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‘HIV/AIDS strategies working in India’

Jul 25, 2008

Last year India had revised its HIV figures downwards. Sujata Rao, head of National AIDS Control Programme in India, says the country now needs to sustain the turnaround and then work towards elimination of this dreaded disease.

Sujata Rao is head of the National AIDS Control Organisation (NACO), which provides leadership to the HIV/AIDS control programme in India through 35 HIV/AIDS prevention and control societies.

Sujata Rao.jpg

As Director General of NACO since November 2005, she commands a staff of 150 and an annual budget of Rs 1,100 crore.

In an interview with Rashme Sehgal, she explains why the HIV/AIDS programme in India has been “a very successful” and major public health programme.

Rashme Sehgal: What are the implications of the correction in the HIV figures, from 5.7 million to 2.5 million?

Sujata Rao: It will not affect the HIV/AIDS programme in any way. We operate with the same budget. After all, whether we have one case or five million cases, HIV/AIDS remains a recognised public health problem.

We are in the business of preventing the disease and prevention is always more expensive. This change in numbers has not impacted the amount of money that has been allocated to us. Our budgets remain the same.

To give you an example, we may have just 100 polio cases but that does not mean we do not vaccinate 150 million children to prevent polio.

The earlier panic and exaggerated estimates that in the next ten years we would have 25 million AIDS victims is now behind us.

Earlier, it was being made out to be a runaway epidemic and resulted in a tremendous amount of depression among patients.

Now we know the strategies are working. No epidemic can be controlled in a day. We need to sustain the reversal and then work towards elimination. Let us not forget that if we are not vigilant, the figures can shoot up again.

RS: Is AIDS skewing the priorities of the public health system? Some health experts have suggested that a larger AIDS allocation has meant less money being allocated for other diseases.

SR: I don’t think there is a substitution effect. Nor do I believe HIV/AIDS is taking away money from other diseases. You must not forget that it has no cure.

Therefore, in a quantum sense it is more expensive to treat than other diseases. Tuberculosis can be cured within six months and the cost of the medicines is much less than that of HIV/AIDS. AIDS is a much more complex disease to treat.

RS: How much funding is HIV/AIDS receiving through the Global Fund and how has this impacted the ART (Antiretroviral Therapy) programme?

SR: We receive $700 million from the Global Fund, the World Bank gives close to $300 million, United States Agency for International Development (USAID) has given us $ 150 million for five years, United Nations Development Programme (UNDP) has given $15 million while the Bill and Melinda Gates Foundation also gives us a substantial amount of funding.

RS: What are the numbers of people suffering from HIV/AIDS at present?

SR: There are over 30 lakh HIV/AIDS patients. Of these, 10-15% are from the higher socio-economic strata. They are teachers, businessmen and so on while 80-85% belong to the poorer sections of society – labourers, truck drivers and farm workers.

Thirty per cent of those affected are women. These women acquire it not because they are having extra-marital relations, but from their husbands. Most of these women have been found to be in a monogamous relationship with their husbands.

RS: Is that why people feel there has been an increasing feminisation of HIV/AIDS?

SR: This terminology used to be utilised especially with an increasing number of low-risk women getting infected. What we mean is that women are getting infected also because they are more vulnerable. It helps provide us with a gender perspective.

Also, it must be remembered that at the care-giving level, they bear a disproportionately higher burden because they are care providers in a family.

RS: What is the prevalence of HIV infection among sex workers (SW) and men who have sex with men (MSM)?

SR: Prevalence in the SW and MSM population is about 8-10% as compared to those in monogamous marriages where prevalence is 0.3%. Eleven per cent of truck drivers are HIV-positive, as was highlighted in a recent study.

RS: Which states have the largest number of people with HIV/AIDS?

SR: Seventy-five per cent of cases are found in Andhra Pradesh, Maharashtra, Tamil Nadu, Kerala, Nagaland and Manipur.

RS: Why is prevalence higher in these states?

SR: These states are more affluent. They have more inter-state migration by the single male who belongs to the sexually active age group.

Such a male is living away from his family for long stretches of time. They have the paying capacity and so can transport the infection unlike those belonging to poor, backward communities who do not have the money and therefore are not in a position to build a sexual network.

It all depends on migration flows and the ability to buy sexual services. This is the flip side of development.

RS: Is the government going to club the ART and TB treatment programmes? Now that it is supplying second-line treatment for HIV, will government also give drugs for multi-drug resistant TB (MDR-TB)?

SR: We have two centres that are providing second-line drugs for AIDS. These are JJ Hospital in Mumbai and Tambaram in Chennai.

