IN the summer of 1981, the Center for Disease Control (CDC) in the United States reported that five previously healthy homosexual men in Los Angeles were suffering from an unusual type of pneumonia caused by Pneumocystis carinii, a parasite normally harmless to humans. CDC also reported that 26 previously healthy homosexual men in New York and Los Angeles had developed a rare form of skin cancer called Kaposi’s sarcoma. These reports signalled the arrival of a mysterious acquired disorder of the human immune system, which disabled the body’s defences. This, as we know, is how it all began.
HIV (human immunodeficiency virus), once considered solely a sexually transmitted disease (STD), is now known to be also transmitted through the sharing of unsterilised needles among injecting drug users; common medical injections if the same syringe is used without sterilisation between injections; and blood transfusion in settings where routine screening of blood is inadequate or deficient. AIDS (acquired immune deficiency syndrome), a condition of progressive ill health, is the end stage of the HIV infection. It has become the most significant global public health challenge of the 21st century.
HIV infection is caused by two strains of the human immunodeficiency virus, HIV-1 and HIV-2. HIV-1 is the most common form, with at least nine differing sub-types, each predominating in different parts of the world. Once introduced into the human body, HIV attacks mainly a subset of immune system cells, which bear a molecule called CD4. These cells perform tasks critical to the normal functioning of the immune system. Like any other viral infection, HIV may be characterised as a battle between the immune system and the invading virus. What makes HIV unusual is that it is a relatively even match for the human immune system, resulting in a long struggle, usually between eight to ten years. During this period, the HIV advances slowly but inexorably. HIV finally triumphs when the infected person develops repetitive and serious opportunistic illnesses. This stage is labelled as acquired immune deficiency syndrome or AIDS.
The battle between HIV and the immune system is generally fought in three stages.
Stage 1: Known as the primary (or acute) HIV infection, this stage begins at the time of infection and lasts until the body’s initial immune response gains some measure of control over viral replication, usually within a few weeks of infection. During this period both the CD4 count plus the T-cell count drops dramatically. Between 30 and 70% of people experience flu like symptoms. These usually disappear within three weeks, as the cell counts of both the CD4 as well as the T-cells recoup and rebound to apparently somewhat normal levels.
Stage 2: Generally asymptomatic and it accounts for about 80% of the time from onset of initial infection to death (among those who fall prey to AIDS). At the beginning of the second stage, antibodies become detectable in the bloodstream by most HIV tests. Prior to this stage, it is usually not possible to determine if a person is infected. Most HIV infected people remain clinically healthy during this stage. All the time, however, the immune system is waging an intense but invisible struggle against the virus. Although the bone marrow compensates by speeding up production of new cells, the rate of loss exceeds the rate of replacement. With each passing year, the CD4+ T-cell count per cubic millimeter of blood diminishes by about 50-70 cells per year. When the CD4+ T-cell count diminishes to around 200 per cubic millimeters of blood (as opposed to between 800-1000 cell count in a noninfected individual), the rate of decline accelerates and the individual becomes susceptible to opportunistic infections and other illnesses.
Stage 3: The third and final stage of the HIV infection begins when the individual becomes susceptible to repeated infections. This marks the beginning of the final stage of the HIV infection: clinical AIDS. Some of the illnesses that typically strike people with AIDS are communicable, such as TB. The likelihood of TB infecting other parts of the body (as opposed to being typically a lung infection) is higher in the HIV infected. Other common infections tend to become unusually severe in people with AIDS, example sinusitis or pneumonia; candidiasis and HIV-related cancers.
At the early stages of clinical AIDS, some of the AIDS associated infections can be treated with conventional antibiotics. However, as the immune system continues to deteriorate, treatment becomes increasingly difficult. The number and variety of illnesses increase, leading to death.
The length of survival after infection depends on many factors, including the strain and subtype of the virus, the general state of the person’s health, and access to medical treatment for opportunistic illnesses. Prior to the use of triple drug therapies, the median time from HIV-1 infection to death in the industrialised countries was around 12 years. Stage 1 and stage 2 would typically comprise eight to ten years. The final stage, clinical AIDS would comprise about 14 to 25 months. In the developing countries, although there is far less documentation, both the time from infection to AIDS and the time from AIDS to death are believed to be much shorter, with a total survival time from infection to death of perhaps seven to nine years.
