The APAC experience

Two HIV-positive women with their HIV-positive daughters at the Government Hospital for Thoracic Medicine, Chennai. - M. LAKSHMAN /AP

The Chennai-based AIDS Prevention and Control Project has, in the last nine years, contributed immensely to spreading awareness about and removing the stigma associated with AIDS.

IN a nondescript village in Tamil Nadu, a woman is digging earth at a feverish pace at a spot where human habitation ends and an expanse of sewage begins. She has been doing this for several days now, unmindful of the blazing peak-summer sun. Ask her why she is doing this and she replies without any emotion: "I am digging a grave for myself." If the resignation on her face and defeat in her voice shock you, her story will move you to tears.

Suguna was driven out of her in-laws' house after her husband died of Acquired Immune Deficiency Syndrome (AIDS) and was ostracised by the village after she tested positive for human immunodeficiency virus (HIV). She lost her one-year-old son to the deadly disease after two months of desperate efforts to feed the sick and hungry child. Now she is digging a grave for herself very close to where her child is buried - she knows very well that no one is going to do it for her when she succumbs to the disease. "At least in death, let me have some dignity," she says.

The over 5 million HIV carriers across the country may empathise with Suguna, but a majority of the rest of the population either indifferent or ignorant of the victims of the virus. It is to shake them out of this attitude that peer educators from non-governmental organisations (NGOs) affiliated to the Chennai-based AIDS Prevention and Control Project (APAC) have adopted Suguna's story as the script of a street play. The play has moved many an audience. To prevent and control a disease that has eluded cure in the past two decades, communication appears to be the only effective weapon, and APAC's street plays have struck a chord.

There has been a dramatic rise in HIV infections over the last decade in India. From a few thousands in the early 1990s, it has risen to around 5.1 million in 2004. The medium of transmission of HIV is diverse: in some States, through sex with multiple heterosexual partners, in some others through the use of shared needles for intravenous drug injection. Thus, tracking the pandemic and designing effective programmes to deal with it pose a serious challenge. But one model that is projected by the National AIDS Control Organisation as "effective" and "worthwhile" is APAC's, which has managed to slow the spread of HIV/AIDS among the high-risk groups in Tamil Nadu - the State with the highest number of AIDS cases (about 37,000) in the country.

In 1995, nine years after the first case of HIV was reported in Tamil Nadu (first in the country too) the APAC project was formulated under a tripartite agreement among the Voluntary Health Services (VHS) in Chennai, the United States Agency for International Development (USAID) and the Government of India with the primary objective of preventing and controlling the spread of HIV/AIDS, particularly the cases of sexual transmission, which account for nearly 90 per cent of HIV infections.

In the last nine years, APAC has crossed many milestones and contributed immensely to spread awareness in the State about the AIDS virus. Its success comes from its meticulously planned, well-networked and systematically researched approach, which has been carefully calibrated to meet the changing needs, demands and responses of target groups.

APAC has focussed on developing programmes to reduce sexual transmission of the virus; building the capacity of the NGOs involved in the AIDS prevention effort; increasing access to condoms and providing quality care for those affected by sexually transmitted diseases (STDs); marshalling political and civil society support for AIDS prevention and care programmes; creating awareness on HIV/AIDS by dispelling myths surrounding it and bringing positive behavioural changes among the target communities to adopt safe sexual practices; and monitoring the effectiveness of its programmes.

According to APAC Project Director Dr. P. Krishnamurthy, the organisation has concentrated on four high-risk population groups - long-distance truck drivers, commercial sex workers, tourists, and youth in urban slums - for targeted intervention, and has adopted five strategies to achieve its goal. The strategies are:

1) Supporting NGOs financially and technically: APAC funds and provides technical help to some 72 carefully selected NGOs, which work in one of the following thematic areas that the APAC has identified to fulfil its mandate: prevention along the highway (PATH), women in prostitution (WIP), slum intervention programme (SIP), tourists and women in prostitution (TWIP), clinical intervention programme (CLIP), men who have sex with men (MSM), migrants, integrated STD/MCH, care and support, and industrial intervention programme (IIP).

2) Preventing and controlling STDs: APAC gives importance to controlling the spread of STDs using five strategies: spreading peer education, promoting condom use, creating awareness through street plays and other local art forms, and setting up a network of trained medical personnel for the promotion of quality STD care at the local level.

3) Promoting condom use: APAC has been actively promoting their use, particularly among the high-risk group. APAC entered into a contract with three condom manufacturers - JK Ansel, Hindustan Latex Ltd and TTK-LIG - which cover specific areas in Tamil Nadu. Innovative schemes for retailers and consumers were introduced to increase the sale of condom. Within a year of implementing this strategy, over two lakh single-piece condoms were sold by 2,337 outlets.

4) Inducing behavioural changes: Crucial to this is effective communication, and APAC adopted various strategies, ranging from advertising and mobile exhibitions to street theatre and folk arts, for this. APAC empanelled five advertising agencies, which designed posters, leaflets, prescription pads for doctors and audio-cassette covers to spread the message of condom use. It extensively used attractive posters on public transport to spread awareness and remove the stigma attached to those afflicted with STDs/HIV/AIDS.

It has established three Resource and Training Centres - at Chennai,Madurai and Kanyakumari - to train the trainers in traditional media. For the first time in the country, APAC established Demonstration Centres for targeted interventions. For truckers (Association for Rural Mass India or ARMI, Villupuram), women in prostitution (CSR, Nagercoil) and slum population (Development Promotion Group or DPG, Tiruchi). APAC has also set up Information Technology Centres that are hubs of information on STDs/HIV/AIDS.

