Challenges in Karnataka

Print edition : December 31, 2004

The HIV/AIDS control initiative in the State, involving the government and non-government sectors, appears to have begun showing results.

in Bangalore

Wives of agricultural and unskilled workers, particularly those who have been migrant workers, show high rates of infection in Karnataka.-M. LAKSHMAN/AP

SHAHIN TAJ, 22, from Bangalore, pregnant for the second time, starts weeping with relief when told that she has tested negative for the human immunodeficiency virus (HIV). She first learnt about HIV and Acquired Immune Deficiency Syndrome (AIDS) from Noor Saira, the counsellor at the antenatal clinic in the D.J. Halli Government Referral Hospital. This is one of 14 such centres in corporation hospitals run by the Freedom Foundation, an organisation working in the area of HIV care and support. "But can I or my child still get infected?" She listens carefully as Noor Saira explains the infection routes for HIV and how she and her husband can protect themselves.

"I have gained courage ever since I joined the group of AIDS-positive people," said Sarala (name changed), a young widow and a mother of three, who was infected by her husband. She is a member of Milana, a group of AIDS-positive women run by ActionAid. Sarala first knew she was HIV-positive in 1993. When she developed AIDS, she could not afford Anti-Retroviral Therapy (ART). She has survived only because of the treatment she now gets free of cost in the Bowring Hospital in Bangalore.

There is a small but growing response to the HIV/AIDS challenge in Karnataka, as Shahin's and Sarala's experiences exemplify. With an estimated five lakh adults living with HIV infection, Karnataka is among the six high-prevalence States for HIV infection in India. Along with Andhra Pradesh, Tamil Nadu, Maharashtra, Manipur, Mizoram and Nagaland, the State has now a 1 per cent incidence of HIV infection among adults in the general population, with much higher rates in the high-risk categories.

One measure of the outlook for the spread of HIV infection is to compare its incidence among groups with "high-risk" sexual practices with its incidence in the general population. In Karnataka, for example, according to the 2003 Sentinel Surveillance data, collected by the Karnataka State Aids Prevention Society (KSAPS), the prevalence of HIV among patients in Sexually Transmitted Disease (STD) clinics is 10.4 per cent, with one district in north Karnataka reporting the highest prevalence of 27.2 per cent. In the category of antenatal women (80 per cent of women in Karnataka attend ante-natal clinics), the prevalence of HIV infection is more than 1 per cent in 22 out of the 27 districts. In some of these districts, the figure goes up to 6 per cent. This is cause for alarm, as it shows a high prevalence of HIV infection among what is possibly the lowest risk category - women in the general population who mostly report sexual contact only with their husbands. These figures went up in the 2004 survey, with HIV prevalence rates ranging from 1.5 per cent in antenatal clinics to 21.6 among women in the sex trade.

Karnataka thus presents a certain pattern of incidence and spread of HIV infection that dictates the specific nature of the intervention to control the epidemic and reverse the infection rate. The spread of the infection is firmly linked to poor development indicators. The State has a sex ratio of 964, which is even lower in some districts. Male literacy is 76 per cent and female literacy 57 per cent. Data drawn from district-level surveys undertaken by government and non-governmental organisations (NGOs) suggest that groups with mobility - temporary migrants to a city or truck drivers, for example - are vulnerable to infection.

In the State, for example, 2.2 per cent of pregnant women with their husbands in the transport industry tested positive for HIV. Wives of agricultural and unskilled workers, particularly those groups that have been mobile, show high rates of infection. The northern districts of Karnataka - where the devadasi system still exists in varying forms, where economic and agrarian backwardness has traditionally resulted in high levels of migration, and where proximity to the neighbouring States of Maharashtra and Andhra Pradesh has resulted in inter-State movement - have been particularly vulnerable to HIV infection.

The most vulnerable high-risk group remains women in the sex trade. The sex trade takes different organisation forms in different regions, and many of its victims are integrated with society and are therefore `invisible'. Economic and agrarian distress was further fuelled by a three-year drought in the State.

While NGOs are important players in the HIV/AIDS prevention and care sector, the magnitude and spread of HIV infection puts the onus of dealing with this looming crisis primarily in the hands of the State. Given the ramifications of a rapidly increasing HIV infection rate, non-governmental initiatives, however large, well-funded and effective they may be, must function within the parameters set by a national strategy on HIV prevention and care.

The experience of Africa has shown how poverty and underdevelopment provide fertile soil for HIV/AIDS assuming an endemic form. The AIDS endemic wiped out whatever development gains many African countries had made, changing demographic profiles and sharply eroding national incomes. The problem and its portents therefore calls for strong state intervention, as only the state would be able to fund a programme aimed at reversing the HIV infection rate. Secondly, the public health networks created by State governments at the district, taluk and village levels still remain the only agencies for transmitting HIV awareness and treatment. "There is little doubt that the HIV/AIDS crisis in moving out of control," Ashok Rau, Director, Freedom Foundation, told Frontline. "If Africa is any lesson, then development could get wiped out. In India, where health is a State subject, the challenge is before the State governments."