HIV/AIDS is unique in that it typically affects men and women in their economically most productive years, between the ages of 18 and 50. In turn, within enterprises and at the work place, this promotes absenteeism and increase in labour turnover due to illness and death, fall in production, loss of skills and experience, increase in expenditure on employee replacement and training, health care and social security cost, and a reduction in profit levels. Within the affected household, the illness of a family member means loss of that person’s work and income, increasing medical expenses and the diversion of other family members from work or school to caring for the patient. Women in particular, have to take on additional burdens, of care and work, in the affected households. HIV/AIDS has been seen to deprive families, communities and entire nations of their young and most productive people. It deepens and spreads poverty, worsens gender inequality, erodes government capacities to provide essential services, and reverses human development. For all these reasons we need to facilitate at the work place, in educational institutions, and within informal settings a nurturing, enabling and nondiscriminatory environment.
Although, AIDS is overwhelmingly fatal, it must be placed on record that over 20 years after the emergence of HIV it has not been proven that the HIV infection is always and invariably fatal. Roughly 10% of those infected continue to remain healthy for over 25 years. These more fortunate persons are labelled as long-term non-progressors. They have become the source of inspiration for intense efforts to develop a vaccine that would boost the immune system and protect the average person against HIV infection.
At the end of 2001, WHO and UNAIDS estimated that 40 million people around the world were living with HIV; four million more than at the end of the previous year. During 2001, it was estimated that there were five million new HIV infections and three million deaths due to AIDS. Among the new infections, 800,000 occurred among children under 15 years and more than two million were among women. Since the first clinical evidence of AIDS was reported in June 1981, some 25 million people have died of AIDS – including 3.6 million children. Nearly 14 million children have been orphaned due to AIDS.
The diversity of HIV spread throughout populations is striking: 16 countries (all in sub-Saharan Africa) report an overall adult HIV prevalence over 10%; eight countries between 5% and 8% (all in sub-Saharan Africa); 28 countries between 1% and 5% and the remaining 119 countries of the world have less than 1% of HIV prevalence among adults. Several countries currently have concentrated epidemics whereby overall population prevalence remains low, but high risk groups manifest rising trends as seen among female sex workers (FSWs), injecting drug users (IDUs) and men having sex with men (MSM).
The Indian Council of Medical Research (ICMR) initiated surveillance for HIV infection in India in late 1985. Anti-HIV antibodies were first detected among sex workers in Chennai, South India in 1986. Soon thereafter, the first AIDS case in India was reported from Mumbai in 1986. More and more cases began pouring in. The HIV-2 infection in India was first reported in 1991, from Mumbai.
The National AIDS Control Organization (NACO) initiated ‘Unlinked Anonymous Sentinel Surveillance’ in 55 sites across the country in 1994, to monitor the trends of the epidemic. At that time, lack of credible data did not facilitate a comprehensive determination of the HIV infection burden within the country. Hence, in 1998, the scope of surveillance was expanded to making estimations. In end 2001, on the basis of nationwide sentinel surveillance, NACO estimated that approximately 3.97 million persons in India were infected with HIV/AIDS. These estimations of 2001 indicated that at least 0.8 % adults in the age group of 15-49 years were infected.
There is not one single HIV epidemic in India. A number of distinct epidemics often coexist, sometimes within the same state, with different vulnerabilities, stage of maturity and impact. While the predominant route of transmission of HIV/AIDS in India is through the heterosexual route (84%), however, in northeastern India, the epidemic is mainly among intravenous drug users. The HIV infection is steadily moving beyond its initial focus among commercial sex workers into the wider general population. At the same time, sub-epidemics have evolved with potentially explosive spread among groups of injecting drug users (IDUs). There has been a broadening of the epidemic in the southern, western and a few northeast states of India. In other parts of the country, the overall levels of HIV prevalence continue to be categorised, even globally, as low.
