Time for midcourse corrections : AIDS policy in India

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Time for midcourse corrections

The Hindu Monday, Jun 07, 2004, By Jaya Shreedhar

Shaping a cohesive and co-coordinated national response to the AIDS

epidemic is imperative.

ELECTIONS 2004 have ushered in a new dispensation whose stated goal

is to reorient itself to tackle certain fundamental development

challenges that impact the daily lives of the people. The change of

guard coincides with the conclusion of the second phase of the World

Bank-funded National AIDS Control Programme (NACP-II). The country is

scheduled to embark on the third phase of the NACP later this year.

This therefore is an opportune moment to take stock and carry out

midcourse corrections, where necessary, in our national response to

the AIDS epidemic.

With over 4.5 million people living with HIV by the close of 2002,

India's nearly two decades old epidemic is estimated to be the

largest in the South and Southeast Asian region and the second

largest in the world. The officially reported country-level HIV

prevalence rate is less than one per cent in the adult population, a

deceptively diminutive figure. Given the country's large population,

even a 0.1 per cent increase in the HIV prevalence rate would

increase the number of adults living with HIV by over half a million

people.

The HIV epidemic in India is a crazy quilt of smaller epidemics with

a handful of States appearing to be more severely hit than most.

Maharashtra, Tamil Nadu, Andhra Pradesh, Karnataka, Manipur and

Nagaland are categorised as `high-prevalence' States because they

report concentrated epidemics among highly vulnerable populations

such as sex workers, and HIV prevalence rates of 1 per cent or more

among pregnant women (taken to represent the general population as

opposed to `high risk groups'). Recent surveillance data of HIV

prevalence rates among these pregnant women suggest that the epidemic

may have begun to stabilise in these States. The rest of the States

are said to have moderate to low rates of HIV prevalence and surveys

show that the rate of spread of the virus is slow.

This reassuring picture suggests that the World Bank ordained goals

of restricting the HIV prevalence rate in the general population to

below 5 per cent in the worst hit States and below 3 per cent in the

moderately affected States may in fact be achieved. There are,

however, certain unsettling undercurrents. The surveillance data are

incomplete and may not reflect the real rates of HIV prevalence in

the so-called low prevalence States. The overall HIV prevalence rate

may be low but it conceals intense, explosive rates of infection

among vulnerable populations such as sex workers. It is only a matter

of time before the virus reaches the general population via bridge

populations such as the clients of sex workers, unless effective

prevention programmes are in place.

Independent assessments by the United States' National Intelligence

Council predict that at the present rate of spread about 25 million

people in India would be HIV-infected by the year 2010. The UNDP

Human Development Report (2003) places the figure at 110 million

infections by 2025, with a 13-year reduction in life expectancy from

the present 61 years. These projections are not, however, endorsed by

the Government of India.

The National AIDS Control Programme, meant to cover the whole

country, is at present coordinated by a federal apex body within the

Health Ministry — the National AIDS Control Organisation (NACO). The

NACP and the activities of non-governmental AIDS Service

Organisations are almost entirely run with donor assistance totalling

pledges of over $800 million; the Central Governmental commitment in

fiscal terms is negligible.

NACO has, over the last few years, been trying to assess how many

habitual risk-takers there might be in the country and map where they

could be accessed so that HIV prevention services could be provided

at locations convenient to them. This mapping exercise is being

carried out through professional research agencies with additional

funding from the United Kingdom's DFID. Although the mapping is said

to be complete in most of the States, the enumeration of risk takers

is by no means comprehensive and can only be considered to be the

lowest estimates of people practising high risk behaviour. Currently,

barely a quarter of the population with high risk behaviour is being

reached with HIV information, counselling, STD treatment, condoms or

clean injecting equipment.

Meenakshi Datta-Ghosh, Additional Secretary and Project Director of

NACO, states that surveillance on the HIV epidemic is being expanded

to overcome the dearth of information regarding the extent of the

epidemic in highly populated, large States such as Uttar Pradesh.

Many States report low levels of HIV and some report no cases of AIDS

at all. Over 95 per cent of HIV infections seem to be concentrated in

just 10 of the States, with the four in the south among those

severely affected.

