Bmj.com response: Why India should disregard the advise of Potts and Walsh

[Guest guest]

http://bmj.com/cgi/eletters/326/7403/1389#33841

Why India should disregard the advise of Potts and Walsh

Joe . MSc. Ph.D

Director, International Centre for Health Equity Inc. Melbourne,

Australia

Mridula Bandyopadhyay. MSc. Ph.D

Lecturer, Key Centre for Women's Health in Society

School of Population Health

The University of Melbourne

3010

Australia

Malcolm Potts and Walsh's article (2003;326:1389-92)? Tackling

India's HIV epidemic: lessons from Africa ? is a timely contribution

to the much needed education and debate on HIV prevention in India.

However, these are the types of advice the Indian policy makers

should precisely disregard.

Although it may not be apparent, looking at the timing of the

article, it appears that the authors are expecting to achieve two

objectives:

a) the authors are trying to position themselves as the lead

advisors of the proposed Bill Gates Foundations multi million India

HIV initiative;

to take a gentle swipe at the Indian manufactures of generic

anti retroviral medications.

Besides, this article should also be criticised on grounds of the

authors' lack of empirical understanding of the social determinants

and consequences of HIV infection in India. In addition, they also

demonstrate a patronising attitude and lack of appreciation of the

intellectual leadership of Indian researchers and policy makers in

addressing HIV/AIDS related issues in India. In this context, it is

essential to closely examine the conceptual poverty of the

assumptions put forward in the argument of Potts and Walsh.

A) While prescribing the involvement of " high risk groups " in all

phases of the programs, unfortunately Potts and Walsh demonstrate how

divorced they are from the current literature or thinking about the

conceptualization of risk and risk behaviours in the context of HIV

infection. To state bluntly, there are no `high-risk groups' in

India. Only, there are people practicing `high-risk behaviours'.

Those who are familiar with the ground level, lived experience, or

have access to large amounts of empirical data on the complexity of

HIV infection in India, would know that mathematical models might not

be able to precisely predict the cultural and social complexity of

risk and risk behaviours in India.

Further those who are familiar with the social epidemiology of HIV

infection in India would also agree that, currently India is

experiencing an aggregate of multiple epidemics of HIV in different

geographical settings and among people with different types of risk

behavior. Hawkes and Santhya (2002) observed that the number of cases

in women infected through heterosexual transmission within marriage

is increasing. Seroprevalence of 13-24% HIV have been reported among

female STD clinic patients who are not sex workers. For many

monogamous women in India, marrying a person who is practicing high-

risk behavior is the source of HIV infection.

The focus of intervention should not be on high-risk groups but

rather on people and communities who are vulnerable to HIV infection.

The pattern and process of their vulnerabilities should be the target

of intervention. Involvement of vulnerable population should be

welcomed in all aspects of intervention programs. In the past

interventions targeted at `high risk behaviour groups' was one of the

major source of HIV/AIDS related stigma and discrimination, leading

to a critical barrier in developing effective HIV prevention programs

(UNAIDS 2002).

C) Focus of interventions should be on evidence based prevention

programs rather than on economic rationalism alone. Apparently Potts

and Walsh's understanding on the impact of poverty as a cause and

consequence of HIV infection is too narrow. Poverty reduction should

be one of the overall goals of HIV prevention in developing countries

as HIV infection could lead to poverty. People living with HIV/AIDS

in India are one of the key resource group who could be marshalled to

fight against HIV. Greater involvement of people living with or

affected by HIV/AIDS (GIPA) have been universally accepted as key

principle of HIV prevention (UNAIDS 1999)

D) There is a need to secure adequate supplies of condoms,

antibiotics and antiretroviral medication as part of HIV prevention

programs. Potts and Walsh have correctly observed that India has the

advantage of a large, competitive, and technically competent

pharmaceutical industry, and the government is subsidising

distribution of condoms to low-income families. This subsidy should

be extended to antibiotics for controlling sexually transmitted

diseases and antri-retroviral as well. The international donor

community should ensure that priority is given to funding condoms,

antibiotics and antiretroviral medications. Specific resource

allocation for enhancing access to care and treatment for people

living with HIV/AIDS should be one of the critical criteria for

accepting international donor assistance.

