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New optimism, old challenges: Prioritising high-risk groups at the frontline of AIDS

Dec 01, 2012

James Robertson argues that while India’s admirable progress in achieving an estimated 50 per cent reduction in new HIV infections deserves accolades and emulation, yet it should not be mistaken for victory over the epidemic.

2012 has been a year of heightened public optimism about the future of HIV/AIDS. From UNAIDS audacious “Getting to Zero” campaign to US Secretary of State Hillary Clinton’s aspiration for an “AIDS-Free Generation,” everywhere it seems that the end of AIDS is finally on the horizon.

New strategies and new tools have injected new hope into the global response. Last summer’s International AIDS Conference was abuzz with the potential that antiretroviral treatment has to prevent HIV transmission by reducing a treated person’s infectivity. Our investments in treatment can now be understood to contribute to limiting the epidemic’s spread: a virtuous cycle of responsible public health.

Yet this optimism has emerged as governments anddonors are questioning the scope and scale of their HIVfunding. Excitement notwithstanding, who will fund treatment as prevention when we still struggle to fund treatment as treatment? In low and middle income countries, we’re a long way from relying on drug regimens to control this epidemic. Barely a quarter of the 34 million HIV-positive people around the world are currently being treated, and the quality of care remains variable at best.

Political will to scale up treatment has not yet coalesced, and even if it does, it will not suffice. Pharmaceuticals and other tools remain only part of what is needed for us to masterthis epidemic. Expansion of treatment must be coupled with more and better-focused prevention. Weneed to significantly increase our efforts to address HIV among those most at-risk, even if they are not politically popular or socially accepted. And we must address larger structural factors that continue to impede our progress the world over.

As we observe World AIDS Day 2012, India has made admirable progress. The collective and collaborative efforts of government, civil society and donors have contributed to an estimated 50% reduction in new HIV infections. This has been no small accomplishment. It rightly deserves accolades and emulation, but this progress should not be mistaken for victory over the epidemic.

After South Africa and Nigeria, India has the third largest population of people living with HIV: 2.4 million. India’s epidemic is concentrated in high-risk groups: sex workers, people who use drugs, transgenders, and men who have sex with men. Each of these groups bears a burden of social marginalization, stigma, and criminalization or legal discrimination of one form or another.

In spite of these challenges, India’s momentum addressing HIV in part can be attributed to a focus on prevention of HIV in these groups motivated not by dogma but by data.Though marginalised, these high-risk populations remain epidemiological priorities for India's HIV response. India's national AIDS strategy has long understood that HIV prevention efforts must emphasize those most at-risk.

But getting prevention right is only part of the challenge. All aspects of HIV services need to be able to attend to the needs of these groups in ways that protect confidentiality, afford access and maintain dignity as essential elements of quality treatment, care and support that complement and strengthen targeted prevention.

To achieve these ends, building community institutions for these groups to collaborate with the government, clinical partners and other stakeholders still needs more support. Again and again, engagement and empowerment of these communities has proven not only to the most effective strategy to address vulnerability to HIV, but it also serves to improve overall health and wellbeing.

The scale of India’s epidemic still must give us all pause. Rapidly and silently, its dynamic could change if we fail to expand our efforts at this critical juncture. Next year, the Government of India will launch its new HIV strategy (NACP IV), developed in a process that incorporated insights and guidance from high-risk groups. Our task over the next five years will be to ensure that these priorities remain vital and at a scale necessary to have an impact across India’s sometimes overwhelming complexity. Even as India continues to lead the way, the challenge to the rest of the world will be to follow India’s lead.

James Robertson is Country Director of India HIV/AIDS Alliance based in New Delhi.

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