Yes, you're positive, but there's nothing we can do
By Sandhya Srinivasan
What can the National AIDS Control Programme achieve in the absence of
integration of HIV-related services into the health system as a whole?
The second in a series assessing the HIV/AIDS situation in India
When the National AIDS Control Programme was first set up in 1992 its
first priority was to make people aware of HIV.
HIV is transmitted through unprotected sex, infected blood and blood
products and from an HIV-positive pregnant woman to her baby either
during pregnancy or through breast-milk. The programme publicised these
In some ways the programme took a bold step by starting to talk about
sex - the main route of transmission of HIV - in a society which didn't
like to talk about such things. Public information campaigns were
launched which actually spoke of how HIV infection was acquired - and
how it wasn't, through casual contact, for example. These continue to
meet with resistance: some feel that talking publicly about sex corrupts
the young and is antithetical to Indian culture. Doubts have also been
expressed about the quality of information provided: some messages seem
to confuse and create fear more than they educate.
The programme also sought to provide a bare minimum of preventive
services by protecting blood supply and setting up an effective
treatment programme for sexually transmitted diseases (people who
already have certain STDs are more vulnerable to HIV if exposed to it
through sexual contact, so treating STDs would make people less likely
to get infected with HIV if exposed to the virus). Finally, the
programme worked at developing a system to monitor the prevalence of HIV
in various parts of the country by conducting unlinked anonymous tests
on STD clinic users, commercial sex workers, injecting drug users,
pregnant women attending antenatal clinics, and gay men.
Phase II: More of the same
The second phase of the National AIDS Control Programme (1999 to 2004)
tries to take all these activities one step further and build on them.
The primary focus of the second stage of the programme has been
'targeted intervention' to increase awareness among those believed to be
at high risk of infection, and to change their behaviour. This includes
the promotion of condom use among these groups.
Other activities include developing a safe blood supply through the
establishment of properly-equipped blood banks where all blood is tested
for HIV and other infections before use; promoting blood Alternative Treatments and
banning trade in blood; setting up testing centres where people are
encouraged to go for testing which is preceded and followed by
counselling; further establishing STD treatment services, and setting up
a programme to provide a short course of anti-retroviral drugs to
pregnant women reporting to antenatal clinics who test positive for HIV
(called the PMTCT or prevent mother-to-child transmission programme).
Phase II of the NACP also has, as stated objectives, the provision of
decentralised services and strengthening of the system's long-term
capacity to respond to HIV.
Finally, the number of sentinel surveillance sites, conducting HIV tests
for monitoring purposes, increased dramatically in the second phase.
These were in STD clinics and antenatal clinics and among groups of sex
workers. As a result, it is believed, surveillance data collected in the
last few years may present a more accurate picture of the prevalence of
HIV infection in India. (Still, the programme continues to be plagued by
queries about the quality of its data and many limitations have been
noted by public health experts and activist groups.)
NACP II was implemented at the state level using state AIDS control
societies, autonomous bodies headed by a senior civil servant, but with
independent financial authority. These societies funded voluntary
organisations to carry out prevention.
The targeted approach
Overall, the targeted approach dominates the second phase of the
National AIDS Control Programme. The targeted approach is touted as a
success story in states like Manipur and Tamil Nadu where HIV prevalence
has reduced among target groups such as injecting drug users (in Manipur),
commercial sex workers and clients of STD clinics (Tamil Nadu). Indeed,
surveillance figures for 2000 and 2001 show a drop in HIV prevalence in
targeted groups in a number of states. However, it is not clear if
figures for the two years can be compared. Interestingly, the NACO
website does not contain any HIV prevalence figures after 2001.
The programme quotes reports from successful AIDS control efforts to
argue that the best way to reduce HIV transmission is to target
interventions at groups most vulnerable to HIV. These vulnerable 'core
transmitter' groups are preferred for interventions to groups that are
more difficult to identify and approach, such as clients of sex workers.
