National AIDS Control Programme: A Critique

[Guest guest]

National AIDS Control Programme: A Critique

Rami Chhabra

Perspectives: Economic and Political Weekly January 13, 2007 103

Condom-centric ways of controlling the spread of HIV/AIDS, coupled

with targeted interventions among high-risk groups, have been

advocated with near-religious fundamentalist zeal for prevention. But

what is urgently needed is a fundamental shift to

an alternative approach, one that reduces risk-exposure and builds an

enabling ethos for strongly reinforcing and expanding the predominant

base of low-risk behaviour/lifestyle patterns through community-based

strategies.

The human immunodeficiency virus (HIV) causes acquired immune

deficiency syndrome (AIDS), which is a condition in humans wherein

the immune system begins to fail, leading to opportunistic infections

that can be life threatening. Infection with HIV can occur by the

transfer of blood, semen, vaginal fluid, Cowper's fluid or breast

milk, the major routes of transmission being unprotected sexual

intercourse, infected blood transfusion, and transfer from an

infected mother to her baby. However, with suitable precautions,

prevention is quite feasible. Safe sexual behaviour and hygienic

medical practices, particularly safe blood transfusion, are two basic

requirements.

In this article, we focus our attention on the technical and ethical

bankruptcy of strategies involving targeted interventions among high-

risk groups (TIHRG). We examine the role of the National Aids Control

Organisation (NACO) since its inception and trace the evolution and

growth of targeted interventions among high-risk groups with heavy

external resource inputs. TIHRG strategies are currently being centre-

staged in Phase III of the National AIDS Control Programme (NACP-III)

with World Bank (WB) and development partner support for a $ 2.2

billion package (more than half of which is allocated to targeted

intervention strategies) for which India is committing nearly $ 1

billion of its own resources to receive $ 250 million IDA-credit,

plus donor packets from the UK's Department for International

Development (DFID) of $ 80 million, the Gates Foundation (GF)

– $ 317 million, and the Clinton Foundation – $ 25 million. Earlier

slated for WB board approval in October 2006, this is now postponed

to January 2007, because insufficient donor commitments have left

a " financing gap " of $ 805 million.1

An examination of NACP Phase I and II reveals the following:

– International funding biases in setting up NACO/NACP in the

vertical thrust mode;

– How little NACO's past record justifies the gigantic expansion of

its programmes;

– Expansion and up-scaling despite poor performance, lack of

accountability and evidence of failure;

– Unreliability of NACO data; and,

– Negative social consequences of TIHRGs.

The International Response

Although an international priority since HIV's identification, the

international community-led response to HIV/AIDS has not delivered

results. Universal blood safety and good medical practices have not

been guaranteed beyond first world countries, while a heavily condom-

centric, sexual transmission prevention bias has befuddled sexual

issues. The escalation of HIV/AIDS to a global pandemic in less than

three decades – 65 million infected, 25 million dead, 40 million

living with HIV2 – underlines the failure of received wisdom. Sub-

Saharan Africa, the earliest site of internationally directed

interventions and the epicentre of the pandemic, is a tragic

testimony.

Originally steered by World Health Organisation (WHO), HIV/AIDS is

the only disease with a dedicated UN agency: the joint UN programme

of HIV/ AIDS (UNAIDS). Since 2000, the coordinated might of nine UN

agencies plus the WB are tackling HIV/AIDS prevention/ management.

Global budgets – far exceeding any other disease – have been pledged.

Funds for low/middle income countries are up 30-fold – from $ 300

million in 1996 to $ 8.9-10 billion in 2006-07, but are still

considered inadequate.3 Mounting gaps – $ 6-8 billion projected over

2006-07, and growing in the future have been identified for

meeting " actual needs " .4

Few dispute the need for urgent action. But notwithstanding strategic

road maps, hammered out at glittering global conferences, concerns

mount on how to deal with the pandemic. World Bank/UN agencies,

actively partnered by Northern governments and foundations, including

the GF, bring homogenised, " laissez-faire " sensibilities to high-risk

sexual behaviour, with a bias towards technology-based fixes.

Condom provision, social marketing, and focused promotion to

different segments, particularly high-risk populations, are the

centrepieces of the AIDS response (2006-08).5 But condom surveys

estimate condom use in only 9 per cent of acts of sexual intercourse

with non-marital/noncohabitating partners in 2005,6 a decline since

2003,7 which is a pitiable outcome of two decades of condom promotion

to prevent HIV/AIDS. But the global juggernaut for condoms is

relentless.

Condom-centric ways of preventing sexually transmitted diseases

(STDs) coupled with TIHRG have been advocated with near – religious

fundamentalist zeal in HIV/AIDS prevention. " Costeffectiveness " and

the claim that this is the " only available preventive method " are

strategic arguments. Ironically, international agencies solicit ever-

greater national contributions to implement their defined

perspective.