States/union territories in India are classified as follows, on the basis of cumulative data derived from the annual national sentinel surveillances:
Group 1 (high prevalent/generalized epidemic states): Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, Manipur and Nagaland where the HIV infection has crossed 1% or more in antenatal women.
Group II (moderate prevalent/concentrated epidemic states): Gujarat, Goa and Pondicherry where the HIV infection has reached 5% or more among high risk groups but the infection is below 1% antenatal women.
Group III (low prevalent states): The remaining states and union territories where the HIV infection is less than 5% in all high-risk groups, and less than 1% in antenatal women.
High levels of sexually transmitted infections, the evident presence of sexual networks and growing urban migration point towards a significant vulnerability. The epidemic continues to shift towards women and young people with an expected accompanying increase in vertical transmission and paediatric HIV. Migration both within and between states and mobile populations, are a source of spread of HIV between urban and rural populations. Gender imbalances between men and women, with women not feeling empowered to negotiate safe sex remain major obstacles to check the spread. In the case of drug users, indications point towards a shift from inhaling drugs to over the counter injecting drugs. Within the national programme, we pursue a harm minimisation approach in areas of high drug use, like the northeastern states of Manipur and Nagaland and the metropolitan cities of Mumbai, Chennai and Delhi.
India’s epidemic seems to be following the Type 4 pattern, first described in Thailand. In the first wave, HIV infection is seen amongst sex workers or intravenous drug users (IDUs) that are also known as the core transmitters or core groups. In the second wave, the epidemic spreads from these groups at highest risk to bridge populations (clients of sex workers, patients of sexually transmitted infections, partners of drug users, mobile populations such as truck drivers, single male member migrants etc.). When evidence suggests affliction of spouses and children of the clients of sex workers, the HIV epidemic is understood to have reached its third wave. Some scientists consider that IDUs constituted the first wave, which was followed by the sex workers and so on. Recently, a fourth wave comprising of adolescents has been proposed to indicate the severity of the epidemic. This shift usually occurs where the prevalence in the first group reaches 5%. There is a time lag of 2-3 years between shifts from one group to the next.
Sexual Route: The risk of acquisition of HIV infection depends upon various factors such as number of sex partners, type of sex partner (regular/casual/sex worker), frequency of at risk sexual exposures, local HIV prevalence rate, i.e. in core groups, bridge population etc. type of sex act, use of condom, and the presence of sexually transmitted disease in any one of the partners. The overall transmission efficiency of HIV infection through sexual route ranges between 1:1000 and 1:5000. Despite the low transmission efficiency associated with sexual route, it has become predominant due to the high frequency of sex acts. The efficiency of male-to-female transmission is 2 to 3 folds higher than that of female-to-male transmission for various well known anatomical, biological and sociological reasons. Anal sex is more risky due to absence of natural lubricant and elasticity, and comparatively thinner mucosa, which together increase the risk by making it more trauma-prone.
Several studies have established the association of STIs and HIV. Both ulcerative and non-ulcerative STIs are known to enhance the transmission efficiency of HIV. Presence of ulcers on genitalia due to STIs presents a raw area through which the entry of HIV in the body is facilitated. Similarly in cases of genital discharge, the concentration of HIV in the discharge is also higher.
Parenteral Route: Transfusion of blood collected from a HIV infected individual is a major but easily preventable route of transmission with a very high transmission efficiency – more than 95%. In other words, every person receiving such blood will develop HIV infection. Accordingly, in June 1989 in India, screening all the units of blood collected for transfusion purposes was made mandatory. Simultaneously, professional donors were also banned due to higher HIV sero-prevalence among them. And this has had an immediate and salutary impact on the transmission of HIV/AIDS in India through unsafe blood.