Those who have developed resistance require more sophisticated patient management. Another four centres are being opened in Gujarat, Andhra, Karnataka and Manipur.

RS: What is the status of the HIV vaccine research? Controversies surrounded the first trial of a vaccine in Pune.

SR: At the National Aids Research Institute (NARI) in Pune, the Phase 1 trials did not succeed but the Phase 1 trials in the Tuberculosis Research Centre in Chennai have been successful.

They have to enter the second and third phases. These trials will, of course, take a much longer time because they will involve hundreds of people and will involve getting their consent and a great deal else.

RS: As a major health programme how successful has the HIV/AIDS programme been? How exactly is this success being measured?

SR: It has been a very successful programme given the high levels of heterosexual transmission with their propensity for multiple partner behaviour.

Our statistics show the figures at 0.36%. If we had not intervened, the figures could have been 1-3% of the population. In South Africa, the epidemic is 18%.

As far as behaviour sentinel surveillance is concerned, Tamil Nadu does it every year. We have targeted one lakh adults and encouraged them to use condoms.

Also, we have helped bring down the number of their sexual partners in some areas including Andhra Pradesh and Tamil Nadu.

The MSMs and sex workers comprise our core group. The problem with the former is that they are basically underground.

Many of them are married and have children. Revoking Section 377 of the Indian Penal Code would help them come out. At present, we get hold of MSMs by contacting MSM organisations. We access them through these groups.

A lot of work needs to be done with sex workers who also remain very vulnerable. They will not use condoms in their desire to earn money. We need to build a rapport and also build risk perceptions among them.

RS: A number of NGOs working in this field have been blacklisted after being accused of misappropriating funds.

SR: I think this has been exaggerated. Some NGOs had not submitted accounts and vouchers, others had committed financial and administrative mistakes, while some did not want to participate in this programme any more.

I would say there are around 1,000 NGOs working on various aspects of this disease. From these, 25% have been accused of financial mismanagement.

RS: Is the National AIDS Control Programme (NACP) designed to take on the epidemic? What are the lessons learnt from NACP 1 and 2?

SR: We have to focus now on rural areas and shift our focus to youth, women and children – they really are most vulnerable in the years to come. When we say rural areas, it is, as the prime minister said, a comprehensive package of services. That will be our approach.

We will also look at what can be done at the community level, at the level of the primary health centres and sub-districts. That will be our major challenge. We would also try to saturate people who have high-risk behaviour with appropriate interventions.

You cannot have a testing centre in every village. There has to be a certain population that the Voluntary Counselling and Testing Centres (VCTCs) must command.

RS: The VCTCs require trained counsellors and laboratory technicians who can do the tests.

SR: These are scarce skills and we are yet to develop them. Most definitely, we will start with 30-bed Community Health Centres (CHCs).

There are about 2,500 to 3,000 CHCs in the country. As years roll on, we will move on to Primary Health Centres, one for every 30,000 people. Our focus would therefore be to deepen access to these services in rural areas.

RS: What efforts are being made to include access to ART drugs among the more marginalised groups?

SR: From the one million AIDS patients we have identified, 35% are under ART treatment. The other 65% do not need it. A patient has to satisfy certain clinical conditions before he is put on drugs.

ART drugs for a month are presently available for Rs 550. We have to beat down the prices even further.

If you include the expense of the CD-4 count test that has to be done twice a year, the cost works out to Rs 7,600 per year, per patient. If you buy ART drugs in bulk, it can be slightly cheaper.

RS: Are you planning to install condom vending machines for female condoms?

SR: We have already sanctioned a Rs 4 crore pilot project on female condoms. Each imported female condom costs Rs 45 at present.

Although imported condoms are being used for the pilot trial, an Indian laboratory has also developed female condoms. The project will be implemented with the help of the State AIDS Control Societies.

Condom-vending machines are certainly an empowering tool for women.

RS: You have cautioned against drug resistance to HIV/AIDS. Could you please elaborate?

SR: In the UK, 9.9% of HIV-infected persons were found to be drug-resistant even before they got started on antiretroviral therapy. If this happens, people have to go for second-generation drugs that are phenomenally expensive.

In India, it would cost a minimum of Rs 10,000 every month per patient. Who can afford this? Even the government will not be able to afford it, let alone individuals.

Drug resistance to ART can develop either when the person living with HIV/AIDS has not taken medicine regularly or when a person with drug-resistance establishes sexual contact with another person.

We have to be very careful that we do not create this risk pool of such persons.

Source : Infochange
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