Re: NACO rejects Feachem's nonsense.

[Guest guest]

Dear Friends,

I work as a researcher with a Mumbai based NGO, I have been listening to all

arguments about the HIV/AIDS numbers in India and so on so forth and it really

made me to write this letter.

Soon after completion of my masters degree I joined as a Senior Research Fellow

to coordinate a part of a larger project on HIV/AIDS.

This project aimed to look at the Behavioural dynamics of HIV/AIDS, though I

suppose not to interview people since I was given the responsibility to monitor

and instruct the research assistances, but the data was not coming right so I

had to put my efforts as well and interviewed nearly 95 men in-depth.

I was shocked to see that how these men are ignorant about this disease and how

they are indulged in such activities. I found that even most elite class is

unaware about how the HIV infection transmits and what they can do in order to

protect.

During the course of the study, I my self came across five HIV(newly detected)

positive cases since I was closely working with civil hospitals. I met a guy who

himself was HIV positive including his wife and most importantly five out of his

six children where infected and are getting treatment from the Civil Hospital. I

met another HIV positive man who by profession was bus conductor, I by my own

eyes saw

his papers, he was keep denying the facts and told me that he still have sex

without protection with his wife and his other women friends.

He also told me that he knows about the symptoms of HIV/AIDS and since he has

none of them it means he is all right and can have sex as he wants.

I can see how our women and Children are vulnerable to HIV infection. It is not

only the matter of our sisters getting widow or children becoming orphan, this

problem is beyond mentioned problems. I trust those who are working closely with

rural areas of India can see that how largely women are suffering with STIs

which they get from their husbands.

Most of the women I worked with, didn’t heard about HIV and don’t know how to

protect themselves. Even if they knew looking at the gender dynamics do our

women have enough negotiation power or are they allowed to do so.

Billions of money is flowing in this industry (sorry to call it industry), every

body wants to work on this issues, zillions of NGOs are working in this field,

million dollars projects are running even after that what is the picture. Still

there are denial to ARV and other basic necessities.

I think a strong action is needed in this regard. Un arguable the number of HIV

infected people is increasing and it hardly makes difference whether we are 5.1

or 5.4, we honestly and really need to do something jointly.

Regards

Sunita

Centre for Enquiry into Health and Allied Themes (CEHAT)

Survey No. 2804 & 2805, Aram Society Road

Vakola, Santacruz (E) Mumbai - 400 055

website: www.cehat.org Email: cehat@...

E-mail: <singh_sunita10@...>

[Guest guest]

Dear FORUM,

The following are my thoughts on the debate between Drs Quraishi and Feachem.

To put the latest round of debate between Drs Quraishi and Feachem,over the

number of HIV/AIDS cases in India, into perspective it is important to

understand how these estimates are derived. To help clarify the discussion I

would like to provide a simple description of the steps that go into such

statistical analyses. I must stress from the outset that in providing this

outline I am guessing at what is done in practice since NACO does not provide

details of its analysis nor does it give raw numbers from sentinel surveillance.

All data used in the analysis comes from sentinel surveillance centers. In the

latest (2004) round of surveillance 670 designated centers carried out

surveillance. The distribution of these centers is not uniform and reflects a

bias of where NACO thinks the need is greatest.

Data is collected over a fixed period every year - from 1 August to15 November.

Surveillance consists of testing, for HIV, people coming to these centers, and

assessing the risk class they belong to by gathering data on their background

and behaviors using a standardized questionnaire.

From these data one gets a geographical distribution of

* People tested

* People positive

* The people tested are then divided into categories that label them by their

primary risk (for example, sex workers, MSM, house wife,

migrant worker). The ratio (those tested positive/total tested) then gives the

prevalence fraction for that risk class for that geographical area.

* An estimate of the total number of people in that risk class in that

geographical area is then made as a fraction of the population of that region

(as far as I am aware the model used for this estimation has not been explained

to the public by NACO).

This number is then scaled by the ratio (those tested positive/total tested) to

get the total number of people that could be HIV positive within that risk

category and geographical area.

* These numbers are then added over all geographical areas and risk

categories to get the final national figures.

NACO has typically quoted as the central value a figure at the higher end of the

range. A curious statement that has usually accompanied this first estimate is

that a 20% leeway is assigned for under surveillance and underreporting. The

final estimate is then obtained by scaling up the first estimate to account for

this.

