Yes, you're positive, but there's nothing we can do for you

[Guest guest]

Yes, you're positive, but there's nothing we can do for you

By Sandhya Srinivasan

What can the National AIDS Control Programme achieve in the absence of

integration of HIV-related services into the health system as a whole? The

second in a series assessing the HIV/AIDS situation in India

When the National AIDS Control Programme was first set up in 1992 its first

priority was to make people aware of HIV.

HIV is transmitted through unprotected sex, infected blood and blood products

and from an HIV-positive pregnant woman to her baby either during pregnancy or

through breast-milk. The programme publicised these facts.

In some ways the programme took a bold step by starting to talk about sex - the

main route of transmission of HIV - in a society which didn't like to talk about

such things. Public information campaigns were launched which actually spoke of

how HIV infection was acquired - and how it wasn't, through casual contact, for

example. These continue to meet with resistance: some feel that talking publicly

about sex corrupts the young and is antithetical to Indian culture. Doubts have

also been expressed about the quality of information provided: some messages

seem to confuse and create fear more than they educate.

The programme also sought to provide a bare minimum of preventive services by

protecting blood supply and setting up an effective treatment programme for

sexually transmitted diseases (people who already have certain STDs are more

vulnerable to HIV if exposed to it through sexual contact, so treating STDs

would make people less likely to get infected with HIV if exposed to the virus).

Finally, the programme worked at developing a system to monitor the prevalence

of HIV in various parts of the country by conducting unlinked anonymous tests on

STD clinic users, commercial sex workers, injecting drug users, pregnant women

attending antenatal clinics, and gay men.

Phase II: More of the same

The second phase of the National AIDS Control Programme (1999 to 2004) tries to

take all these activities one step further and build on them.

The primary focus of the second stage of the programme has been 'targeted

intervention' to increase awareness among those believed to be at high risk of

infection, and to change their behaviour. This includes the promotion of condom

use among these groups.

Other activities include developing a safe blood supply through the

establishment of properly-equipped blood banks where all blood is tested for HIV

and other infections before use; promoting blood donation and banning trade in

blood; setting up testing centres where people are encouraged to go for testing

which is preceded and followed by counselling; further establishing STD

treatment services, and setting up a programme to provide a short course of

anti-retroviral drugs to pregnant women reporting to antenatal clinics who test

positive for HIV (called the PMTCT or prevent mother-to-child transmission

programme).

Phase II of the NACP also has, as stated objectives, the provision of

decentralised services and strengthening of the system's long-term capacity to

respond to HIV.

Finally, the number of sentinel surveillance sites, conducting HIV tests for

monitoring purposes, increased dramatically in the second phase. These were in

STD clinics and antenatal clinics and among groups of sex workers. As a result,

it is believed, surveillance data collected in the last few years may present a

more accurate picture of the prevalence of HIV infection in India. (Still, the

programme continues to be plagued by queries about the quality of its data and

many limitations have been noted by public health experts and activist groups.)

NACP II was implemented at the state level using state AIDS control societies,

autonomous bodies headed by a senior civil servant, but with independent

financial authority. These societies funded voluntary organisations to carry out

prevention.

The targeted approach

Overall, the targeted approach dominates the second phase of the National AIDS

Control Programme. The targeted approach is touted as a success story in states

like Manipur and Tamil Nadu where HIV prevalence has reduced among target groups

such as injecting drug users (in Manipur), commercial sex workers and clients of

STD clinics (Tamil Nadu). Indeed, surveillance figures for 2000 and 2001 show a

drop in HIV prevalence in targeted groups in a number of states. However, it is

not clear if figures for the two years can be compared. Interestingly, the NACO

website does not contain any HIV prevalence figures after 2001.

The programme quotes reports from successful AIDS control efforts to argue that

the best way to reduce HIV transmission is to target interventions at groups

most vulnerable to HIV. These vulnerable 'core transmitter' groups are preferred

for interventions to groups that are more difficult to identify and approach,

such as clients of sex workers.