New evidence comes from Thailand, a best practices icon in the

HIV/AIDS literature, where there is national promulgation of a " 100

per cent Condom Use in Brothels Strategy " .8 Past HIV prevalence

decline, partly as a result of high mortality from the disease,

partly from fear-propelled reduction of entrenched commercial sex

patronage and multiple partner sex behaviour patterns, alongside

condom use increase,9 has reduced Thailand's adult HIV prevalence

rate. However, a second wave of HIV infection is hitting Thailand,

particularly among monogamous partners of philandering men and men-

having-sex with-men (MSM) and minors.10

The UNDP's report on Thailand (2004) warns that the HIV epidemic is

getting worse. Indeed, it acknowledges sinister new developments:

increased demand for and supply of commercial/casual sex; a 50 per

cent increase in " sex-service " establishments over 1998-2003;11

high " staff-turnover " in " sex-establishments " ; a significant number

of new HIV infections in the sex trade;12 more young people drawn

into the sex trade as workers/clients; rising experimentation with

sex, drugs and alcohol amongst young Thais, including schoolgoers; 13

increasing numbers of " sex workers " , particularly " indirect sex-

work " , operating in diverse, more-difficult-to regulate settings, now

accounting for a sizeable portion of the sex-industry; and

authorities expressing an inability to monitor condom compliance in

vastly increased direct/indirect " sex-service establishments " .

A `Best Practices' Icon?

Soon after the first HIV infection was detected in Chennai in 1986, a

modest HIV/AIDS control effort was launched by an AIDS cell in the

union health ministry under WHO guidance, with a $ 10 million budget,

financed from external sources.15 In 1992 this AIDS cell was

significantly expanded. A $ 84 million IDA credit was sanctioned for

AIDS prevention (NACP-I) conditional to setting-up the quasi

autonomous NACO and accepting a strategy- package16 that included a

blood safety component and surveillance activities, and active media

communication.

A seemingly innocuous community based health research study (backed by

WHO) for ascertaining the incidence of HIV/AIDS/STDs in Kolkata's " red-light "

Sonagachi area17 (HIV prevalence was 0.53 per cent in 1991)18 graduated during

Phase I to the first TIHRG with NACO, Norwegian NORAD and UK's DFID (then ODA)19

collaboration to implement methodologies adopted and extensively funded in

Africa. The strategy was predicated upon non-interference in the illicit

" sex-trade " and bringing about " behavioural change " through condom promotion,

early STD identification and treatment through trained, paid " peer outreach sex

workers " working within the " sex workers " community, without disturbing the

" trade " .20 This small project's key importance is gauged from its multiple

financiers and provision of extensive " technical expertise " – 200-250

international experts over the early 1990s, besides VIP visits, with local

political bigwigs and union home and health ministers attending

inaugurations/seminars to provide legitimacy.21

The Sonagachi project was rapidly scaled up to the West Bengal Sexual

Health Project (WBSHP), with DFID providing £ 3.9 million during 1995-9822 for

254 sites involving nearly 30,000 high-risk persons Its goal: avert

half-a-million STDs, including 860 HIV cases.23 But despite mega funding with

meagre targets, WBSHP's final evaluation report expressed its concern over

rising HIV prevalence rates and

admitted an inability to assess STD/HIV outcomes, for this would have

required a large-scale study involving control groups, raising ethical

considerations, and so on.24

Yet Sonagachi acquired an iconic status in HIV/AIDS circles.

The reality of Sonagachi is worth dwelling upon. Thus, what about HIV

prevention in Sonagachi – the TI prototype/best practices icon – whose

initiators and outreach workers are now experts for the replication of TIHRG?

Strangely, NACO has no independent studies on HIV infection control and the

cost-effectiveness of the Sonagachi project (RTI communication with the author).

Neither are there such studies on Kamathipura, India's biggest brothel area

where TIHRG

projects commenced from the early 1990s. NACO's reports on Sonagachi

consistently project low HIV infection rates (6-10 per cent), long belied by

studies conducted by others, including the Indian Council of Medical Research.25

In 2002, the West Bengal SACS shared studies by the All India Institute of

Hygiene and Public Health showing

Kolkata " sex-workers " having an over 20 per cent incidence of HIV-

infection.26

But Sonagachi has succeeded remarkably in organising large

national/international public assemblies in assertion of " sex-worker " identity,

" sex-workers' cooperatives " , trade unionisation and demand for legalisation of

" sex-work " , recognition as legitimate occupation with workers' entitlements,

pensions, self-regulatory boards, and so on.

Leaders of selfstyled " sex-networks " access top political leaders –

as they did to protest proposed Immoral Traffic (Prevention) Act

(ITPA) amendments penalising " clients " /brothel running as affecting

their " right-to-livelihood " .

The Parliament Standing Committee taking note of this demand could

well help legitimate if not legalise sex as work.27 But has

such " empowerment " reduced the incidence of sexually transmitted infections?

