Re: 50% lesser people with HIV government says. Who will benefit from re-estimates [Part 2]

[Guest guest]

Dear Friends,

The spate of news reports and statements appearing in Indian media and the

networks have prompted me to write this piece purely from a personal point of

view.UNAIDS has already spelt out its stand and my views need not reflect the

views of the organisation (there are not greatly divergent,though ).

I am particularly struck by the tone of anger in Pallava Bagla's article and

despondency in Ramesh Venkataraman's insertion in the (AIDS INDIA) groups.

From these two pieces,one can imagine the frustration caused among people who

feel for the cause because of the utter confusion which followed the release of

the revised numbers of HIV infected persons in the country.The selectively

engineered leaks which preceded the release of the numbers by the Government has

given the whole episode a Harry Potter like mystery and did not help in giving

the exercise the seriousness it needs or deserves.

At the end, we now have two groups of people,one announcing triumphantly that

the 'war has been won' or saying 'did we not say so' and other feeling totally

let down by the euphoria and fearing a loosening of the grip on the AIDS

sitiation by the Government and its partners.

Unfortunately,the national media has,to a large extent joined the former group.

If you followed the story closely, you get the impression that the Government,

under pressure from external agencies including UNAIDS has been consistantly

inflating the number of infected persons to avail larger sums of foreign

assistance for AIDS programmes.

Now that some researchers have brought out new insights in the numbers through

household surveys which showed a substantially lower rate of infections among

the general population, Government has been forced to revise the numbers and

finding it hard to justify the large outlay for NACP 3 which has recently been

launched.

The UNAIDS and WHO who supported the Government's estimates all these years also

stood exposed on the charge of inflating the numbers in India.

It is a very juicy story which satiates the appetite of an average reader/viewer

and makes the breakfast tastier in the morning.

But what has been forgotten is that we are dealing with a deadly virus which has

taken millions of lives across nations and infected millions more. Even the

revised numbers put India's infection level at 2 to 3 million. Add the family

members who are affected. It will be a crore of people shouting for help, for

care, treatment and for a rightful place which the mainstream society has denied

them due to their HIV status. Is this a cause for celebration or introspection?

One reason for the atmosphere of celebration is that India, thank God, is not

the No 1 country in terms of number of infections any more. It will be South

Africa, followed by Nigeria. We are no 3. But is this a cause for comfort?

Somebody can turn around and say, you are still no 1 in Asia! What is our

answer?

To be fair to the celebrators, I feel the blame lies elsewhere. All along,the

people have been fed on the game of numbers and not on the risks or

vulnerabilities which fuel the epidemic. We should not lose sight of the fact

that the reduced numbers have not automatically reduced the vulnerability and

risk factors which are inherently present in the Indian society. And so long as

they are present, none can rest. I can guess, these are the fears of Pallava,

Ramesh and many others who are silent witnesses to this drama being enacted in

the country now.

But,first on the numbers. Ten years back, we were still arguing out that India

is not at risk and has only some 80 thousand 'reported cases '. It took quite

sometime to make everybody that matters understand that reported cases are like

the tip of the iceberg. When the iceberg size was estimated it turned out to be

in millions! To a large extent the first estimation of numbers done in 1998 was

responsible for shaking off the complacency and taking the business seriously in

India. The NACP 2 which was launched at that time as a logical follow up, has

achieved, among others,one principle objective, of keeping HIV on the radar

screen of high level policy makers in India. The limited success it achieved in

some states and not others also shows its uneven ride across various states in

the country.

In 1998, there was also no other parallel source of data as we have today. The

NFHS was only focussing on reproductive health indicators and no other research

study was available for validation /comparison.

The sentinel survey is normally used only to track the progression of the

epidemic and not to estimate the total number of new infections.

But in the absence of any other source of data, it was used by the Government

for estimation purposes. And in helping India make these estimates were several

national and international experts. Prominent among the external ones was Dr Jim

Chin and Dr Stanicky.

While generally endorsing the numbers as the closest one can get to actuals, the

experts recommended constant validation of adopted norms through household

surveys. But it took the country almost 10 years to get any credible survey done

as an alternative source of data. Now that it is available,the numbers have been

validated and corrected.

Somehow this message did not seem to register in the midddle of all the

euphoria.

Will the reduced numbers mean reduced effort or reduced funds for the programme?

The Health Minister has done well in emphasizing that the effort must go on,

whatever are the numbers.

The message is ,it is not the numbers who are infected, but the numbers who are

at risk which should guide the country's effort. And that number has not

changed. In fact with increased economic activity and population growth,it must

have actually increased.

Epidemiologists have shown that in Asia, in a low prevalence but high

vulnerability scenario where sexual contacts acoount for large number of

infections, the single most important determinant for spread of the epidemic is

the number of adult men who indulge in multi partner sex.

And the added fact is that they chase a lesser number of women who are sex

workers,girl friends or transgender men. The largely monogomous Asian women and

their children are the ultimate silent sufferers of the epidemic. None of these

factors are adequately addressed in our response.

Add to this the high level of stigma and the discrimination against HIV positive

people and their families (even by health care providers ) and the job is cut

out for us.

Treatment costs are also not going to alter much because of the revised numbers.

Government has projected ART for 300,000 people in NACP 3.It would have fallen

short of the target if the numbers were 5.7 million.But with 2 to 3 m

infections,India can look to achievement of the Universal Access target by 2010

if Government can cover this number with ART.

The conclusion is,nothing that matters has changed. We still have a huge problem

on hand and the next 5 years are crucial. If the success in Tamil Nadu can be

repeated in other states (easier said than done !) the number of new infections

(or the incidence as experts call it ) will register a fall and will bring down

the numbers further.

That is the REAL reduction which will be the cause for celebration.

J.V.R.Prasada Rao.

Director,

UNAIDS Asia and the Pacific.

BANGKOK.

e-mail: <raojvrp@...>