A probable explanation is that the States that appear to have serious

HIV epidemics are those that were quick to move out of the denial

mode, were not squeamish but instead tried to assess the magnitude of

the epidemic as honestly as possible. Most have better infrastructure

for health delivery and are hence able to detect more cases. There is

no evidence to indicate that the rest of the States are somehow

`different' or less vulnerable to HIV.

Meantime, the epidemiological categorisation of States into `high',

`moderate' and `low' prevalence has had undesirable repercussions. It

has bred a false sense of complacency among the so-called low

prevalence States resulting in lethargic governmental and NGO

responses even while the virus continues to spread silently.

In contrast, the high prevalence States have managed to attract the

lion's share of funding from NACO, thanks to their demonstrations of

`absorptive capacity'. They have been quicker to put programmes

together, get NGOs and the public health services involved, and apply

for generous slices of the cake.

States such as Tamil Nadu were quick off the blocks and set up a

quasi-governmental State AIDS Control Society that could receive

funds directly from the Centre, a model now replicated in all the

States. On the other hand, States such as Chhattisgarh and Madhya

Pradesh, which have been either less motivated or less capable of

demonstrating their need and capacity, have fallen behind.

Low prevalence States such as Bihar, where the public health delivery

system is in urgent need of upgradation and expansion, say the

funding they receive from NACO is insufficient for them to upgrade

HIV preventive services such as clinics for the treatment of Sexually

Transmitted Infections. NACO's response has been that it is more than

willing to fund those clinics whose records show that they regularly

treat people — and there aren't many.

The impasse continues, pushing `low' prevalence States into a vicious

cycle of neglect. A case in point was the recent governmental

initiative to pilot free Anti-Retroviral Treatment (ART) to people

living with HIV/AIDS to only the six high prevalence States and

Delhi. The move provoked an outcry from some of the other States

whose people living with AIDS felt they were being subjected to step-

motherly treatment as they too enjoyed the right to access ART.

In addition, the initiative threw the ill-preparedness of our much

neglected public health delivery system into stark relief. The

initiative prompted criticism from the WHO and others who warned that

it would be counterproductive to introduce ART when neither the

health infrastructure nor the personnel were fully equipped.

Meantime, reckless media reports that talk of ART as a `cure' for

AIDS are already leading to misconceptions and complacency among

highly vulnerable populations.

A serious gap in our national response to AIDS is the scarce sharing

of research data and lessons learnt from HIV prevention and care

between the States. The menace of a disparate State-wise response to

HIV is that effective HIV prevention brought about within one State

cannot be sustained owing to the ebb and flow of populations across

porous State borders.

A person travelling from a State where condoms and STI treatment are

easily available, to one where they are not will again become

vulnerable to HIV or a threat to a vulnerable local population, as

the case may be. Pushing the States to synchronise their respective

HIV control programmes with the NACP is a vital requirement that can

only be attained by motivated political leadership and a proactive

bureaucracy both in the States and at the Centre.

The exigent responsibility for the NACP during the third phase is to

ensure that no State fails to implement a minimally acceptable

response to HIV/AIDS. The onus is on the new Health Minister to

uphold his declared commitment to strengthening the rural health

services across the country and in personally galvanising political

commitment from the States that are lagging behind to inspire a

holistic national response to AIDS as against scattered regional

reactions.

With the conclusion of Elections 2004, the draft legislation on

HIV/AIDS is expected to be circulated among the newly elected Members

of Parliament. The draft makes a number of proposals within the

framework of human rights that proposes to amend existing laws to

decriminalise homosexuality and sex work, allow the free flow of

information in the mass media on safer sex, and introduce new laws to

protect the rights of PLWHA.

The proposed legislation is expected to generate considerable debate,

and constructive support from the media is critical to a positive

outcome. Shaping a cohesive and co-coordinated national response to

the epidemic is imperative to stemming the looming threat to our

social stability and national health security.

(The writer is a medical doctor, writer, health communications

consultant, at present with Internews.)

____________

Dr.Jaya Shreedhar,

Health Communications Consultant,

9, Nungambakkam High Road,

Chennai 600 034, Tamil Nadu, India

Telefax: 91-44-5208 9969, Mobile: 91-44-33-666-969

Email: jaya_shreedhar@...