More than two decades after India’s first case of HIV/AIDS was discovered in Tamil Nadu in 1986, the government has begun rolling out its most ambitious strategy yet to fight HIV at the grassroots level. As part of this, it plans to open district-level offices in many parts of the country and deploy as many as four lakh workers and volunteers, according to public health officials.
But those same officials question whether the programme, which will cost more than Rs11,000 crore and still needs to meet Cabinet committee approval, will succeed, given the lack of infrastructure and knowledge to combat the epidemic at local levels.
The proposal marks the third phase of the government’s HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome) policy since the National AIDS Control Organization (Naco), the arm of the health ministry tasked with coordinating the nation’s response to HIV/AIDS, launched its first national policy in 1992.
The latest plan will require a “staggering” deployment of resources in a very short period of time, said Ashok Alexander, director of the Bill and Melinda Gates Foundation’s India AIDS initiative, Avahan, which has deployed $258 million in HIV prevention programmes here since 2003. “The numbers really are quite unbelievable. It’s arguably the largest scale-up ever undertaken in HIV/AIDS,” he said.
The plan, developed along with several patient advocacy, non-governmental and international aid organizations, is described as wide-ranging and ambitious in its goals for the treatment and care of India’s 5.7 million people estimated to be living with HIV/AIDS—and prevention for countless more—over the next five years. It aims to reduce new HIV infections by 60% in states with the highest rates of the disease, and to reduce new infections by 40% in states considered vulnerable to the spread of the epidemic in the first year, according to a draft of the plan obtained by Mint.
Many targets in the new plan are significantly higher than in the last round. For example, the government wants to take the number of condoms distributed from 2.3 billion to 3.5 billion per year. It wants to more than double the number of female sex workers reached to one million, and close to double outreach among males who have sex with males and intravenous drug users, according to a draft of the policy and sources familiar with the goals under the last initiative.
To combat the increasingly rural face of the disease in India, the new policy relies greatly on the district level for the first time, with state AIDS control societies also taking up a much larger role. Every district—there are more than 600 in India—will have a local AIDS control and prevention unit, overseen by the state.
Taking the fight to this level is necessary as differences in the epidemic, even between neighbouring districts in the same state, can be vast, said Alexander. “HIV prevention is a very local game and you need plans that reflect local realities. It is absolutely the right thing to do.”
Even though India has the largest number of HIV infected people in the world, according to UN estimates, the 5.7 million infected represent less than 1% of India’s 1.1 billion people. That’s a much lower portion of the population than in places like South Africa, where 5.5 million, or one in five adults, are estimated to be be living with HIV/AIDS.
“On the whole, it is a decent programme,” said Dr Denis Broun, country head for UNAIDS, the joint United Nations programme for HIV/AIDS, who was involved in drafting the policy. But the challenges will lie in implementation since the plan relies on strong state AIDS control societies that don’t exist in nearly all cases, never mind the lack of capacity at the local level to control an epidemic that has grown slowly here, he said.
“Naco, by going to the district level, has set itself up against a very difficult situation,” said Broun.
Sujata Rao, Naco’s director general, was out of the country and unavailable for comment, according to an operator who answered the phone. Several calls and text messages to the Naco official to which comment was referred went unanswered. A separate Naco official declined to comment, except to confirm that the plan is pending Cabinet committee approval, but began implementation earlier this month.
The programme has identified and will concentrate its efforts and funds on more than 100 districts where the rates of the epidemic are high and will also draw on capacity building initiatives at the National Rural Health Mission in order to strengthen the response at the district level, said Broun.
It also calls for training 40,000 community and district level outreach workers and recruiting four lakh volunteers to perform outreach at the most local level in currently under-served sections, particularly rural women and youth, over the next five years.
Avahan has a dedicated $23-million programme to train and build programme management and staff capacity at the national and state level through 2009. The foundation has also embedded a team with Naco and hopes to do the same with some of the states, according to Alexander.
The problem, say some organizations that work in the field, is that some states don’t even spend the funds they already get from Naco. Several people who track the epidemic and work on prevention initiatives attributed that to a lack of political attention to the matter and general inefficiency.
“If you have bad management coupled with weak political will, how much of what you intend, no matter how good it is, actually will happen?” asked Ashok Rau, executive trustee and CEO of the Bangalore-based Freedom Foundation, which operates HIV/AIDS treatment and support centres. “I’m sceptical.”
Much of the funding and intervention activities has been concentrated in the six states in the South and Northeast with the highest rates of infection. The Avahan project, for example, funds prevention programmes in Tamil Nadu, Karnataka, Maharashtra, Andhra Pradesh, Manipur and Nagaland, as well as along the nation’s highways to reach high-risk population such as long-haul truck drivers.
Apart from taking the fight against the disease local, the plan also significantly expands resources devoted to treatment and care initiatives and monitoring programmes, dedicating Rs1,953 crore for care, support and treatment and Rs360 crore for new monitoring initiatives, according to a plan draft.
Despite the increased attention on treatment and care in the new plan, Anjali Gopalan, executive director of the New Delhi-based Naz Foundation (India) Trust, which runs HIV prevention and treatment programmes, says the new plan remains “weak” on treatment.
Prevention efforts are slated to garner close to 70% of the resources in the new plan, mainly through interventions with groups at high risk for contracting HIV, but also through outreach efforts in the general population.
SPREAD OF THE RED RIBBON (Graphic)