Ignoring HIV infection rate controversies and accepting high condom use claims,

the high rates of STDs and abortions still

highlight continuing HIV vulnerability.

Sonagachi's own surveys reveal a considerable influx into " sex work " .

A recent survey indicated that among the new recruits, a majority are in their

teens or twenties; one third to half engage in group-sex; 87 per cent got

pregnant; 41 per cent underwent abortion, 17 per cent three times or more; 50

per cent underwent STD treatment during the previous year;28 14 per cent never

used condoms; while " always use " condoms indicated 90 per cent of time.29

NACP Phase I

Sanctioned for five years, the $ 103 million NACP Phase I (including

$ 27 million from the union government) extended to seven years. Sizeable

unspent funds were frantically spent in the two year extension period, as NACO

allowed the states to sanction NGOs up to Rs 10 lakh for maintenance and

contingency expenses.30 Rupees 75 crore was spent on communication campaigns in

one year, with one state spending on this account as much as the amount spent by

all the other states.31 Such frenzied media-friendly campaign funding

furnished " evidence " of NACO's efficient gearing-up, making way for higher

allocation of funds for Phase II!

Interestingly, NACP Phase I had no ongoing audit and evaluation.32 An

evaluation was done only after Phase II had begun (experts/activists were

agitated about this, amongst other matters). The Planning Commission recorded

strictures on the way the NACP had spent its funds and was critical of its

funding patterns.33 Reviews by the Comptroller and Auditor General's office were

undertaken and highlighted considerable problems.

Notwithstanding all this, the WB singled out the NACP Phase I as the

only one amongst Bank-financed endemic disease control and health system

projects in India to receive a highly satisfactory rating.34 It dangled $ 191

million IDA credit, linked with $ 100 million bilateral/multilateral grants,

which together with the union government's and states' contributions would be

quite a bonanza for

NACP Phase II.35

NACP Phase II

Phase II (1999-2004) committed India to a dramatic " paradigm shift "

as insisted on by the WB and allied donors. This was to involve setting-up of

decentralised state and municipal-level AIDS control societies (SACS/MACS), as

also registered societies functioning outside government control, assigning a

pivotal position to NGOs in

implementation and a focus on nonjudgmental " high impact prevention

interventions targeting populations engaging in high-risk-behaviours " . The DFID

earmarked Rs 104 crore for sexual health projects in four states, besides West

Bengal, which was subsequently increased to Rs 783 crore and geographically

expanded to include

West Bengal and Madhya Pradesh.36 The targeted intervention (TI)

component's crucial importance was underlined in the overall assessment of

India's capacity to respond to HIV/AIDS, which would be measured by the

percentage of states/municipalities in which SACs are functioning, and the

actual record of effectively managing TIs.37 The experience of targeted

interventions of high-risk groups in Sonagachi and Thailand were specifically

cited to technically justify the selection of the TI strategy.38

Women-activists who condemned " verticalisation " and the conceptually

flawed TI strategy, as " anti-law, anti women, and anti-poor " demanded

an independent evaluation of Phase I and a reexamination of Phase II prior to

its launch.39

The union government had by then already agreed to funding outside

established government procedures and a strategic state response predicated on

tolerance of prostitution (de facto including women being forced into

prostitution), not rehabilitation/reintegration policies for " commercial sex

workers " . Despite the then prime minister A B Vajpayee's assurances to a women's

delegation that

demanded immediate re-examination and rectification, NACP Phase II

went ahead.40 Opposition to the programme was sidetracked by

bureaucrats in the prime minister's office and the union health

ministry (many of these bureaucrats subsequently moved on to

prestigious international and national assignments).

TIHRGs have now acquired such a Midas touch that nobody speaks of

the Emperor's new clothes. Virtually conceding Phase I lapses,

NACO declared for Phase II: " For the first time monitoring/evaluation

(is) made (an) integral part of project strategy " .41 An independent national

monitoring and evaluation agency was to be selected within the first year of the

project and mid-term and end-term evaluations were mandated. Yet, as admitted

under a right-to-information (RTI) complaint, neither mid-term nor end term

evaluations (due 2004

when the project period concluded) took place.42

NACP Phase II was extended till end-March 2006, enabling expenditure of unspent

amounts and Phase III planning. An end-line behaviour impact study was expected

in October/November 2006, but the status of

the mandatory independent evaluation remains unknown. Moreover, NACO's

sponsored research, at huge cost to the public exchequer, has been

unavailable in the public domain.

For long the NACO website was stuck on PR material, the data section was on

" maintenance " mode; it is now operational, with a few reports posted after RTI

activists pursued the matter. The NACP III draft, which has been claimed to be

conducted in " participatory, inclusive " mode, was secured by this writer under

the RTI Act, but is still unavailable in the public domain, as are the `End-line

Impact

Study and Evaluation'.