WHAT has been the nature and impact in Karnataka of state policy and programmes to tackle the HIV/AIDS crisis, and how has state policy enmeshed with non-governmental initiatives?

"According to an estimate made two years ago, the total expenditure on HIV/AIDS prevention and care in Karnataka, inclusive of funds from the National AIDS Control Organisation (NACO), the State government, United Nations agencies, and other funding agencies, was in the region of $8 million for a year," a senior government official, who did not wish to be named, told Frontline. "Botswana, on the other hand, with a population of just 1.6 million (roughly the population of an Indian district), spent $99 million in the same period."

While this comparison underscores the need to upscale the HIV/AIDS control programme, it is state funding, sorely inadequate though it is, that keeps the programme going. In Karnataka, for example, the budget sanctioned by NACO for the National AIDS Control Project (II), implemented by KSAPS, was Rs.17.56 crores in 2004-2005, up from Rs.12.22 crores in 2003-2004.

The priorities of the State government's HIV/AIDS control programme is indicated by the heads of expenditure under which funds are sanctioned. For example, the largest head of expenditure, Rs.4 crores, listed under the Targeted Intervention for Groups at High Risk, was towards funding NGOs for targeted intervention in HIV prevention and care. Awareness programmes of various kinds were accorded Rs.2.5 crores. The School AIDS Education Programme received Rs.1.5 crores. This is an innovative programme called Bichu Mathu (`Speak Openly'), which has been extended to all 10,000 high schools in the government and private sectors in the State, in collaboration with the United Nations Children's Fund (UNICEF) and the National Council for Educational Research and Training (NCERT). Community care centres received Rs.1.2 crores.

BROADLY, the State government's AIDS control programme has four components. The first includes all interventions among targeted or `high-risk' groups and is the area where the NGO sector has played a significant role. The KSAPS is providing financial and technical support to 30 NGOs here - six working with migrant workers, 10 with women in the commercial sex trade, 11 with truckers, and one each with children, men in the sex trade, transsexuals, and people living with HIV/AIDS. The second thrust area is preventive interventions for the general population, which includes information, education and communication activities through awareness programmes - in schools, for panchayat members, for hospital workers, and so on. It also includes the Voluntary Counselling and Testing Centres in the district- and taluk-level hospitals, and the fairly successful Prevention of Parent to Child Transmission (PPTCT) centres, of which there are 85 in the State. Mothers are tested for HIV, and counselled in confidence on prevention and management of HIV, in these antenatal centres. The third component is that of low-cost AIDS care and support. This is again an area where NGOs have played a role. There are eight such care centres that KSAPS supports. The fourth component is that of inter-sectoral collaboration, within the government, and between the government and non-government sectors. "Prevention is still our priority," said T. Mukthamba, Project Director of the KSAPS.

A measure of just how much in its early stages the HIV/AIDS control programme is is revealed by the state of ART, the only form of treatment for AIDS, in the government AIDS control programme. First introduced in the public health sector in April 2004, ART covers a woefully small percentage of those who require treatment. ART is expensive and is supplied free under the AIDS control programme. In Karnataka, ART units are functioning in just four government hospitals, two in Bangalore and one each in Mysore and Hubli. Only around 263 persons are on the ART programme, a minuscule number in relation to the five lakh HIV-infected persons, who may at one stage or the other require ART. However, the ART programme is an enormous challenge in itself, as doctors have to ensure adherence to the medication by patients if it is to be effective. The careful, if slow, progress of introducing ART in the State health system has resulted in a high, 98 per cent, adherence rate among users. "In Karnataka we need a scale-up of all programmes to take their reach to uncovered areas," said Vandana Gurnani, Executive Director of the Karnataka Health Promotion Trust (KHPT). "We may then achieve what Tamil Nadu has done, of stabilising the HIV prevalence rate."

In a situation where the HIV/AIDS control initiative is spread so thin, Karnataka has nevertheless worked out a fairly successful model of collaboration between the government and non-government sectors, which has avoided the replication of work. An example of this is the KHPT, a partnership between the State government and the University of Manitoba in Canada, funded by the Bill and Melinda Gates Foundation, which conducts HIV prevention projects in 16 districts with NGO partners. The India Canada Collaborative HIV/AIDS Project (ICHAP), funded by the Canadian International Development Agency (CIDA), has prevention and care demonstration projects in Bagalkot and Dharwad districts. The ICHAP offers technical and management support to other NGOs. The Global Fund will begin funding care and support programmes, including ART, from 2005.

"I think a breakthrough is happening in the AIDS scenario in a small way," said Christy Abraham, Regional Manager of ActionAid, Bangalore, and a member of the group that has adapted Stepping Stones, a training package on HIV/AIDS first developed for Africa, for Indian conditions. "We are seeing better partnership models between the government and non-government sectors in the AIDS control programme. But NGOs need to build successful replicable models and the government structures need a whole new cultural approach to HIV and AIDS.

The HIV/AIDS control initiative in Karnataka, comprising the government and non-government sectors, appears to have just broken the surface of what could become a serious health issue. But a beginning has been made.

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