Injection of any sort is more efficient in spreading HIV than sexual intercourse. Injecting drug users are often linked in ‘close’ networks and commonly share non-sterilised injecting equipment with others leading to a rapid spread of HIV in these populations. As injecting drug use is illegal in most countries, it is difficult to surmise exactly how many people inject drugs and share equipment; it is harder still to gauge how many are infected with HIV. Many estimates of HIV infection rates among injecting drug users come from tests of drug users who have been arrested or were registered at treatment centres. However, information collected by outreach services that take HIV prevention and other health and social services to drug using communities, suggest that official figures underestimate the true rate of infection in this population. In India, the northeastern states, particularly Manipur, have shown rapid progression of HIV infection among injecting drug users.
Needle stick injuries are a comparatively rare mode of transmission. The risk of transmission is about 1 in 250 to 1 in 1000 HIV contaminated needle stick injuries. About 130 such cases are reported in the world despite the fact that millions of health care workers are knowingly or unknowingly handling HIV infected individuals. Despite such a low risk, an unrealistic fear remains a major hurdle in extending health care to HIV infected individuals.
The Constitution of India lists public health as a state responsibility. While resources on several counts in respect of national disease control programmes may flow from the central government, responsibilities for the actual implementation and management of programmes, projects and initiatives vest entirely with state governments. The Government of India, Ministry of Health and Family Welfare periodically monitors the implementation of these national disease control programmes and the utilisation of resources.
Since its inception, HIV/AIDS control has been a centrally sponsored and financed scheme. The government recognised the grave impact of HIV/AIDS and has responded to the epidemic. It might be useful at this stage to trace the response of the government:
1987: National AIDS Committee constituted in the Ministry of Health and Family Welfare.
1992: National AIDS Control Board set up in the Ministry of Health and Family Welfare.
1992: National AIDS Control Organization (NACO) constituted to administer the National AIDS Control Programme.
1995-1999: Installed state level bodies (State AIDS Control Societies) in 25 states and 7 union territories.
2000: Mainstreaming HIV/AIDS became one of 14 national socio-demographic goals in the National Population Policy, adopted by the government.
2000: Government of India, Ministry of Health and Family Welfare and the Indian Council of Medical Research (ICMR) signed a Memorandum of Understanding with the International AIDS Vaccine Initiative (IAVI) to construct and evaluate one or more vaccines appropriate for use in India.
2001: India endorsed the Declaration of Commitment on HIV/AIDS at the UN General Assembly Special Session on HIV/AIDS (UNGASS).
2002: Integration of vertical programmes like HIV/AIDS through convergence in delivery systems became one objective of the National Health Policy, adopted by the government.
1998-2002: Installed 384 sentinel sites across the country to monitor trends in the spread (prevalence as well as incidence) of HIV and AIDS.
2002: The government adopted the National AIDS Prevention and Control Policy.
2002: The government adopted the National Blood Policy.
The Government of India is currently implementing the second phase of the National AIDS Control Programme (NACP II, 1999-2004). NACP II was developed through a process of consultation and deliberation between Government of India, state governments, people living with HIV/AIDS, UNAIDS and bilateral partners, with community members, industry and labour organisations, NGOs and civil society. It has five key components: (i) Targeted interventions for communities at highest risk, (ii) Prevention of HIV transmission among the general population, (iii) Provision of low cost care and support, (iv) Strengthening institutional capacities, and (v) Inter-sectoral collaboration.
The key objectives of NACP II are to: (i) Reduce the spread of HIV infection in India; and (ii) Strengthen India’s capacity to respond to the HIV/AIDS epidemic on a long-term basis, in collaboration with multiple sectors, NGOs and civil society. There is a firm commitment of the government at the highest political level to contain the epidemic. The national response has galvanized over the past five years.
Each state and union territory has registered a State AIDS Control Society (SACS), which is responsible for implementation of the programme at the state level. The cities of Mumbai, Chennai and Ahmedabad have formed Municipal AIDS Control societies to effectively implement the AIDS Control programme in these large metropolises. Each SACS developed a Project Implementation Plan (PIP) as part of preparation for Phase II, which allows for addressing the specific needs of the state and the epidemic.