But available from the Comptroller and Auditor General's office is

the CAG report on NACO's and SACs' performance in Phase II. Reviewing the

programme in its penultimate year, the CAG categorically concludes: " (I)t had

achieved limited success mainly due to failure in generating sufficient

awareness among the masses and the slow pace of the implementation of the

various components… various activities under the programme could not be

conducted efficiently for want of infrastructure facilities, drugs, equipment,

trained manpower, etc…Targeted Interventions…[had] not been conducted

efficiently " .43 CAG picks many holes, both in implementation and financial

handling.

Likewise, in 2005-06 the Public Accounts Committee (PAC) examined

NACO/SACS performance. In summing up, the PAC report states: " Analysis of the

performance of various components of NACP – both Phases I and II revealed that

the programme had achieved limited success due to various reasons such as

failure in generating sufficient awareness among the masses; under-utilisation

of funds;

non-reconciliation of accounts; absence of adequate infrastructure facilities;

lack of adequate drugs quantity of drugs and trained manpower; non-completion of

mapping exercise for identification of Target Groups; ineffective Targeted

Interventions programme; failure of NACO to procure and distribute enough

condoms; inadequate number of STD clinics, modernised blood banks and voluntary

counselling and testing centres in every district of the country, etc, and

non-assessment of the impact of various components of the programme due to

failure of the National AIDS Committee to meet after 2001. " 44

The PAC recommended an immediate independent evaluation to identify

bottlenecks/constraints and suggest measures for effective

implementation.

Targeted Interventions

TIHRG was evaluated in 2003 through a study conducted in over 17

states, according to which the efficacy of implementation, on average, was a

poor 37.8 per cent.45 The DFID – a principal donor cum technical advisor – was

scathing. Its 2003 evaluation of targeted interventions in five states termed

the technical strategy " largely

inappropriate to the epidemiology of HIV/AIDS in India " ;46 deplored

the remarkable sameness of TIs across five states, the poor quality of research

and STD treatment, the lack of attention to social vulnerabilities to HIV/AIDS,

and the irrelevance of " predetermined formats guaranteeing…`standardised'

interventions " .47 DFID's evaluation categorically stated that NACO did not have

the

information to measure the overall progress and impact of the TI component as

NACO's sentinel surveillance system does not provide for it.48 The DFID report

assessed the cost effectiveness of the HIV/AIDS programme as a whole and of TIs

as low; further, the effectiveness of TIs in preventing HIV transmission was

also assessed as low.49 Financial accountability issues were raised. There was

" considerable unease " with one state; " possible corruption in the allocation of

funds by states to NGOs " was " a greater or lesser problem varying from state to

state " . All this raised an " important accountability and transparency issue that

warrants more attention from DFID " .50

But inexplicably thereafter (2004), GF green signalled $ 200 million

support for HIV/AIDS prevention, meant exclusively for TIHRG in six high-

prevalence states, reducing the WB and the DFID to smaller players.

Overall, the linkage of TIHRGs to reduction in the incidence of HIV

is fallacious. Curiously, while the evaluation by DFID describes 300 DFID funded

TIs accounting for 80 per cent of the TIs implemented in India in 2003,51 the

NACP Phase III Draft, reviewing Phase II " achievements " , lists over 1,000 TIs

implemented, 700 covering 6,60,000 " core high-risk persons " .52 If one accepts

the authenticity of these figures, then obviously the majority TIHRGs are

post-2003, and hence their linkage with a reduction in the incidence of HIV is

fallacious.

It is curious that despite the adverse findings of the CAG and the

PAC, DFID dissatisfaction, and the failure to schedule mid-term and end-term

evaluations, the WB is now proactively processing a $ 2.2 billion loan for NACP

Phase III that will " significantly scale-up " India's HIV/AIDS response,

saturating it with targeted interventions.

Despite the poor implementation evidence, as marshalled, the WB

certifies that " India has developed valuable experience " with TIs, which are

projected as generating a " high-impact " with a " multiplier effect " , and

therefore the need for " greater synergy with (the) financing of other

Development Partners " .53

Agenda-driven HIV Numbers

NACO's HIV estimation processes are as cavalier as its

implementation/monitoring/ evaluation record; projections are clearly

agenda-driven. Correspondingly, NACO estimates have zoomed: The end-1994

estimate was 1.75 million HIV-infected, which grew to 4 million prior to the WB

appraisal mission, although Sentinel Surveillance

(SS) published data (1994-98) failed to substantiate the increase and

1998-99 SS data indicated a decreasing trend. 54 Challenged, the NACO

estimated 3.5 million persons as HIV infected (mid-1998).

