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Responding to HIV and AIDS


Responding to HIV and AIDS
                    in India health and nutrition

At one end while it is needed to step up research to understand the rural dynamics of the epidemic, at the other end HIV testing, provisioning of treatment and condoms, quality health personnel and awareness generation needs to be scaled-up as per the rural needs 


Taruni, from Guntur district of Andhra Pradesh recently delivered a healthy baby girl. She is an HIV positive from the district which has the highest HIV prevalence in the country and has been on Antiretroviral Treatment (ART) since the last few years. Early screening and diagnosis of HIV, followed by the treatment regime prevented the transmission of the disease from Taruni to her child - undoubtedly good news for many in the fight to combat HIV and AIDS. 

India has come a long way since 1982, when the first case of HIV was diagnosed in Mumbai and in the same year the first AIDS case reported in Chennai. Thereafter in 1986 the first HIV case through injection drug use (IDU) was diagnosed in Manipur. In India the epidemic is of concentrated nature with almost 90 percent of infections transmitted through one of the following three routes -heterosexual contact, homosexual contact and injection drug use. 

The virus is concentrated mostly among sex workers, men who have sex with men, transgender, injecting drug users, and bridge populations like clients of sex workers, truckers, prison inmates, street children and migrants. At present, there is an estimated 2.39 million people living with HIV, 39 percent of whom are women and 3.5 percent children below 15 years. Broadly, the Government’s response to prevent and contain HIV and AIDS has been through awareness generation and prevention programmes; regular surveillance for HIV and AIDS related data and research focusing on epidemiology of HIV and AIDS.  

Soon after the first AIDS case was diagnosed, the National AIDS Control Organization (NACO) was created in 1992 by the Government to prevent and contain HIV. Since its inception, NACO’s key role has been to oversee the formulation of policies and strengthen prevention through early screening of HIV, expanding the reach of Antiretroviral treatment, provisioning of condoms and enhance awareness for HIV prevention. These have been done through three consecutive phases of National AIDS Control Programme (NACP-I, II & III). 

NACP Phase I (1992-1999) established the administrative and technical basis for Programme management and formed the State AIDS Control Societies (SACS) in 25 states and 7 union territories. The overall objective during this phase was to slow and prevent the spread of HIV with a thrust to prevent HIV transmission. The Programme also aimed at addressing the control of Sexually Transmitted Infections.  During NACP-I, NACO provided nearly Rupees sixty crore, with 40 percent earmarked for blood safety, and 21 percent for awareness generation. “The Programme has managed to make a number of important improvements in HIV prevention such as improving blood safety,” a health ministry official said. 

In 1999, NACP II (1999- 2004) was launched which expanded the scope of HIV prevention activities with an increased budget of around Rupees 250 crore. The focus was to reach out to high-risk groups through targeted interventions - a package of services which entailed behaviour change communication, peer education, treatment of sexually transmitted infections, condom promotion, needle and syringe provision; creating an enabling environment and community mobilization.

During the third phase NACP-III from 2007-2012 the highest priority was placed on reaching to almost 80 percent of high-risk groups including sex workers, men who have sex with men, and injecting drug users. The aim of NACP III has been to reverse the epidemic through integration of prevention and treatment programmes, decentralised effort at the district level, and engage more nongovernmental organisations. A new migrant strategy was launched to reach out to migrants- administered at source and destination points of the migrant populations.  

Over the years, thus, there has been scaled-up coverage, decentralised management and better infrastructure and systems. Latest NACO data accomplishes providing prevention services to overall 31.32 lakh population covering 78 percent Female Sex Workers, 76 percent injection drug users, 69 percent men having sex with men, 32 percent migrants and 33 percent truckers. It has also enabled access to safe blood through a network of 1,127 Blood Banks, Syndromic Case Management through 1,038 clinics, distribution of 25.5 crore pieces of condoms (until Jan 2011), counseling and testing through almost 7500 Integrated Counseling and Testing Centers and setting up 5.46 lakh condom outlets. Behaviour change communication, information education and communication and the much acclaimed Red Ribbon Express train (Phase II) traversing 25,000 kms and covering 152 stations across 22 states have been instrumental in awareness generation for HIV prevention.  

Besides, appropriate programme planning needs data or evidence. As the National AIDS Prevention and Control Policy says “to adopt the right strategy for prevention and control of IV/AIDS/STDs, it is necessary to build up a proper system of surveillance to assess the magnitude of HIV infections in the community.” For reliable data on HIV and AIDS, thus HIV sentinel surveillance (HSS), Behavioural Sentinel Surveillance (BSS) and STD surveillance systems were initiated under the AIDS Control Program.  