Bringing all partners and stakeholders such as the central government, state governments, the medical community, paramedical personnel, providers of technology, research agencies, the non-government organisations, the private sector health care providers, people living with HIV and AIDS, patient advocacy groups and others onto one platform, defined by and in support of the national programme is a key objective of NACO. During 1999, a common strategic response to the challenges facing the National AIDS Control Programme was documented. This brought together specific action plans of the different agencies as part of an ‘integrated’ work plan for 1999-2001. An ‘integrated’ work plan for 2002-2003 is currently under development. WHO and the UN system provide a range of technical and funding support across all areas of the National AIDS Control Programme.
In December 2000, Ministry of Health and Family Welfare, Government of India and the Indian Council of Medical Research (ICMR) signed a Memorandum of Understanding with International AIDS Vaccine Initiative (IAVI) to construct and evaluate one or more vaccines appropriate for use in India.
IAVI’s Vaccine Development Partnership (VDP) in India is focused on the HIV strain C, a subtype of the virus most common in the country. Therion Biologics of Cambridge, Massachusetts will develop the first of these vaccines. Working closely with the Indian team, Therion will design and manufacture a vector-based vaccine, the Modified Vaccinia Ankara (MVA) vaccine that aims to stimulate the production of immune cells that kill HIV infected cells. The National AIDS Research Institute, Pune and the National Institute of Cholera and Enteric Studies, Calcutta, subsidiaries of ICMR are the nodal organisations in India for vaccine research and development. There has always been strong political commitment in India to vaccine research. And now there is additional progress as development and deployment has solidified, dialogue with communities is beginning, and professional readiness for trials is improving.
The NACO-ICMR-IAVI partnership is promoting community mobilisation and keener understanding on vaccine research and deployment under the terms of its Memorandum of Understanding. Broadly, the India vaccine programme seeks to sustain the objectives achieved and to accelerate the momentum generated during 2002 to pave the way for Phase I trials in the last quarter of 2003 and early 2004 also establish the pace for the Phase III trials.
The two major activities that set the pace for the GOI-IAVI programme were the setting up of the Advisory Board and the Policy Makers Conference in May 2002.
A 36-person National Advisory Board including persons with longstanding experience in social, political and economic dimensions of AIDS prevention and care was set up in March 2002 to advise the three partners on all aspects of vaccine development and access. Two meetings of the advisory board have been held thus far.
With the need to build political support, an International Policy Makers Conference with representatives from eight countries was held on May 2002 in New Delhi. Delegates and speakers included Members of Parliament, academics, international organisations and reputed media persons. At the inaugural session, in a landmark speech, the prime minister of India said, ‘…a vaccine is the only solution,’ thus mandating support from the highest political quarter. Sonia Gandhi, leader of the opposition, said, ‘As we did with smallpox and are poised to do with polio, so we will succeed in eliminating HIV/AIDS.’ The two outcomes of this meeting were the Delhi Declaration and the setting up of a working group to draw up a comprehensive legislation.
In India, NGOs have been at the forefront trying to address the multiple medical, social, legal, ethical and policy dimensions of the AIDS problem. During the 1990s, new strategies, innovative approaches, and different service delivery packages have been designed to address the needs of various high-risk groups, including women in prostitution, their clients, injectable drug users, migrant workers and youth. Advocacy by national NGOs has greatly influenced policy and practice. With the rise in HIV positive numbers, there will be growing demands on NGOs to respond to these new challenges. Community-based responses will be needed to address a range of sensitive issues such as sexuality, gender roles and family relationships among vulnerable populations and people living with HIV and AIDS. NGOs have the ability and flexibility to work in collaboration as the most effective way of strengthening partnerships, reducing costs, sharing resources and skills. Networking is a strength that NGOs have, typically enabling an integrated response to HIV/AIDS.
Relationships and roles across civil society are being redefined as we discover new ways of working together. We now know that vertical approaches to service delivery are inefficient, and need to be replaced with expanded outreach along with enhanced accessibility and higher affordability. The previous rigid distinctions that separated government from non- government, and public from private are rapidly disappearing. Nowhere is this more apparent than in our combined endeavour to combat communicable diseases.