Subsequently, an expert group estimated the number by suggesting a

range between 2.4 million and 3.7 million. NACO arbitrarily picked the

higher-end, coming close to the WB's estimate of 4 million at the start of NACP

Phase II.55 The WB's estimates and projections when NACP Phase II was on the

anvil were altogether startling in terms of its loose assumptions and

statistical incoherence, e g, 1.3 million new-infections estimated per year;

approximately 1 per cent of the

Indian sexually-active female population assumed to be in " sex-work " ,

4.2 million new HIV cases in India during 1999-2004 without the WB project; 3.7

million new HIV cases with the same project 50 per cent successful; lacking

successful intervention, the WB then projected 37 million plus HIV-infected

persons by 2005! 56

All this perhaps led the Independent Commission on Health in India to

note at the start of Phase II that " Flawed estimates at the outset could result

in scams of enormous public expenditures vindicated through notional reduction

of `infections averted' from levels not scaled in the first place! Fudged

figures as in the family planning

`sterilisation and births averted' claims could lie ahead. " 57

Notably, such disregarded critiques are proving prescient in the context of the

current claims of a decline!

The shrill hype on exploding numbers has since muted. An expert group

is resolving the differences between NACO's estimate of 5.2 million and UNAIDS'

estimate of 5.7 million HIV-infected in 2005; the WB's estimate of 37 million in

2005 has been thrashed. But it should be noted that the current requirement is

to demonstrate that the HIV explosion has been stemmed with the successful

implementation of the TI strategy of NACP Phase II. Pertinently, a study

highlighting

a one-third decline in HIV-incidence in south India got world media-

hyped on March 31, 2006, on the day NACP Phase I I closed.58 The findings –

widely quoted to substantiate Phase II achievements – come from research

spearheaded by a former task force leader during the time when Phase II was

being formulated.

NACO's sentinel surveillance eventually tabulated 1.3 million new HIV

infections over 1999-2004.59 Now the most recent data indicates that the

increase in HIV infected persons is at a snail's pace; the total number of

persons infected is 5.10 million in 2003, 5.13 million in 2004 and 5.21 million

in 2005.60

It is another matter that a plateau may actually have been reached in

the numbers infected. This would vindicate the theory of leading Indian

epidemiologists who have argued that the HIV/AIDS infection, like all other

communicable diseases, would initially spread quickly, saturating the

susceptible, then peak and decline.

They postulated that the declining trend would continue after

the " susceptible " population had been exhausted, unless and until fresh entrants

to the " promiscuity pool " grew by an order exceeding those leaving through death

or reversal of promiscuous behaviour. The key is the extent of promiscuity and

its effective self-restraint.61

This thinking suggests a paradigm shift involving the reduction of

risk-exposure, not harm reduction during exposure, requiring a fundamental

strategic shift from targeted interventions among high-risk groups to

community-based strategies.

This will entail deferring to people's innate wisdom to arrive at appropriate

solutions, together with programmatic inputs concentrated on instituting primary

preventive interventions against causative factors identified by the people so

that exposure to the risks or behaviour in question is tackled together with

effective, appropriate information and counselling, including secondary

preventive measures like condoms.62

Epidemiological theories apart, NACO's SS tracking needs further

scrutiny. The spread of SS sites over the years from 55 in 1994 to 384 in 2002

and 703 in 2005 mocks scientific longitudinal tracking, rendering the shifting

scene non-comparable.

Epidemiologists point out that SS was set up to provide trends, not

magnitudes; sites do not have an additive value, nor are they representative of

the population. Further, trends can be gauged from a fixed number of sites over

the years.63 Queries to NACO

(under the RTI Act) reveal that in a tracking of 170 constant sites

during 1998-2005 showed an increasing trend in 18 STD sites, a decreasing one in

nine STD sites, an increasing trend in 20 ANC sites, and a decreasing one in 14

ANC sites, while in the remainder there is no clear trend (with sharp

fluctuations from year to year).64 Both, NACO's HIV estimates and claims

regarding a decline

lack a scientific basis. Similarly, estimates of numbers exposed to high risks

of being infected with HIV lack scientific rigour. NACP Phase III baseline

estimates for TIHRG provide a fascinating re-run of HIV numbers being inflated.

Participatory mapping of high-risk-persons was a key Phase II output indicator.

Each state spent Rs 5-15 lakh for each " mapping " exercise.65 The expert group on

high-risk estimates received mapping data from all the states (except Tamil Nadu

and Tripura).

The data pinpoints 5,23,000 women who have been forced into prostitution in the

country.66 Highlighting the limitations in mapping, the expert group has

dismissed this figure as a " crude estimate " . With several

adjustments/assumptions, a range estimate is arrived at: 8,31,677-12,50,115.67

NACP III has settled for the higher end of the range. Déjà vu?

Even more loose estimation procedures and arbitrary assumptions

underlie the calculation of the number of MSM. The figure from the mappings of

0.01 per cent of adult males zooms to 5 per cent of two thirds of adult males

considered sexually active. Extrapolating from small studies, 2.3 million MSM

are put in the multipartner category – half selected for Phase III target.68 On

the basis of unverified assumptions, 3 million " vulnerable " truckers are added;

so are 9

million " vulnerable " migrants as " bridge " populations.

