NACO and HIV/AIDS in India

Javed M Iqbal *

The human immuno-deficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), is the leading infectious cause of adult deaths in the world. Given the scale of the epidemic, HIV/AIDS is now considered not only a health problem, but also a developmental and security threat. Even if a cure is found tomorrow, the toll of death and suffering by 2010 will far exceed any other recorded human catastrophe, any other previous epidemic, natural disaster, war, or incident of genocidal violence.

India is experiencing rapid and extensive spread of HIV. This is particularly worrisome since India is home to a population of over one billion. As a single nation it has more people than the continents of Africa, Australia and Latin America combined. The situation is graver in States like Tamil Nadu, Maharashtra, Andhra Pradesh and Karnataka.

A report by the World Bank released at the 16th International AIDS Conference says that India is home to 60 per cent of South Asia's HIV patients. The NACO and UNAIDS paint a contrasting pictures of HIV/AIDS estimates in India. According to the UNAIDS 2006 report, out of an estimated 46 million people living with HIV worldwide, 5.7 million people are living with the virus in India, more than any other country in the world.

On the other hand, NACO's projections shows that by the end of 2005 there were 2.5 million people were infected by HIV. The UNAIDS statistics reveals that India is the most infected country surpassing South Africa. On the other hand the Union Health Minister renounces the UNAIDS claims and asserts that India stands next to South Africa in terms of number of people living with HIV/AIDS.

These figures make it very difficult to ascertain the exact status of AIDS cases in India. It is unfortunate that even after more than a decade of existence of the National AIDS Control Organisation (NACO), the nation is still debating the accuracy of the HIV/AIDS statistics.

It seems that instead of addressing the issues of primary concerns, NACO is involving itself more in trivial cases of data projections and collections. The much-needed treatment, healthcare and infrastructural development has taken a back seat in the current strategies and policies of NACO. As Peter Piot, the Director of UNAIDS, in an interview with Associated Press rightly said, "At the recent meetings in India, I heard great speeches, but as for action, zero."

Soon after reporting of the first HIV/AIDS cases in the country in 1986, the government launched a National AIDS Control Programme in 1987. The programme stressed on surveillance, screening of blood and blood products, and health education. By this time, the HIV/AIDS had already attained an epidemic status in the African region and was rapidly spreading in other parts of the world. Realising the intensity of the epidemic, the Government of India, with the support of the World Bank, established the National AIDS Control Organisation in 1992 to enhance the ongoing programmes.

The same year that NACO was established the government launched the National AIDS Control Project under which State AIDS Control Societies were set up. The purpose of the setting up of State AIDS bodies was to carry out NACO's AIDS control programmes. NACO's initial efforts were to control sexually transmitted diseases, to promote condom use, to provide testing, counselling, care and support for people with HIV/AIDS, to conduct surveillance, and minimising harm for injecting drug users, to provide blood safety and blood products and supporting research and product development.

Unfortunately, these efforts remain a dead letter as no serious steps were taken for effective implementation. Even the prime HIV/AIDS control measure, like making HIV screening mandatory in all blood banks, was initiated only due to the landmark Supreme Court directive in 1996.

Still after more than two decades of HIV/AIDS in India, the issues and concerns remain unaddressed. NACO's initiatives were inadequate in combating the new millennium pandemic and are focused mainly on urban populations rather than rural. Its reluctance to intervene in prevention efforts in rural areas has in a way increased the epidemicity as the rural populations are more vulnerable and a large proportion of the Indian population resides in these areas.

The epidemic is gradually getting concentrated in rural areas with 58 per cent infections being reported from villages. According to Dr Meenakshi Datta Ghosh, HIV/AIDS is no longer affecting only high-risk groups or urban populations, but is gradually spreading into rural areas and the general population. One can also find an interesting dichotomy in State response in terms of HIV/AIDS awareness programmes. The government- run awareness programmes are more concentrated in urban areas as compared to rural areas.

Thus the increasing susceptibility and lack of community participation in HIV/AIDS prevention programmes. NACO's commitment in dealing with children and women living with HIV/AIDS is quite dismal as there are no specific guidelines for the treatment, care, and support of HIV positive children and women. As per UNAIDS 2006 report, approximately 700,000 children became infected with HIV and 95 per cent of children got the infection from their mothers.

The report also reveals an alarming increase in the number of women with HIV/AIDS, reflecting the greater vulnerability of women to HIV/AIDS, especially in the rural areas. There are about 16 lakh women, aged 15 and above, living with HIV. Despite these burgeoning statistics, NACO's responses are far short of meeting the demands and in their policies, women and children with HIV remain a neglected face.

The AIDS control mechanisms are not well integrated with the basic public health care infrastructural facilities. Surveillance of HIV/AIDS is the weakest link in the health infrastructure and preventive strategy. HIV/AIDS surveillance has been always accorded low priority in national planning and resource allocation causing discrepancies in surveillance mechanisms.

This resulted in inappropriate epidemiological data causing confusions in policy-planning vis-à-vis policy failure. Epidemiological data remains a major weakness affecting policy planning and even today tell us virtually nothing about what is happening in the rural areas. At the same time, there are discrepancies in the surveillance facilities between the more urbanised and less urbanised States.