The HIV Sentinel Surveillance System covers all the districts of the country and gives HIV related data for Pregnant women attending Antenatal clinics, Patients attending STI Clinics, Female Sex Workers, Injecting Drug Users, Men who have Sex with Men, Migrant Population, Long distance Truckers, Eunuchs and Fisher folk as well as all the high risk population groups, comments NACO. Based on the data, all the districts in the country are categorized as A, B, C and D. Category A refers to high prevalence of HIV and D with lower prevalence rates. Likewise the Behavioural Surveillance Surveys (BSS) have information on knowledge, awareness and behaviors related to HIV and AIDS among general population, youth and different high risk groups. It also throws light on impact of the intervention efforts being undertaken by NACP.  

India’s HIV surveillance system has evolved over the years and has fulfilled several important programme needs ranging from estimating the number of people affected with HIV, targeting the highly affected geographic areas and vulnerable population groups, identifying new sub-epidemics,   and evaluating the impact of interventions, reports NACO. NACO has also recently initiated computerised management information system and a computerised project financial management system, for strengthened tracking and programme monitoring.  

Realising that interventions for control of HIV infection need  to be backed and synergised with quality research, the National AIDS Research Institute was set up by Indian Council of Medical Research in 1992 simultaneously with the formation of NACO. The Institute is located at Pune, Maharashtra and carries out multi- disciplinary research on HIV and AIDS in different parts of the country. In similar lines, towards invigorating research for HIV prevention, the Translational Health Sciences and Technology Institute (THSTI) was launched by Former President of India, A.P.J. Abdul Kalam. This surely how cases the vision of the Government for an integrated and interdisciplinary approach. It also reinforces the importance for research-based and evidence informed programming, to address HIV and AIDS. 

Such multifaceted and concerted efforts by Government and other stakeholders has shown positive results over the years. There has been decline of adult HIV prevalence at the national level from 0.41 percent in 2000 to 0.31 percent in 2009 and among Antenatal Care clinic attendees. Azad recently stated a 56 per cent drop in HIV-related cases in India and duly credited the strong prevention programme which goes hand in hand with care, support and treatment. 

Meanwhile it’s not a very happy state for Rameshwari, an Auxillary Nurse Midwife (ANM). She is expecting her second child, and during her routine Antenatal Care check up it was revealed that she is HIV positive. Monogamous in practice, the detection came as a mix of extreme shock and resentment to her, more so when she was told that she contracted the infection from her husband, who was subsequently diagnosed HIV positive.  is not a singulate voice, but representing any such men and women, especially in remote rural locations, many of whom are unaware of their own HIV status and often unknowingly infect their intimate partners/spouses.  

Recent surveillance data shows that the epidemic is spreading from urban to rural areas, and from individuals practising risk behaviour to the general population, mentions the National AIDS Prevention and Control Policy. Acknowledging their surgence in commercial sex-work, NACP, gearing up for its fourth phase (2013 onwards) calls for evidence generation and interventions for hard to reach populations in the non-brothel, non-street-ased and home-based settings, especially in rural areas.  

Rural population, particularly those along truck routes, migrant labour from rural to urban areas and wives/partners of male migrants are the most vulnerable groups to contract and transmit HIV. Problems compound with poor health infrastructure, restricted access to health facilities, inadequate surveillance, and dearth of knowledge of HIV transmission and reception on prevention among the rural populace.  

National Family Health Survey, Phase III (2006- 7), the most comprehensive household level survey on health issues reveals 'poor knowledge' of HIV transmission and prevention among the rural masses than the urban. While 57.7 percent urban women knew that HIV cannot  e transmitted by mosquito bite, only 28.3 percent rural women had the same information, the survey noted. Similar is the trend among rural male, wherein 67.3 percent urban men were aware that HIV could not be transmitted through mosquito bite, only 44.7 percent rural men know about the same. NFHS III also notes that young women living in urban areas were more than twice as likely as those in rural areas to have comprehensive knowledge of HIV/AIDS. A scanty 1.8 percent in the rural areas as against three times- 5.4 percent in the urban areas, were tested of HIV and received results. Utilisation of barrier/prevention methods is equally bleak, with condom use almost half (29.7 percent) among rural men as compared to the urban counterparts (52.9 percent).  

Thus, with some evidence, much concern, yet little known about the dynamics, context and social impact on people living with HIV and AIDS in rural areas, HIV in rural areas often remains silent and invisible. Discourses are beginning to highlight the need for adequate surveillance and systematic data on HIV and AIDS related deaths among the rural populations. Stakeholders are also concerned in how to ’translate scientific breakthroughs into affordable, accessible and available interventions, customised for the rural poor. ‘Combination Approach’, addressing all the aspects- Prevention, Care, Treatment and Support, tailored for rural areas, could help in addressing the same. At one end while it is needed to step up research to understand the rural dynamics of the epidemic, at the other end HIV testing, provisioning of treatment and condoms, quality health personnel and awareness generation needs to be scaled-up as per the rural needs. This an surely lead to an AIDS free country- with zero incidence of HIV, zero AIDS related deaths and no stigma and discrimination.

Tapati Dutta The author is working with an NGO and specialises on public Health/HIV issues. 


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