NACP Phase III: Flawed Strategy

Thus, a flawed and failed TIHRG strategy using wild guesstimates is

NACP III's centrepiece with an allocation of over half of the Rs 11,585 crore

direct outlay.69 This is a mind-boggling operational blitz, with the condom as

the " Superman " , which is a clear bonanza for the condom lobbies. A distribution

target of 3.5 billion condoms a year is aimed at by 2010, two billion social

marketed, half a billion commercially sold, and a billion distributed free

through

subsidies.70 The basis for these optimistic targets is also not clear; nor is

there a basis to assume consistent/correct

usage on such a scale to justify a huge allocation of funds for

public health.

NACP III's overall goal is halting and reversing the HIV/AIDS

epidemic in India in the next five years by integrating programmes for

prevention, care, support and treatment. But less than 17 per cent of the total

allocation is for care/support/treatment of the 5.2-5.7 million HIV infected, at

least 10 per cent (5,20,000-5,70,000) of whose immunity is seriously

compromised. Treatment and care targets

are cautiously sketched, obviously leaving as many out. For instance,

free ARTs will reach only 3,00,000 persons by 2011. Indeed, the total allocation

for care/support/treatment is under three-fourths of the Rs 2,000 crore that has

been earmarked for a single prevention commodity – condoms. Prevention consumes

two thirds of the total allocation, but blood safety is allocated a mere 8.2 per

cent and communication and social mobilization a mere 8.8 per cent. The

rest is mostly for TIHRGs (nearly Rs 3,000 crore), limited " services " (Rs 1,400

crore), condoms (Rs 2,000 crore), and for an " enabling environment " (Rs 50

crore) for this work, including advocacy for legal changes in the ITPA, IPC,

etc, identified as " hampering " TIHRG implementation.71

In NACP III, 2.3 million " core-transmitters " – 1.0 million

" commercial-sexworkers " ; 1.3 million MSM; 1,90,000 IDU – are to be rapidly

mobilised and organised in groups for outreach within three years.

Half of the TIHRGs will be implemented through new community-based

organisations, but ironically these are of the newly created " communities " of

the " core-transmitters " .

Funding provisions are made for immediate payouts of onetime costs,

fixed recurring costs irrespective of numbers, etc.72 Enormous public

resources are to be utilised to create organisations around sexual

identity/ practice and networking communities exclusively around high-risk

behaviour, not for abandonment of harm- causing habits but persuading persons

engaged in sexual behaviour involving high-risk to go in for " harm-minimising

protection " , i e, condoms, STD treatment, new needles and possibly, substitute

drugs, and so on, the state becoming " proactive for creating safe spaces " 73 for

commercial sex work and other high-risk situations.

NACP III is conspicuously silent on structural socio-economic

vulnerabilities and the root causes of the continuing flow of sub-populations

into situations involving high-risk behaviour. It offers nothing to address

these vulnerabilities through creating viable, holistic alternatives for those

presently entrapped.

Hardly any resources are being dedicated to prevent, rescue,

rehabilitate/reintegrate endangered persons and survivors of " sex work " to

enable to overcome their endangering lifestyles that make them highly vulnerable

to HIV/AIDS. The perspective, targets and

budget allocation are preoccupied with getting high-risk groups to

use condoms, besides addressing " certain vulnerabilities particular to the

commercial-sex-trade " 74 and other high-risk situations, while the 5.2 million

persons living with HIV/AIDS – are not approached with the same zeal and

efficiency.

The NACP Phase III, which will spend $2.2 billion, besides cornering

considerable human resources and public energies, is being launched on a

deficient set-up, strongly censured by the country's public audit systems for

its performance and supervision. This set-up, which needs dismantling, is to be

fortified and up-scaled, contradicting the national rural health mission's

preference for integrated

programmes.

The vertical NACO empire of SACS, MACS and funded NGOs, created by

external fiat, will now further extend to the district and sub-

district level units. Earlier externally-promoted vertical

programmes, e g, family planning, pulse polio, etc have demonstrated,

" convergences " notwithstanding, an erosive effect on the primary

health care infrastructure and delivery-systems (the primary health

centres) that desperately need consolidation and substantive capability

improvement to cater to basic community health needs and critical medicines,

including ART. In other words, functioning integrated public health systems are

needed, not vertical

programmes with a supra-status for one disease, or else, HIV/AIDS treatment/care

itself will be the casualty, alongside other critical health requirements.

