because

HIV/AIDS is a relatively " young " disease, much more will have to invested in

prevention and control in the initial years. This might appear

disproportionate compared to other more basic diseases in the

country, but in the long run this kind of investment will pay in reducing the

spread of the disease.

Dr. Duggal, however, suggests that resources and their use are

important in terms of the overall public health infrastructure. This needs to be

strong to ensure that health programmes actually work. He points out

that the attention given to HIV/AIDS should not detract from the reality

that there has been a declining trend in allocations for the health

sector.

In the mid-1980s, the Centre's health sector allocations were 1.3 per

cent of GDP while today they are 0.8 per cent of GDP. In contrast to this

decline in the public sector, there is increasing investment in the private

health sector, and particularly in the super-speciality areas.

More serious is the gap between the per capita spending between

urban and rural areas. Says Dr. Duggal, " out of Rs. 200 billion allocated for

health care, the average for the country as a whole works out to Rs. 200 per

capita. In reality, however, urban areas get Rs. 600 per capita

(metros close to Rs. 800 per capita) while rural areas get hardly Rs. 40-50

per capita. We need to overturn this paradigm. Canada, for instance,

allocates resources on a per capita basis. Under such a system a primary health

centre would get resources equivalent to the number of people it serves.

Thus rural areas would get more and metros would get less. "

Finally, there is the question of rights, especially of the vulnerable

" high-risk " groups. By targeting them, the Government has contributed

to their being victimised, say health activists. For instance, while Ms.

Seshu has gained recognition for her work outside India, earlier this year

local thugs supported by the Shiv Sena harassed her organisation. When they

went to file a complaint at the police station, the women — most of whom

are sex workers trained as AIDS educators — were told that they were not

" normal citizens " and therefore had no right to file a complaint. Ms.

Seshu has faced attacks in the Press and has even been accused of using

HIV/AIDS education as a ruse to run brothels.

Equally difficult is the situation for gay rights groups who have

tried to work on these issues. The police constantly harass them. This arises

from a pre-colonial law, Section 377 of the Indian Penal Code on " unnatural

offences " , which gives the police the power to harass men working on

these issues. As World AIDS Day approaches on December 1, it is time for a

reality check on the direction of the HIV/AIDS control programmes in this

country.

To quote Ms. Seshu again, " the Gates Foundation can do India and

its own large investment a favour by helping to broaden the analysis and

address the hard reality of women, violence and HIV/AIDS in India. "

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