The National AIDS Control Organization partners through the State AIDS Control Societies, with over 700 NGOs. We are now poised to bring about a paradigm shift by further expanding this partnership to include the private corporate sector, community based organisations, mahila samakyha samitis and groups from diverse faiths, to build a human chain that will bring about a national movement.
What have been the achievements?
(a) Political commitment has been achieved at the highest level. On the eve of Independence Day 2000, in his address to the nation, the prime minister emphasised the need to effectively contain and control the spread of HIV/AIDS in India. This has been translated as political commitment and advocacy in the states. This strong and unambiguous commitment at the highest level has since been reiterated on every conceivable occasion, and it continues to inspire our efforts.
(b) Intensive awareness campaigns through electronic and print media and the field publicity units of the Ministry of Information and Broadcasting in both the urban and rural areas has generated more universal awareness about HIV/AIDS among both the high risk groups and the general population. As part of monitoring and evaluation activities, a nationwide behavioural sentinel surveillance (BSS) survey was carried out in the general population in all 35 states and union territories in the country between April-September 2001. The survey provides baseline information on the behaviour risk patterns in the country. A total of 84478 respondents were contacted in the entire country during this baseline survey. 76.1% had heard of HIV/AIDS (82.4% males and 70% females). Low awareness rates were recorded among rural women in Bihar, Gujarat, Uttar Pradesh, Madhya Pradesh and West Bengal.
(c) Awareness programmes through school and college education have been taken up on a large scale by state governments by involving NGOs and Departments of Education.
(d) To ensure safe blood to the population, blood banks in the government and voluntary sector have been modernised in phases and blood component separation facilities established in major blood banks throughout the country.
(e) For control of sexually transmitted infections that have a direct correlation with HIV/AIDS, STI clinics in district hospitals have been established. Medical and paramedical workers have been trained in syndromic management of STIs.
(f) Voluntary counselling and testing centres (VCTCs) have been established in all medical colleges and major hospitals, and the process of providing such facilities in all district hospitals is in progress. About 500 VCTCs are functional.
(g) For tracking the epidemic in the country, 384 sentinel sites have been established. These sites include both high-risk groups like sex workers, intravenous drug users as well as low risk group, i.e., pregnant women attending antenatal clinic. One round of sentinel surveillance is carried out each year during the period of August-October.
(h) Over 700 targeted intervention projects have been implemented all over the country for groups practising risky behaviour. These interventions include outreach activities, IEC and interpersonal communication, condom promotion, and general health and STD service provision. Targeted intervention projects such as those for commercial sex workers in Kolkata’s Sonagachi area, the men who have sex with men project in Chennai, truck drivers in Rajasthan, and injecting drug users in Assam, Manipur and Nagaland have increased the use of condoms and reduced STD, providing lessons in best practice.
(i) After the successful completion of prevention of mother to child transmission (PMTCT) feasibility study in 11 centres of excellence, the government is presently up-scaling PMTCT to all the district hospitals in the high prevalence states and later to all the medical colleges in the low prevalence states.
(j) All government hospitals have been instructed to admit HIV/AIDS cases without any discrimination and ensure that they are managed in the general wards of the hospitals along with other patients. For the promotion of community/home based care 26-community care centres established by NGOs are being supported by NACO. Drugs for treatment of opportunistic infections are being provided at all government hospitals admitting AIDS patients. As TB is the most common serious opportunistic infection in HIV/AIDS, linkages are being established between the AIDS and TB control programmes to ensure that HIV-TB co-infected patients get anti-TB drugs free of cost under the national programme. At present there are 11 antiretroviral drugs available in the country. However, due to prohibitive cost of antiretroviral therapy, the government is not providing these drugs presently for the clinical management of HIV/AIDS cases. However, in order to make these drugs affordable, excise duty has been exempted and the states have been requested to exempt antiretroviral drugs from sales tax and other local duties.
(k) Government has provided funds to State AIDS Control Societies to provide antiretroviral drugs for post exposure prophylaxis to health care workers in the event of any accidental/sharp injury while providing care to suspected HIV/AIDS patients.