It is true that in the US and Australia, for example, well-organised
information programmes for gay men, by organisations of gay men, are
believed to have brought a sharp reduction in HIV prevalence relatively
soon after the appearance of HIV infection in these groups.
What about those outside the target group?
A number of activists have complained that the targeted approach misses
people who are outside the target group. So, for example, messages on
the risk of unsafe sex between men are presented only in situations
where men congregate to have sex with other men, or to groups
self-identified as having sex with other men. Since messages on the
risks of gay sex are not presented to the general population, those who
do not identify themselves as gay are excluded from important
Likewise, partners of injecting drug users risk acquiring HIV but there
are few efforts to speak to them as a group.
Targeting groups for interventions also stigmatises these groups.
Surveillance figures in recent years indicate that HIV infection is not
confined to the 'target groups' of people with high risk behaviour. A
number of women who are HIV positive report having had sex with only one
partner -- their husband. However, there is no effort to reach the 'low
risk' woman and discuss how she might protect herself from infection.
Need for quality counselling
The general call for people to get themselves tested for HIV is not
supported by counselling services before and after testing. The
voluntary counselling and testing centres (VCTCs) set up by the
programme are reportedly under-staffed and counsellors are often poorly
trained. There are too many reported incidents of people being informed
of their HIV status in front of other patients, of little or no effort
being made to educate those who test negative of how to avoid risk
Yes, you're positive, but there's nothing we can do for you
It must seem particularly unjust to those who are encouraged to test
themselves and find themselves HIV positive, that they have nowhere to
A few voluntary organisations do provide treatment and support but they
can meet just a fraction of the demand for such care. In general, both
private and public health services are completely unprepared to respond
to the growing need to care for people with HIV. Private services
generally refuse treatment, or provide it at exorbitant costs to those
who can afford it. Very few public health services are equipped to
provide treatment of any kind. Drugs are in short supply, as are
protective materials to be used for all patients (following universal
precautions). And few personnel have been trained in standard procedures
to prevent transmission of HIV or other infections. The kind of resource
allocation, education and regulation needed to ensure treatment to
people with HIV-related health problems do not exist.
In such a situation, there is no scope for treatment with anti-retrovirals
through the public health system, a demand made by some groups working
with people with HIV.
A weakened health system
There is much talk about integration of HIV prevention and treatment
into the system. However, not only are preventive programmes patchy and
integration poor, there is no integration of HIV-related services into
the health system as a whole.
Further, public health services in India have deteriorated steadily over
the last few decades. There is no evidence of efforts being made to
strengthen the health system and prepare it for a growing burden of ill
people. Barely 20% of all health-related expenditure is made by the
government; the rest is within the private sector, where payment is made
by individuals spending their own money since health insurance is
available to a negligible percentage of people in India. The increase in
HIV-related problems calls for increased government spending on health.
As more awareness is generated and more people test positive, this
demand is bound to grow.
This increase in government spending on health is a decades-old demand.
Instead, the amount spent on health has gone down, not up. There are
innumerable instances illustrating the collapse of health care through
the government, from the rural primary health centre all the way up to
the municipal hospital representing the tertiary level of care.
Equipment does not work, drugs and other materials are not available,
staff are absent, and so on.
In fact this general deterioration of public health services actually
increases people's vulnerability to HIV as shortages encourage the reuse
of unsterilised equipment.
Further, the absence of treatment may in fact exacerbate the stigma
attached to HIV.
HIV is driven by inequities
HIV is intrinsically linked to poverty and to inequalities of all kinds
- social, economic and gender. However, awareness and other preventive
programmes do not address inequities that are intrinsic to the problem.
The married woman is unable to refuse her husband unprotected sex. The
commercial sex worker will not insist on her client using a condom if he
threatens to go elsewhere. The national HIV programme fails to take into
inequities into account.
(InfoChange News & Features, July 2003)