With an understanding of the process let me come back to the question of whether

Dr. Quraishi or Dr. Feachem is right. I will make some observations and allow

you to draw your own conclusions.

I suspect that most of you already have a very definite opinion!

The numbers quoted - 5.1 million for India and 5.3 for South Africa -

represent figures from the end of 2003 (See

http://www.avert.org/safricastats.htm for SA data).

Given the much larger population of India (almost 25 times larger) and the

figures for the increase in HIV prevalence figures during the last two rounds

2001-2002 and 2002-2003 (which average to 0.6 and 0.4 million for India and SA

respectively) it very likely that the new figures for end 2004 are 5.7 million

in both India and in South Africa.

It is unfortunate that the debate has detracted us from the real issue we should

be focusing on -- that both these numbers are large and need immediate and

serious attention.

All these figures are estimates with huge uncertainties. In India the

cumulative AIDS cases reported are 103,875 until march 2005 (see monthly reports

and the 2002-2004 Annual Report at

http://www.nacoonline.org/about_annulareport.htm ) with 1124 new

infections in the last month. (I am assuming that AIDS cases in these reports

simply means HIV positive.) Thus, one must not forget that from less than 5,000

HIV cases detected during 2003 Indian surveillance, the number 5.1 million was

derived. Given that the model has so many unknowns I am sure that neither Dr

Quraishi nor Dr. Feachem would wager even Rs. 10 on either of them being right

to within a million.

So what is the bottom line? If Dr. Quraishi is willing to accept 5.1

and 5.3 million respectively at end of 2003, then he should have little

hesitation in accepting that India could easily have surpassed South Africa

given its much larger population and today have the dubious distinction of being

the country with the largest HIV positive population. He most certainly

understands the uncertainties in the estimates. So why is he objecting so

vehemently?

I hope the answer is pride. Pride in the fact that he is devoted to

making a difference in the spread of HIV/AIDS in India. Pride that he does not

want India to known as the lead country. And pride that India will not go the

route of South Africa. I certainly hope that is the case.

Rajan Gupta

E-mail: <mailto:rajan@...>

http://t8web.lanl.gov/people/rajan/AIDS-india/

[Guest guest]

Hi to the List Readers,

Many of us know because we go where neither NACO or Feacham goes, that India is

approaching the 8-10 million mark in HIV infections, most of them undetected and

asymptomatic, but so what about the numbers! It is the inaccuracy of the expert

opinion that worries me even more than the numbers.

The use of the words 'sentinel surveillance' for the way that India does its

predictions is an insult to the english language and bears no resemblance to any

reasonable sense of understanding of epidemiology.

India is the classic example of the gates being locked after the horses have

bolted in so many respects and there are many people whose opinions are never

sought but who know that as well as me from my vantage point.

This list is describing graphically the examples of ignorance and wilful

negligence that prevails everywhere and I don't need to highlight the examples

but two recent cases where C.M's in Delhi and Goa have personally worsened the

epidemic on moral and cultural grounds shows just how immune these people think

they are.

I love the acronym for IAS " I Am Safe " Oh how much are they kidding themselves.

We just celebrated the 20th anniversary of the Bhopal tragedy and by

courtesy of Amnesty International the world mailing list is focussed on that

travesty of justice to the people of M.P. in the current month's International

appeal mailing. I was in Bhopal while the Tsunami was in Chennai and people

there think the risks have passed. Who is monitoring hospital admissions in

Bhopal where HIV seems to be less prevalent?

Epicentres of infection with HIV are in Indore, Jabalpur and Ujjain and where is

the surveillance data? All I heard was that M.P. was 'low prevalence' but I was

meeting many sexually active young people there, many from rural villages who

come to the towns to study and support each other the best and easiest way they

can, and guess what is the easiest way to get money for a bed, a meal or some

essential study notes? The level of ignorance about risk management in sexual

behaviour was high.

Dr Ajith is highlighting the plight of failed medicine supply to people who have

been lured into ART therapy believing that they can actually use it reliably to

save their lives.

One very important factor in the health surveillance is the matter of the

absence of testing of already enrolled patients who the ART medicine is killing

for want of competency in treatment and testing.

I saw this in Thailand - They have a waiting list for ART but not because they

don't have the medicine but because they can't adequately monitor, test and

support any more patients in their hospitals to ensure that the drugs are being

used properly and effectively.