(l) NGOs have been involved to play a major role in initiating and ensuring effective interventions, defending the human rights of people living with HIV/AIDS and in providing care and support to people living with HIV/AIDS.
(m) NACO has promoted inter-sectoral collaboration with other ministries/departments such as human resource development, information and broadcasting, railways, defence, labour, steel, social justice and empowerment etc. for the implementation of HIV/AIDS prevention and control programme.
(n) Effective collaborations have also been built with the private sector through the Confederation of Indian Industries (CII), the Federation of Indian Chamber of Commerce and Industries (FICCI) and the Bengal Chamber of Commerce. The Tata Iron and Steel Company has incorporated HIV/AIDS prevention in their ongoing family welfare programme and control activities.
(o) A Memorandum of Understanding was signed between NACO, International AIDS Vaccine Initiative and the Indian Council of Medical Research in December 2000. The vaccine being developed will be tailored to Indian isolates of HIV sub-type C. The development is on a fast track schedule and the vaccine should be ready for preclinical testing in 2002-3.
(p) Over 50,000 medical and over 2 lakh para-medical personnel have been trained in different parts of the country.
We need to strengthen the HIV evidence/database within South Asia, and to increase capacity to utilize data for advocacy and tracking the spread. The UNAIDS inter-country team for South Asia has developed and is implementing the ‘South Asia Political Advocacy Project’ since February 2001. Additionally, we need to collaborate within the South Asian region with respect to cross-border prevalence and incidence of HIV and AIDS, as aided and abetted by the trafficking of women and young girls and by drug runners through migration.
1. Put in place a comprehensive all India surveillance with a burden of disease approach, together with studies on socioeconomic impacts, that will include mobile populations, migrant workers, and tribal and hill populations.
2. Develop comprehensive strategies for behaviour change communication so that messages relating to HIV/AIDS are integrated into diverse sectoral programmes and initiatives, in order to bring about behaviour change, and also simultaneously to expand and strengthen the multi sectoral response.
3. Strengthen public, private and civil society partnerships across the board, in myriad ways to address the unmet need for information, products and services. Evolve criteria by which improvements and deterioration in meeting these needs can be measured.
4. Mainstream and integrate the management of HIV /AIDS into the primary health care system to improve access, as well as to alter the negative popular perceptions associated with the disease.
5. Prioritise targeting to remove inequities. The distribution of products and services must prioritise the under-served segments of the population and redress the rural-urban inequity.
6. Harness social marketing and franchising to improve the basic health of under-served segments, by reducing cost and expanding reach.
7. Continue to encourage research and development in respect of the HIV vaccine.
8. Expand the programme on care and support.
9. Dialogue with the India pharmaceutical industry to encourage lowering of prices for antiretroviral drugs.
10. Set up a chain of state of the art voluntary counselling and testing centres at health sub-centre and primary health centre levels across low prevalence as well as high prevalence states. Develop and adapt standard modules that will ensure quality in service delivery at these centres. Promote voluntary counselling and testing centre as a one-stop shop for information and communication, for health care products, such as condoms, antibiotic creams, paracetamol etc., and counselling services.
11. Scale up interventions particularly for young people.
12. Reducing stigma and discrimination.
13. Put in place diverse public-NGO-private partnerships for sustainable provisioning of services.
14. Constantly evaluate and assess the applicability of emerging new technologies like microbicides, female condom, the vaccine and chemoprophylaxis.
15. Support the development of a comprehensive rights based legislation through a consultative process.
A clear articulation of public-NGO-private partnerships will encourage diverse stakeholders to collaborate in the delivery of advocacy, products and services. This public-private partnership will play an essential role in generating and mobilising the resources and infrastructure needed to fulfil the objectives of the National AIDS Control Programme.
This paper has attempted to draw attention to possible approaches towards prevention, care and support. We believe that together with NGOs and civil society, we can put in place a wide ranging multi-sectoral partnership that will enable India to become a global frontrunner in establishing successful models for prevention, care and support.
MEENAKSHI DATTA GHOSH