The more urbanised States like Maharashtra, Tamil Nadu and Karnataka have greater concentration of facilities and technical skills helping them to determine the number of cases while in the case of less urbanised States like Bihar, UP and Rajasthan these testing facilities are lacking. Thereby HIV/AIDS cases in these States always go unnoticed.

In 2003 both Dr R. Feachem, the then Executive Director of the Global Fund to Fight AIDS, and Dr Meenakshi Datta Ghosh as a Project Director of NACO, in separate interviews stated that the epidemic is moving into the general population. Even many surveillance data suggested the same but unfortunately found no takers. Making the situation worse NACO in their prevention policies completely neglected the general population and clinged on to the approach that the epidemic is limited to high-risk groups such as sex workers, drug users and truck drivers and targeting them is the best strategy.

The low status accorded to both prevention and facilities for diagnosis and treatment in rural India is also one of the major reasons for where we are today on the AIDS epidemic map. The supply of anti-retroviral drugs in villages is erratic. Unfortunately, these issues and voices remain relatively unheard. So even 20 years after the entry of AIDS, the issues here remain just as they were. Public health systems are virtually ineffective and therefore seeking treatment is difficult and most villages have no access to these treatment facilities.

In general, India's ART treatment rate at the present stage is also dismal. The UNAIDS 2006 report says that only seven per cent of Indians who needed antiretroviral drug therapy actually received it and a meagre number of 1.6 per cent of pregnant women, who needed treatment to prevent mother-to-child HIV transmission, are receiving it. Even as per some official estimates of the 5.5 million people living with HIV, only 60,000 are on these drugs. Of these, only 30,000 are being supplied through the public health system.

Further NACO's claims on treatment measures fell flat in Supreme Court, when hearing a bunch of PILs, the Court found that against the target of giving ART to one lakh people by 2005 only 33,000 have got the medication by the same year. Later the policy-makers in NACO in a more unfortunate way shifted the target year to 2007.

The simplest and most effective preventive measure like condom promotion was not taken on a massive scale; sidelining this intrinsic care, NACO invested time, resource and energy in organising conferences, seminars, which are unreachable to the majority of the HIV/AIDS patients. A case in point is India's anxiousness to host the International AIDS Conference in 2012, for which the preliminary preparatory work has commenced on a war-footing. This gives an impression that the government is more serious in flourishing the tourism industry rather than spending a few bucks on most affordable prevention measures like condom promotion.

Last but not the least, insufficient budgetary allocation and HIV discrimination strains many preventive efforts. This is evident from the previous experiences where NACO was allotted a meagre $ 38 million of the government's own funds over the 1999-2004 period. Social reaction to people with HIV/AIDS in India further fuels up the crisis.

The negative attitudes from health care professionals and responsible institutions have further worsened the situation. For instance, in Orissa a young HIV+ couple committed suicide after being ostracised by their locality and surprisingly the State AIDS Cell's anti- discrimina-tion unit claims ignorance about the episode.

Similarly in another instance the Orissa State AIDS Cell was completely unaware of the killing of a youth by his community members in Puri as he was HIV+. Such cases are alarmingly proliferating in various parts of the country. To check this injustice NACO is yet to come up with a concrete legislation.

The proposed draft bill against HIV/AIDS discrimination, which was initiated in 2002, is still under consideration of our lawmakers. The lack of such legislation till date raises questions on the seriousness of the government's commitment and strategies.

Thus far India has struggled to curb the AIDS epidemic and it is high time that we should initiate measures to overcome the weaknesses and drawing appropriate lessons from other successful countries like Brazil, Thailand, Combodia, Uganda and Senegal. Here Brazil's case is important and unique because of the similar socio-economic and political set-up it shares with India and India can emulate the Brazilian model.

First, Brazil has enacted a law which ensures HIV+ people and others having opportunistic infections the right to free access to treatment. Secondly, a strong relationship between the government and civil society groups, including the Catholic Church, has reduced the stigma and discrimination associated with the virus thereby allowing the government to work swiftly.

Thirdly, an innovative and mass campaign on condom promotion resulted in incredible increase in condom use among the general population. This strategy is believed to be one of the most important factors in bringing down the AIDS cases. Fourthly, greater emphasis on treatment and care further proved effective in preventing the spread of the virus. As a result, the AIDS cases in Brazil dropped to 620,000 cases, which is far less than previous records.

It seems that our policy-makers perceive the new millennium pandemic just as a health problem rather than a politico-economic threat or national problem. However, Brazil and other successful countries conceive HIV/AIDS as a national malady. It is true to some extent that there is simply no substitute for state action but at the same time it would be unfair to shift the burden of action or inaction on the state.

We should also recognise the importance of collective commitment between individual and the state as a factor for an effective fight against AIDS as reflected in Brazil's case.

Finally, we should be less defensive about the issues and statistics, rather more offensive in actions and interventions. We should recognise that there is a global commitment in combating HIV/AIDS and it is time to act and deliver to all.