We are wasting time agruing about the numbers. We need to identify the infected

and for that we need programs that support, care and treat reliably. Then we

need effective anti discrimination legislation with the experts whose opinions

are being constantly sought and relied upon to submit their opinions to further

testing because the things that many are saying are just so eroneous and out of

date, yet they sit on boards and panels and tribunals and endorse decisions that

go no where useful.

It is high time that a presumption be taken that every Indian is potentially

positive to HIV and that the citizens act accordingly. Couples need to be aware

of how they test with each other to ensure they represent a safe unit for

unprotected insertive sexual intercourse.

Where one party fails to agree then protective behaviours should become the

norm.

It would not be necessary to test patients in hospitals for routine

admissions because a presumption that they are also positive should reflect in

universal precautions for all doctors and staff and only those that were

candidates for organ or blood donation or transplantation surgery would need to

be tested.

If we keep arguing about the numbers more and more indians will die and more and

more indians will become infected and the numbers will eventually peak at well

over the 10 million mark and then it might be much more difficult to control.

It is possible to eliminate HIV in one generation but only by every sexually

active person knowing how the virus transmits and learning protective behaviours

and that doesn't mean not having sex. It means having safer and safer sex

measured over a range of ages and behaviours and including all the sexually

active citizens, not just the franchised varieties of hetrosexist married

couples.

Only then will we have a chance. If we spend 2005 debating whether Feacham or

NACO is right we will lose too many indians to the infection. The writing is

already on the wall - the problem is that not enough people are reading the

right wall.

Geoffrey

E-mail: <gheaviside@...>

[Guest guest]

Dear Forum,

Rajan Gupta's thought provoking analytical approach to the HIV/AIDS question

under debate is probabaly the right approach to take at this stage.

There is another issue which has not been discussed. Has India done enough to

control HIV/AIDS. I blieve the answer is 'no'. Even as the surveillance system

is perfected, there is aneed to diversify and strengthen prevention control

programmes.

Unfortunaately condoms promoted by funding agencies have crippled our creativity

in prevention programmes. I believe that mat least some of those who are

involved in HIV prevention are coming around to the view that we as Indians have

to sit and plan programmes that are most suitable to the environment in which we

live.

I would like to hear more about what NACO is effectively doing to control the

spread. Based on India's size and the present load it should not be surprising

that India will be the number one country. Still in other epidemiological

parameters India is very different from S. Sfrica, placed in a much better

position.

Yours sincerely,

Abel.

Rajaratnam Abel

E-mail: <rajaratnamabel@...>

[Guest guest]

This is regarding the excellent arguments by Rajan Gupta and Rajaratnam in the

ongoing controversy over the NACO statistics on the number of HIV+ people in

India.

Taking this from another angle altogether and could I gently remind the readers

on this list to glance at the new budgetary guidelines drawn up by NACO in close

consultation with NGOs, CBOs, PLWHA groups and finance people.

This exercise took over 18 months after intense haggling in open sessions in

Delhi.

What is startling is that all three " CORE " groups which have to be

compulsarily funded by every SACS before " other vulnerable " groups can be funded

are: (In their relative importance)

1) Sex Workers (female and male/transgendered).

2) IVD-users.

3) Men-Having-Sex-With-Men (MSM).

Now as somebody who took great pains through advocacy at every layer of

government and health bureuacracy to convince both the Family Welfare and Health

Ministries and NACO to have MSM included into the core sector, I suddenly

realised that ALL THREE CORE GROUPS mentioned above are CRIMINALISED groups who

cannot be engaged without serious systemic changes in the legal, social and

health sectors.

For example, till the Prevention of Immoral Traffic Act (PITA) is

drastically changed you cannot possibly work with female/male sex workers.

Simple things like soliciting become a criminal act.

Till Section 377 of the IPC is changed, even outreach among MSM becomes " an

accessory to abetment of Section 377 " which is punishable on its own. Hence,

outreach to MSM is criminalised and de facto impossible.This is reflected in

fact sheets brought out by the International Gay and Lesbian Assn.(ILGA)

Without drastic changes in the Narcotic Control Acts even possession of small

amounts of drugs like opium, charas can lead to imprisonment and heaby fines.

So please tell me how on earth does one work with whole populations who are

criminalised and driven to the margins of society for their every action and

livelihood.

Let's talk of the figures later on. That's another can of worms altogether.

Please address this first.

Ashok Row Kavi

Humsafar Trust

Mumbai Metro

E-mail: <humsafar@...>