HIV/AIDS: Success Becomes the Enemy

In Yamuna Bazaar, under the flyovers of modern Delhi, a virtual sea of broken bodies can be seen -- hundreds of homeless men who live by pulling a rickshaw or sorting and selling garbage. They left their homes in the poverty belts of North India, in search of work in the big city.

And this is where most of them end up, a place with high prevalence of injecting drug use and HIV infection.

And right in the midst of this community, a small and a very basic centre seeks to reduce the harm. It's a non-judgmental space.

A number of people on the staff are former drug users and the services include counselling for HIV testing, a needle syringe exchange programme to discourage needle sharing which leads to HIV infection.  Used needles and syringes are collected.

In another room, trained staff provide opioid substitution therapy. Under their supervision, buprenorphine is taken orally. It reduces injecting drug use since the clients experience less intense drug cravings. There's also a wound and abscess clinic and this drug user was hit by a car while he was sleeping on the roadside.

This targeted intervention under the Delhi State Aids Control Society is run by Sharan, an NGO which conducts one of many programmes across the country that engages with high risk and marginalised populations like sex workers, men who have sex with men, transgenders and injecting drug users.

Among the men we meet today is a former employee of a club, a wholesale tomato seller, and a daily wage labourer. They say injecting drugs is tapering off, reducing the risk of HIV. "I feel healthier, both mentally and physically. I can do hard work now. I would like to quit taking drugs," says Rajinder, a labourer.

However, to ensure adherence to the treatment, the drug users need a detox programme and an income generation programme to help them reintegrate into society. While the outcomes are good, the community is very fragile. To provide enhanced services, the harm reduction centre would need solidity of investment.

While civil society groups are grappling with the critical issue of scaling up services, there comes news of an administrative decision that they believe has implications for the future.

This month, the Health Ministry merged the Department of Aids Control with the Department of Health and Family Welfare. The Ministry says the consolidation of two departments is in line with Prime Minister Narendra Modi's agenda of minimum government and maximum governance.

The Secretary of Health and Family Welfare, Lov Verma, said, "National Aids Control Organisation (NACO) will be governed by the Department of Health and Family Welfare. So there will be no secretary there. It will function as a vertical programme within the Department of Health and Family Welfare, like programmes for control of TB, vector borne diseases. One of the additional secretaries who work under me will be made in charge of NACO, so that the day-to-day work and files can be disposed off at his level. Obviously, he will send me the policy files, and other important things to me."

Over the last 25 odd years, India's HIV/AIDS control programme has gone through different avatars - each clearly seeking to make a positive impact. So why is its latest avatar causing a crisis of confidence among AIDS experts and the community?

The idea of how HIV should be mainstreamed into the Health Ministry is not new. But activists are asking whether it is the appropriate time? More important, will NACO retain its financial and functional autonomy?

According to Dr Sundar Sundararaman, a physician who has worked in HIV since 1986, "HIV is still so real. It's not like polio or leprosy that we only have to be watchful. Only 50 per cent of the work has been done. Only one in two people have been averted from being affected, which means other ones are being infected. The autonomous nature has shown us that HIV is a preventable disease in India provided resources go in time and supply chain is not disrupted."

Sonal Mehta, director of policy and programmes at India HIV/AIDS Alliance, says she is apprehensive.

"This merger will lead to losing of focus. The AIDS control programme has shown maximum improvement after it became the Department of AIDS Control because decision making and responses became faster," she said.

"What are going to be the generation losses? What are we going to lose out on? This programme needs to be strengthened and built. Our targets and our numbers are talking about 10 years ago. In new populations, and new states, we are finding new evidence of HIV transmission, of TB, of multi drug resistant TB, which is working in synergies. And we are actually reducing scale and the scope of our interventions," remarked Luke Samson, executive director, Sharan.

N R Manilal, former national programme officer, NACO, also agreed.

"This programme works with key populations. Men who have sex with men, transgenders, sex workers, drug users, migrant workers.  Is our existing government system equipped to handle such issues," he said.

International forums have showcased India's extraordinary achievements in AIDS Control, a public health success story next only to polio eradication. The number of new infections in the country is down by 57 per cent while the rest of the world is struggling around 30 per cent. At a special session held at the Melbourne International Aids Conference last month, kudos were given to a robust, technically gifted department. It is the only government department to engage with and respond to the concerns of stigmatised populations like transgenders, men who have sex with men, sex workers and injecting drug users.