NACP III's major component, TIHRG – force-fed to India by external

agencies with very poor implementation results so far – is being taken to an

unprecedented operational scale. This is not only unjustified by past experience

at the national level, but untried at this scale anywhere in the world. The very

scale of this operation

carries serious repercussions, not addressed by India's political

leaders/policy. State and societal legitimisation of " commercial sex work " will

overturn existing societal values of sexual restraint/responsibility that have

acted as the principal bulwark against the rapid transmission of HIV/AIDS so far

and which need to be at the core of HIV/AIDS prevention efforts.

International " evidence-based " showcase examples already

clearly " unravelling " and riddled with second-generation problems afford

valuable hindsight. The Thai experience demonstrates a mechanistic approach

that pragmatically overlooks social-costs which will prove dearer in the long

run, while ironically, failing to dent the HIV/AIDS epidemic. Whatever

Sonagachi's other claims to fame, its HIV infection control profile lacks

credibility. Legitimisation of the " sex industry " must not occur under the

HIV/AIDS prevention mantle.

Towards an Alternative Approach

India needs an alternative approach, one that reduces risk-exposure

and " builds an enabling ethos for strongly reinforcing and expanding the

predominant base of low-risk behaviour/lifestyle patterns yet existing amongst

Indian youth and adults " .

As pointed out by the health experts advocating this: " The entire

trajectory of solutions flows differently depending on the basic approach

chosen " .75 The first step is rejection of NACP-III.

Although it is not within the scope of this article to suggest ways of

operationalising an alternative approach based on a risk exposure cutting

paradigm, formulating and implementing such an approach must be India's top

priority.

Here one can also draw on the Swedish approach, which views women

being driven into prostitution as a form of " male violence " and men

who buy sex as criminal offenders.

The Swedish government does all it can to help women get out of

prostitution. Such an approach can really be an integral part of the

alternative we are suggesting. Harm minimisation efforts, as in

TIHRGs, can only be justified if adopted as a small, carefully calibrated,

" clinical " part of a an HIV/AIDS prevention programme essentially predicated

upon reduction of risk exposure. With commercial sex and injection drug use

identified as core transmission sources, harm minimisation can at best be a

temporary measure to gain a foothold in order to wean away high-risk persons

within a clearly defined time bound plan. A corpus fund dedicated to rescuing,

rehabilitating and reintegrating the " vulnerable " is essential to a

risk exposure cutting approach. Also, calibrated " harmminimisation " requires a

different worldview to prevail, one that is predicated upon an " enabling ethos "

that effectively curbs high risk situations and provides the legal and

structural wherewithal to target and diminish the " demand " factors that fuel

harm exposure, while the supply is stemmed and weaned away, out of the arena of

high risk exposure.

Email: aalna@...

Notes

1 World Bank (2006), `Integrated Safeguards Datasheet', Appraisal

Stage Report No AC2430; prepared/updated November 2001, accessed from

www.worldbank.org on December 3, 2006.

2 UNAIDS (2006), Report on the Global AIDS Epidemic, May, p 4.

3 Ibid, p 24.

4 Ibid, p 249.

5 Ibid, p 226.

6 Ibid, p 287.

7 Ibid, p 287.

8 Lawrence Altman, `Former Model of Success – Thailand's AID Effort

Falters, UN Reports', New York Times, July 9, 2004.

9 United Nations Development Programme (2004): Thailand's Response to

HIV/AIDS: Progress and Challenges, pp 22-24.

10 Ibid, p 45.

11 Ibid, p 52.

12 Ibid, p 70.

13 Ibid, pp 3, 45, 70.

14 Ibid, p 54.

15 NACO (1997-98): Country Scenario, p 4.

16 D Banerjee, `AIDS Threat to India: A Response', Health for the

Millions, November- December 1996, p 26.

17 Durbar Mahila Samanwaya Committee (1997): The `Fallen' Learn to

Rise: The Social Impact of STD/HIV Intervention Programme, p 6.

18 Rami Chhabra (2002): `Sonagachi: An Ignored " Virus " ', Health for

the Millions, p 17; West Bengal Sexual Health Project, 1999; Society

for Human Development and Social Action, STD/HIV Intervention

Programme (2001): `Report of Fourth Follow-up Survey on Sonagachi',

May-June 2001 (mimeo).

19 Durbar Mahila Samanwaya Committee (1997),

op cit, p 9.

20 West Bengal Sexual Health Project (1999): Developing an Effective

Clinical Intervention Strategy among a Sex Workers Community: An

Experience of STD/HIV Intervention Programme (Sonagachi Project), pp

9-10.

21 Rami Chhabra (2002), op cit, p 17.

22 DFID (1997), `Interventions for Sexual Health Andhra Pradesh,

Gujarat, Kerala, Orissa, India: Draft Project Memorandum', New Delhi,

August, p 4 (mimeo).

23 IFH Sexual Health Consultancy – Final Report (1999), `West Bengal

Sexual Health Project Evaluation', September (mimeo), p 38.