Periodically, APAC publishes newsletters, in English and Tamil, highlighting its activities and reporting on developments of global/national interest.

5) Research and Monitoring: Its research covers such areas as mapping different target groups, assessing their high-risk behaviour, estimating the prevalence of STDs in the community, checking the quality and distribution of products and services, and assessing community needs. APAC has also done research to understand the behaviour of high-risk groups and the spread of HIV/AIDS. An advisory group of 60 experts helps APAC in its research effort.

Though APAC focusses on the treatment of HIV/AIDS patients - by providing them with information and medication and attending to all their physiological needs - it gives equal importance to the psychological and psychosomatic aspects of HIV positive persons who are stigmatised and ostracised by the community. APAC has launched programmes to educate people about caring and supporting persons who are infected and also train the victim's family to deal sympathetically with him/her.

APAC constantly monitors its efforts through regular surveillance surveys, the results of which are used to monitor and guide APAC's programmes and activities. The information on behavioural changes among the target groups helps APAC modify and improve its intervention programmes every year.

Behaviour Surveillance Survey (BSS): This annual exercise scientifically done by APAC, to monitor and study the impact of its work, is one of the best by any HIV/AIDS society anywhere in the country.

HIV Risk Behaviour Surveillance Survey in Tamil Nadu: APAC has conducted eight such surveys in Tamil Nadu. The objective is to know the trends in sexual behaviour among the high-risk groups. Since 2000, these surveys have been conducted every year among the urban and rural population; Pondicherry was included in 2001.

This rigorous exercise helped in studying the behavioural changes among various population groups targeted by APAC. The study generated quantitative, qualitative and observed data on behavioural practices.

The results of the 2003 survey indicate a rising level of knowledge among all groups on HIV/AIDS and STDs.

Rural survey: Under Behaviour Surveillance Surveys in the rural areas (the TNSACS conducted the first two rounds of BSS-Rural), over 7,200 personal interviews were done in 20 blocks.

The 2003 survey showed that the awareness on HIV/AIDS was high compared to that on STDs, and that it has also increased over the two previous years. The knowledge level of the disease among females is lower than that among males. Condom use among commercial sex workers had increased from 51 per cent in 2000 to 82 per cent in 2003.

STD health care survey: This detailed study in 10 Tamil Nadu towns was undertaken to ascertain the appropriateness of the clinical management provided to health care seekers, or to those reporting symptoms of STD and to determine the proportion of patients reporting STDs and receiving appropriate advice. APAC also uses this survey to create awareness about STDs among the various high-risk population groups and to motivate them to seek medical help voluntarily.

APAC supports five Continuing Education and Training Centres (CETCs) to train STD health care providers. To understand the impact of its efforts and also to strengthen the programme, APAC conducts STD Health Care Providers Survey once in two years. The study is conducted among practitioners of allopathic and indigenous systems of medicine who treat a minimum of three patients a week. This year the study was extended to understand the training needs of government doctors also.

Community Prevalence Study: This scientific study aims to understand the prevalence of both transmitted diseases syndrome and the etiological conditions of those who have tested positive for HIV.

The HIV Sentinel Surveillance: This is a collation of epidemiological information on the distribution and spread of HIV infection relevant to the planning, implementation and monitoring of HIV/AIDS prevention and control programmes. The latest survey was conducted in 79 sentinel sites and covered antenatal clinics and STD clinic attendees, intravenous drug users, female commercial sex workers and men having sex with men. Cross-sectional studies of HIV prevalence rates are carried out at regular intervals among these sentinel groups. The trends in HIV infection are monitored across time and place.

Women and HIV

Over 22 per cent of HIV-positive persons in India are housewives with one sexual partner. The increasing HIV prevalence among women is also leading to a rise in the mother-to-child transmission of HIV and paediatric HIV cases. Thus, this year's World AIDS Day theme is: "Women, Girls, HIV/AIDS" with a tagline "Have you heard me today?" This theme implies equality for women in the effort to fight HIV/AIDS.

Owing to unequal gender relations - social, economic and political - women are disproportionately affected by the epidemic. Researchers estimate that women's risk of HIV infection from unprotected sex is at least twice that of men's. Low socio-economic status and economic dependence prevent many women from controlling their own risk. With little negotiating power, they are often unable to insist on safe sex.

APAC has programmes to train commercial sex workers in other income-generating activities so that they are economically secure even after getting out of the flesh trade.

At least half the STD-infected women are asymptomatic and do not even realise they have a problem. Women are much less likely than men to seek timely treatment for STDs for this reason. The stigma attached to STDs, especially for women; inaccessibility to clinics; lack of money; and many other responsibilities prevent them from going for treatment.

Strategies to prevent the spread of HIV, such as promotion of condom use, reduction in the numbers of sexual partners and treatment of STDs have failed to address social, economic and power relations between women and men. Among the key strategies to control the spread of the epidemic, particularly among women, is to make men more responsible. APAC tries to involve men in its activities.

Youth and HIV

It is estimated that 50 per cent of all new HIV infections are among young people (about 7,000 young people become infected every day), and that 30 per cent of those living with HIV are in the 15-24 age group. The vast majority of young people who are HIV-positive do not know that they are infected, and hardly a few know the HIV status of their partners. Focussing on young people is likely to be the most effective approach to confronting the epidemic. The majority of the reported cases of AIDS are in the 15-44 age group. Realising this, APAC is now focussing its efforts on educating women and college and high school students.

A deadly disease like AIDS, which defies cure, demands a different kind of response to keep its spread in check. With its extensive networks, support services and trained personnel APAC has come up with such a response, and rightly is its model termed the best available in the country.