Laxmi Narayan Tripathi, a transgender activist, says, "We can call them up at 11 in the night and trouble them. We are there to criticise and they take it positively. We own our own projects. The ownership is with the community and then you see the results."

Its success has prompted more than 200 delegates from 15 countries to visit India and learn from its experience.

 Dr Fonny J Silvanus, Deputy National Aids Commission Secretary, Indonesia, said, "We sent some participants from the National Aids Commission of Indonesia three months ago to visit the Avahan project in India. We need to learn from India how to strengthen communities, especially  key populations."

India's commitment to AIDS control has been visible in other ways. Though the share of external aid had shrunk, the Government scaled up its domestic budgetary support to cover 75 per cent of the financial requirements during the 4th phase of the programme.

Laxmi also appreciated the supportive role played by the Health Ministry through NACO when it submitted an affidavit in support of a petition in the High Court contending that Section 377 acted as an impediment to HIV prevention efforts.

The irony is that while India's AIDS control programme has been a global best practice over the last decade, in real time, challenges are being faced on the ground. For one there is a progressive decline in the use of consultation platforms with civil society groups, like technical resource groups that are moribund. Unlike the first three phases of the AIDS Control programme, the fourth phase could end up losing the momentum necessary in dealing with an epidemic.

Analysts say the lukewarm interest in HIV is partly based on a misconception that India has overcome the HIV epidemic.

They say India has not yet turned the corner and has only learnt to reckon with it as a public health response.

India has an estimated 21-lakh people living with HIV, the third highest number after South Africa and Nigeria.

Currently the national AIDS control programme is facing a challenge with an  impasse in finances and goods for services. A breakdown in the supply chain has caused a shortage of critical commodities like condoms, test kits and drugs.

Over 7, 68,000 people living with HIV are provided free first line and second line ARVs by the Government. The national programme recently completed 10 years of ARV. Shortages and stockouts of second line ARVs and viral load testing kits have been reported from across the country.

Shortages lead to lack of adherence and can cause drug resistance which has serious consequences.

This week the Delhi Network of Positive People sent a legal notice to the Department of Health and Family Welfare, asking it to ensure a continuous supply of ARV drugs.

For nearly six months, there have been no funds for programmes and for disbursing salaries in over 1600 interventions in different states. According to new guidelines for all centrally sponsored schemes, instituted by the UPA government, the finances will move from the Centre to the State Treasury. It will then be provided by each state government to the State Aids Control Society (SACS).  But no transition plan was in place. This has badly affected peer educators and workers who have not received any honorarium or salary in this financial year.

The Government says the situation will ease out soon. In fact, it says the changed guidelines will lead to greater accountability as programmes can be audited by CAG. "You know exactly how much you are committing to the state government instead of it being fragmented and distributed in different programs. State can now take ownership and monitor it more closely," says Lov Verma, Secretary, Health and Family Welfare.

The Government has sought to allay fears that NACO will be downsized in program, manpower or financial outlay. The five year programme has a budget of Rs 14,295 crore.
Activists are however demanding greater focus on women and children with HIV who face discrimination at hospitals and within the family. The existing programme has failed to address the social challenge, which is as important as the medical challenge. 
Anandi Yuvaraj, Member, ICW, said, "Just popping a pill does not help. There are so many long term side effects. Is the health sector going to look at that? Or just dispense a medicine and you deal with all your issues?"

According to Prasada Rao, UN Secretary General's Special Envoy for AIDS in the Asia Pacific region, there is need to scale up the programme for prevention of mother to child transmission of HIV.

"Some of the African countries have coverage of nearly 80 per cent while our coverage level is 25 per cent," said Rao.

Probably, the biggest worry is the proposed integration of the national aids control programme with the national health mission by 2017. The government believes the recent consolidation of departments will facilitate and quicken the process of synergies.

Mona Mishra, Consultant, International Development Programmes, said, "Our question is that the current health system that is unable to provide a range of basic services, for example, family planning. Will that same national health service or health system be able to provide HIV preventional services to let's say a sex worker or men who have sex with men? These populations are all under legal regimes that call these groups illegal."

The Health Secretary says while these issues will be worked out, there will be no let-up in the fight to eliminate HIV by 2030, just renewed commitment to the course. Analysts say it may be the right time to address the concerns of the community. Clearly, it will be as much an opportunity as a challenge.




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