It is true that in the US and Australia, for example, well-organised information

programmes for gay men, by organisations of gay men, are believed to have

brought a sharp reduction in HIV prevalence relatively soon after the appearance

of HIV infection in these groups.

What about those outside the target group?

A number of activists have complained that the targeted approach misses people

who are outside the target group. So, for example, messages on the risk of

unsafe sex between men are presented only in situations where men congregate to

have sex with other men, or to groups self-identified as having sex with other

men. Since messages on the risks of gay sex are not presented to the general

population, those who do not identify themselves as gay are excluded from

important information.

Likewise, partners of injecting drug users risk acquiring HIV but there are few

efforts to speak to them as a group.

Targeting groups for interventions also stigmatises these groups.

Surveillance figures in recent years indicate that HIV infection is not confined

to the 'target groups' of people with high risk behaviour. A number of women who

are HIV positive report having had sex with only one partner -- their husband.

However, there is no effort to reach the 'low risk' woman and discuss how she

might protect herself from infection.

Need for quality counselling

The general call for people to get themselves tested for HIV is not supported by

counselling services before and after testing. The voluntary counselling and

testing centres (VCTCs) set up by the programme are reportedly under-staffed and

counsellors are often poorly trained. There are too many reported incidents of

people being informed of their HIV status in front of other patients, of little

or no effort being made to educate those who test negative of how to avoid risk

behaviour.

Yes, you're positive, but there's nothing we can do for you

It must seem particularly unjust to those who are encouraged to test themselves

and find themselves HIV positive, that they have nowhere to go.

A few voluntary organisations do provide treatment and support but they can meet

just a fraction of the demand for such care. In general, both private and public

health services are completely unprepared to respond to the growing need to care

for people with HIV. Private services generally refuse treatment, or provide it

at exorbitant costs to those who can afford it. Very few public health services

are equipped to provide treatment of any kind. Drugs are in short supply, as are

protective materials to be used for all patients (following universal

precautions). And few personnel have been trained in standard procedures to

prevent transmission of HIV or other infections. The kind of resource

allocation, education and regulation needed to ensure treatment to people with

HIV-related health problems do not exist.

In such a situation, there is no scope for treatment with anti-retrovirals

through the public health system, a demand made by some groups working with

people with HIV.

A weakened health system

There is much talk about integration of HIV prevention and treatment into the

system. However, not only are preventive programmes patchy and integration poor,

there is no integration of HIV-related services into the health system as a

whole.

Further, public health services in India have deteriorated steadily over the

last few decades. There is no evidence of efforts being made to strengthen the

health system and prepare it for a growing burden of ill people. Barely 20% of

all health-related expenditure is made by the government; the rest is within the

private sector, where payment is made by individuals spending their own money

since health insurance is available to a negligible percentage of people in

India. The increase in HIV-related problems calls for increased government

spending on health. As more awareness is generated and more people test

positive, this demand is bound to grow.

This increase in government spending on health is a decades-old demand. Instead,

the amount spent on health has gone down, not up. There are innumerable

instances illustrating the collapse of health care through the government, from

the rural primary health centre all the way up to the municipal hospital

representing the tertiary level of care. Equipment does not work, drugs and

other materials are not available, staff are absent, and so on.

In fact this general deterioration of public health services actually increases

people's vulnerability to HIV as shortages encourage the reuse of unsterilised

equipment.

Further, the absence of treatment may in fact exacerbate the stigma attached to

HIV.

HIV is driven by inequities

HIV is intrinsically linked to poverty and to inequalities of all kinds -

social, economic and gender. However, awareness and other preventive programmes

do not address inequities that are intrinsic to the problem. The married woman

is unable to refuse her husband unprotected sex. The commercial sex worker will

not insist on her client using a condom if he threatens to go elsewhere. The

national HIV programme fails to take into inequities into account.

(InfoChange News & Features, July 2003)

Source: http://www.infochangeindia.org/features119.jsp