E) A careful balance needs to be maintained in investing in large-

scale projects as well as pilot projects. While national level larger

scale evidence based projects are to be priority. Pilot projects for

enhancing access to care and treatment, reducing stigma and

discrimination in various settings, and projects to reduce poverty

among the people living with HIV are also in urgent need. Indian

policy makers and program managers should accrue skills through pilot

projects, as large-scale projects often require expensive

international management, technical assistance, and sacrifice of

project autonomy.

F) The advise to include traditional health practitioners in control

programs should be welcomed at all levels of HIV program management

and intervention development.

G) International donor agencies should acknowledge the opportunity

cost of HIV prevention programs. Quite often resources committed face

unreasonable delay in actual implementation of interventions. Thus,

there is a need for greater appreciation of the opportunity cost of

such delays in intervention developments.

H) While large international meetings waste resources, there is

definitely a need to develop national level meeting to generate

consensus, sharing of experiences, building coalitions and networks.

I) Furthermore, advocacy for increased use of generic antiretroviral

drugs is essential in India. The quality of life of people living

with HIV in rich countries has improved because of antiretroviral

drugs. However, Potts and Walsh fail to present a compelling argument

against facilitating such benefits to people living with HIV in

India. The mindset of people that argue against enhancing access to

care and treatment for people living with HIV/AIDS in India is set in

a colonial time frame, fraught with racist superiority. Such

arguments should be denounced for what they are worth.

In essence, India has the technical ability to produce generic

antiretrovirals which should be widely encouraged and should be

legally protected from international trade bullying. An active

program to enhance the skills of health care providers should be a

priority with much needed research and local data on effective

monitoring of the progression of HIV disease. There is no empirical

data to substantiate the argument " that money spent on antiretroviral

drugs is money removed from prevention, and vice versa " . It is just a

patronising assumption. Treatment is prevention. " The people who

benefit will probably be those who are most educated or have access

to specialist care " is not a valid argument against providing ARV

treatment for them. The much-needed leadership of people living with

HIV comes from these groups itself.

J) One of the most culturally insensitive recommendations of the

authors' is their advocacy for massive male circumcision in India,

could be pardoned given the authors' total lack of knowledge about

the Indian sub-continent. Besides, empirical evidence on the efficacy

of male circumcision to slow transmission of HIV is also sketchy; and

advocating for male circumcision in the Hindu cultural context shows

a total lack of understating about the `cultural meaning of

circumcision' in India. Recommending such solutions broadcast the

authors' ignorance about the complex history of Hindu Muslim

relations in the Indian sub-continent. Or is it another patronising

statement from the authors?

In our view, India should seek local solutions for this global

problem. Capacity building of Indian health care providers and

enhancing the intellectual leadership of Indian commentators and HIV

researchers should be considered as a top priority. Potts and Walsh's

article is a timely reminder of the issues at hand. However, the

solutions they are providing are not evidence based and smacks of

patronising assumptions. One would expect a much more rigorous

analysis and argument presented in the BMJ.

Competing interests: Joe is the moderator of e

FORUM. An electronic forum for information and communication on AIDS

related issues in India.

References:

Potts M, Walsh J. Tackling India's HIV epidemic: lessons from Africa.

BMJ 2003;326:1389-92.

S Hawkes, K G Santhya, Diverse realities: sexually transmitted

infections and HIV

in India. Sex Transm Infect 2002;78(Suppl I):i31-i39

UNAIDS 2002. Live and let live. A global campaign to reduce HIV/AIDS

stigma and discrimination

UNAIDS 1999. From Principle to Practice. Greater involvement of

people infected or Affected by HIV/AIDS