AIDS and some concerns

Print edition : October 23, 1999

As international agencies pour in funds for AIDS programmes in India, doubts are raised in some quarters about the priorities.

MAHARASHTRA has the highest reported incidence of Acquired Immune Deficiency Syndrome (AIDS) cases among the States of India. As of August 31, 1998, according to the National AIDS Control Organisation (NACO), 417,844 persons were screened in the State an d 45,864 of them were confirmed sero-positive or infected with the Human Immunodeficiency Virus (HIV), which causes AIDS, and 3,251 had full-blown AIDS. The State also has the only known cases of infection by HIV-II, a mutated form of HIV, of which there are only two other reported cases in South Asia - in Sri Lanka. According to a 1997 World Health Organisation (WHO) report, the estimated number of people infected with HIV in India are 2.5 million.

On September 28, Maharashtra received $41.5 million from the United States Agency for International Development (USAID) for an AIDS control project to be implemented by NACO in collaboration with the State government. The project, which will receive the USAID funding over a period of seven years, seeks to increase the use of effective and sustainable means to reduce the rate of transmission and mitigate the impact of HIV and other Sexually Transmitted Infections (STIs) and related infectious diseases in the State.

While NACO will implement the project, many more agencies will be involved in the field work. The donor agencies will work closely with the Maharashtra AIDS Society, the Mumbai District AIDS Society, non-governmental organisations (NGOs), private health care providers, municipal authorities and community-based groups. A Health Department official said: "The role of NGOs is crucial because they can operate more freely than government agencies and I admit that they also have better credibility than govern ment medical bodies."

In the red light district in Mumbai.-

Pramod Nigudkar, Deputy Director of the Mumbai District AIDS Society, said: "We will be the facilitators and provide both technical and financial support.'' Nigudkar believes that AIDS control is possible only through a multi-sectoral response from socie ty since AIDS has to be treated primarily as a social rather than a medical problem, especially considering the fact that there was no known cure for the syndrome.

There are three known routes by which HIV spreads and the project would look into all three. The commonest route is sexual intercourse, homosexual and heterosexual. A WHO publication has said that the nature of the virus makes women more vulnerable than men to AIDS because the transmission of HIV from male to female is more efficient than from female to male. Women are more vulnerable also because of their low status in society which limits their choices. It has been noticed that persons suffering from STIs were susceptible to HIV infection. In Maharashtra, STIs figured among the top five diseases for which adults sought medical help. The project planned to vigorously target this group.

The second route of HIV transmission is through infected blood and blood products and contaminated needles and syringes, including those used by injecting drug users (IDUs). The rate of HIV transmission is highest in the northeastern States.

The third route is from an infected mother to a child during pregnancy, at birth or after birth. The possibility of HIV transmission at these stages is believed to be 30 per cent. The trend seen in many countries is that the virus spreads quickly to the general population. Women are increasingly infected, and the number of instances of pregnant women passing on the infection to babies has risen. The programme aims to treat pregnant women. This would involve the use of antiretroviral drugs - as yet an ex pensive and controversial method of treatment.

Nigudkar outlined the main target groups of the project as long-distance truck drivers, migrant workers, street youth, commercial sex workers (CSWs) and their children, patients with STIs and IDUs. In essence, the programme will follow the IEC strategy - Information, Education and Communication - propounded about 12 years ago when the first phase of the battle against AIDS in India was taken up with funding from the United Nations Programme on HIV/AIDS (UNAID) and the World Bank. Although the programme projected the goal of AIDS control, it was generally known that the initial seven-year period was one of learning rather than implementation. "Now we will put into practice what we learnt between 1992 and 1999," said Nigudkar.

Government agencies and NGOs agree that the most effective way to control AIDS is to influence sexual behaviour. "The only way we can do this is by educating them and by implementing complementary programmes to ensure the detection and cure of STIs and t uberculosis (TB), safe blood transfusion procedures and safe injecting behaviour," said Nigudkar.

One success story of the IEC approach is the NACO-WHO project implemented at Sonagachi in Calcutta's red light district in 1992 (Frontline, December 29, 1995). The project initiated an STI-HIV intervention programme for CSWs. The baseline survey r evealed a high percentage of women with STIs. A clinic was established in the area. After a year another survey showed that the number of STI cases had dropped by 30 per cent and the awareness on STI and HIV increased by almost 100 per cent.

FOREIGN funding was increasingly becoming a source of controversy in the field of AIDS control and care. Earlier this year the World Bank sanctioned funds totalling $250,000 for the second phase of another all-India AIDS control programme. For the first phase, from 1992 to 1997, the Bank had allotted $84 million. And UNAID is expected to release an as yet unstated amount for the same programme soon.

Many social workers have objected to the estimates on AIDS cases in India. Requesting anonymity, a worker with an organisation that has received foreign funding insisted: "There is no AIDS pandemic. This is just a big scare." Another social worker descri bed the vast foreign funding as "a dollar-driven agenda with the final goal of using people with AIDS in India as guinea pigs for vaccine trials. Just look at the figures these funding agencies throw at us. Four million! Elleven million! It is unrealisti c to put a number on AIDS or HIV-infected cases."

The 1997 UNAIDS Report on the Global HIV/AIDS Epidemic and the World Health Organisation said: "In India, infection rates, at under 1 per cent of the total adult population, are still low by the standards of many countries, although it is well over 10 ti mes higher than in neighbouring China. Surveillance is patchy, but all indications are that between 3 and 5 million people in India are living with HIV. Even at the bottom of that range, India is the country with the largest number of HIV-infected people in the world. Testing on pregnant women in Mumbai showed infection rates of around 2.4 per cent in 1996."

On a global scale, the same report estimated that 30.6 million people lived with AIDS at the end of 1997, of whom six million were in South Asia and South-East Asia. The report also said: "Nine out of 10 infected people in the world do not know their HIV status. At current estimates, that would suggest there are over 27 million people in the world today who have no idea that they are infected."

In April this year in New Delhi, the parliamentary Standing Committee on Dreaded Diseases said in its report that one in four HIV-positive persons worlwide is in India.

Another common complaint is that funds should be spent for the control of TB and malaria, diseases for which there are cures rather than spending on what one social worker called "a lost hope". Social workers allege that the figures of TB are inverted an d projected as possible AIDS figures and that the blood samples that are taken into account are largely from people who practised high-risk behaviour, such as CSWs and truck drivers, and the test results projected as being representative of the general p opulation.

Workers spoke of the desperate need to change the attitude of the medical profession towards AIDS patients, both in terms of doctors turning away AIDS-affected people and families being informed of person's status vis-a vis AIDS without the consen t of that person.

Some social workers feel that funding is not sufficiently oriented towards care and relief of AIDS patients. "The need of the moment is relief from AIDS. We have seen women who were thrown out of their homes because their families suspected they had AIDS . People have lost their jobs because of social stigma and fear. What about this segment of people?" asked a social worker who says that hardly any funds have been spent to provide relief to AIDS patients.

Health activists and workers say that any AIDS control programme should extend its reach to encompass safe management of blood and sperm banks, management of hospital waste, precautionary measures in hospitals, availability of drugs, provision of counsel ling and terminal care services and sensitisation of the medical profession.

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