24 Ibid, p 39.

25 Independent Commission on Health in India (December 2000):

Presentation made by Members to Member (Health) Planning

Commission of India (mimeo).

26 Lalit M Nath, `The Independent Commission on Development and

Health in India', HIV/AIDS in India: Some Issues, p 27.

27 Rajya Sabha (2006): Parliament Standing Committee on Human

Resource Development's 182nd Report on `The Immoral Traffic

(Prevention) Amendment Bill, 2006', November 2006, pp 15-17.

28 Society for Human Development and Social Action, STD/HIV

Intervention Programme (1998; 2001), `Reports of Third and Fourth

Follow Up Surveys of Sonagachi', April-June 1998; April-June 2001

(mimeo).

29 Ibid.

30 Voluntary Health Association of India, Independent Commission on

Health in India (2001): `National Aids Control Programme: A

Critique' (mimeo), p 6.

31 Ibid, p 6.

32 Ibid.

33 Noting on relevant files by Advisor, Health, Planning Commission,

1998-99.

34 World Bank (1999): Project Appraisal Document on a Proposed Credit

in the Amount of SDR140.82 Million to India for a Second

National HIV/AIDS Control Project Report No18918-IN, May 13, p 9.

35 Ministry of Health and Family Welfare (2001): `National Aids

Control Project, Phase 2 (1999- 2004)', National Project

implementation Plan, May 1999 (mimeo), p 25.

36 www.nacoonline.org/partnership.htm.

37 World Bank (1999): op cit, pp 3, 17.

38 Ibid, p 11.

39 Memorandum handed to Prime Minister by 14 Member Women's

Delegation on December 8, 1999.

40 Voluntary Health Association of India, Independent Commission on

Health in India (2000): `National Aids Control Programme: A Critique'

(mimeo), p 5.

41 NACO (1999-2000): Combating HIV/AIDS in India 1999-2000, p 94.

42 NACO communication to Rami Chhabra in response to RTI Application,

July 25, 2006.

43 Union Government (2004): Report of theComptroller and Auditor

General of India for the Year Ended 2003, No 3 of 2004, pp v-vi.

44 Lok Sabha (2005): Report of the Public Accounts Committee, 2005-

2006, p 185.

45 NACO (2003): TI Evaluation Report, p 6.

46 DFID (2003): `DFID Evaluation of Targeted Intervention in

Reduction of HIV Transmission in Five States in India', September

2003, Second Draft (mimeo), p 9.

47 Ibid, pp 5, 7.

48 Ibid, p 15.

49 Ibid, p 11.

50 Ibid, p 18.

51 Ibid, p 1.

52 NACO (2006): National Aids Control Programme Phase III, 2006-2010

Draft, July

19, p 160.

53 World Bank (2006): `National Aids Control Project III – Project

Information Document (Appraisal Stage)', Report No AB2461.

54 Report of Independent Commission on Health in India

(ICHI), `Consultation with Experts on HIV/AIDS Current Estimates:

World Bank Project Estimates/Assumptions (2000)' (mimeo), p 1.

55 NACO (1999-2000): op cit, pp 5-6.

56 Report of ICHI Consultation with Experts (2000): op cit, pp 5-6.

57 Voluntary Health Association of India, Independent Commission on

Health in India (2000): op cit, p 4.

58 Rajesh Kumar et al (2006): `Trends in HIV I in Young Adults in

South India from 2000 to 2004: A Prevalence Study', www.thelancet.com.

59 www.nacoonline.org/facts_overview.htm

60 www.nacoonline.org/facts_hivestimates.htm

61 N S Deodhar (1998): `Epidemiology of HIV Infection: A Critique',

Indian Journal of Community Medicine, Vol XXIII, No 4,

October-December, pp 176-83.

62 N S Deodhar (2000): `Review of National HIV/ AIDS Control

Programme in India With a View to Make It Community-Oriented, More

Effective and Sustainable', unpublished paper for ICHI (mimeo). Also

see N S Deodhar (2003): `Commonsense and the New Venereal Disease

Called HIV/AIDS', Health for the Millions, Vols 28-29, No 1, pp 21-25.

63 Independent Commission on Health in India Consultation with

Experts (2000):

op cit, p 1.

64 NACO (2006): Communication received under RTI.

65 NACO (2006), Communication under RTI. 66 NACO (December

2005): `Report of the Expert Group on Size Estimation of Population

with High Risk Behaviour for NACP III Planning', prepared by RCSHA,

New Delhi (mimeo).

67 Ibid.

68 Ibid.

69 NACO (2006), National Aids Control Programme Phase III, 2006-2010,

July 19, p 180.

70 Ibid, p 183.

71 Ibid, p 120.

72 Ibid, p 162.

73 Ibid, p 25.

74 Ibid, p 25.

75 Independent Commission on Health in India (2001): `A Call for

Rethinking: National Aids Prevention and Control Policy and

Programme' (mimeo)