In the Vyasarpadi section of this city, the prostitutes stay behind closed doors. But on a recent evening, the men milling about, possibly heading inside to pay for sex, were the target audience.
Against a backdrop of rain, with a crowd gathered around, a street theatre troupe performed and drew on Tamil song and dance—but with a message far from tradition. They shouted brand names of condoms: “Masti! Nirodh! KamaSutra! Moods! Kohinoor!” They urged the crowd to use them to protect themselves from HIV and other sexually transmitted infections.
Such interventions, coupled with making condoms available in the paan shops and tea stalls around areas where sex can be bought, have helped make Tamil Nadu—the place where India’s first case was discovered in 1986—unique because the rate of new infections of HIV have levelled off, according to experts. High literacy rates, a strong health care infrastructure and a political will to combat the problem—absent in many parts of India—all drive the success here.
“No other state is doing as well,” says Ashok Alexander, executive director of the Bill and Melinda Gates Foundation’s Avahan India AIDS initiative, which has deployed $258 million (Rs1,058 crore) since 2004. “Most other states have prevalence levels that continue to rise among high-risk groups and even the general population.”
Tamil Nadu first
Amid differing statistics and views of India’s progress in fighting AIDS and HIV, Tamil Nadu’s success stands out. Current government estimates show 5.1 million HIV and AIDS patients in India, while UN figures place the number at 5.7 million, or less than 1% of the country’s 1.1 billion people. However, the official estimate is expected to fall drastically, possibly by half, when the government releases new numbers based on data collected using different scientific methods, say recent media reports. Officials have declined to comment on the data until they finish the analysis, but say that they are likely to make an announcement by July.
The prevalence of the virus in Tamil Nadu when measured among pregnant women at clinics around the state—on which the government bases its numbers intended to represent the general population— has consistently dropped over the past few years—from 1.1% in 2001 to 0.5% in 2004. The percentage of infected men who seek treatment at clinics for other sexually transmitted infections has also fallen by half—from 16.8% in 2000 to 8.4% in 2004.
“Here (in Tamil Nadu), you have a really strong civil society sector coupled with an active, engaged and committed bureaucracy,” says Padma Chandrasekaran, a Chennai-based senior programme officer for Avahan. These general health indicators place Tamil Nadu ahead of other states, except Kerala, she added.
In Tamil Nadu, the fight against the epidemic started soon after India’s first AIDS case was isolated in a Chennai laboratory. A scientist there, Dr Suniti Solomon went on to found a leading non-governmental organization?(NGO), the Y.R. Gaitonde Centre for AIDS Research and Education (YRG Care), which has led the way for one of the most renowned treatment and prevention programmes in India.
“We got our programmes started very, very early and that makes a big difference,” says?Dr N. Kumarasamy, an epidemiologist and chief medical officer for YRG Care. “We were the first state...to develop a state AIDS control organization and the first to start caring for positive people.”
Programmes such as the ones employed in Tamil Nadu figure prominently in the National AIDS Control Organization’s (Naco) Rs11,585 crore third phase of the national AIDS policy, which aims to distribute more than three billion condoms across India and perform more than one million interventions among female sex workers alone, over the next five years, say observers.
Initially, Tamil Nadu’s focus was on targeting those with the highest risk to keep the epidemic from spreading to the general population, say Kumarasamy and officials from the South India AIDS Action Programme (Siaap). Money to combat the disease also flowed in through the AIDS Prevention and Control Project. The programme, established in 1995 and funded by the US Agency for International Development and the Voluntary Health Services, deployed NGOs to target truck drivers, sex workers and their clients with education programmes.
Whether or not that works in the long-term, remains to be seen. Doctors say that even though infections have plateaued, they are seeing the effects of the epidemic since people often get sick five or 10 years after being HIV-infected.
“In 1999, we used to see two or three new patients a week. In 1995, 1996 and 1997 it was five patients a week. By 2004, it was five new patients a day. Now, they see anywhere between five and 10 new patients a day,” says Kumarasamy, whose clinic treats 10,000 patients, adding that at first they were sex workers,?truck?drivers and their wives. Now, they come from all walks of life—IT, software?professionals.?“People you wouldn’t expect,” he says.
Prevention efforts in Tamil Nadu now have moved to community-based interventions within high-risk groups run by people who know them best.
Organizations such as Siaap organize sex workers and men having sex with men (MSM) to combat the disease at the local level. These smaller organizations are expected to garner the vast majority of the funding set aside for prevention programmes in the third phase of national AIDS policy. But some grass root workers question whether the initiative will be deployed effectively.
“The way we do it is we take the grass roots people we are working with—say MSM or sex workers—and form them into collectives. They put down a deposit then pay monthly dues, so the money comes from them. It’s not handouts,” says N. Muthukumar, senior manager for community advocacy, Siaap.
Since 2003, Siaap has focused on preventing violence against marginalized communities—particularly among female sex workers and MSM—and worked with the authorities to prosecute offenders. “They face a lot of harassment from both goondas and the police. The idea is to get them to fight for their own rights,” says Muthukumar.
In the Chennai slums, organizations such as Population Services International (PSI) not only use street theatre troupes, but also pass out pamphlets explaining condom use and contact numbers of doctors who can treat sexually transmitted infections. A large billboard mounted on the back of a truck that features a dancing cartoon condom and prevention messages in Tamil follows the organization’s street teams in and around the city.
While prevention programmes have worked in Tamil Nadu, it remains to be seen how easily and quickly they will replicate in the rest of the country—where observers are uncertain if conservative political parties will embrace billboards with dancing condoms, let alone condone discussions about them in the street—enough to cut the epidemic off in the early stages.
Implementation and strong, consistent leadership on this issue have made Tamil Nadu different, said Sujatha Rao, Naco’s director general. “Donors have also focused a lot of money and resources there from beginning and have benefited from that. They’ve taken that help and used it well.”
“I think it’s fair to say that you’re going to need a far different approach in North India than you have in the South,” says Alexander. Avahan’s programmes target India’s highways and the six states with the highest incidence of the disease: Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Manipur and Nagaland.
For some of the northern states, while overall rates of the disease are low, some observers say they see emerging “hotspots” in some districts of Rajasthan, Orissa, Gujarat, and along the Nepali border in the North-East—areas where literacy rates and health infrastructure aren’t nearly as strong as in Tamil Nadu.
And since the Naco plan takes the fight to the district level, it could be an effective way to fight the epidemic in these emerging hotspots through “laser surgery”, as opposed to rolling out widespread prevention efforts where they aren’t necessary, concludes Alexander.
Double Spend on HIV, say experts
The Global HIV Prevention Working Group, a panel of leading AIDS experts, called for global spending on the epidemic to double over the next three years, in a report released on Thursday.
Prevention strategies targeted at high-risk groups— sex workers, men who have sex with men and injecting drug users—may avert half of the 60 million HIV infections expected by 2015. It also sugests scaling up prevention programmes that are scientifically proven, such as male circumcision and those that reduce the risk of mother-to-child HIV transmission.
For every person who began treatment in 2006, six people were newly infected, it said. Expanded prevention iniatives may slow new infections to two million a year.