Viewing HIV/AIDS from a development perspective

One of the major development challenges we face is that of tackling the growing HIV/AIDS pandemic. The pandemic is not just a public health issue but has implications far beyond the health sector. This makes it necessary – more than ever before – to adopt a participatory and holistic approach towards halting the spread of the pandemic. Promoting partnerships and collaboration among different State and non-State actors will have to be an important element of this approach.

The AIDS pandemic has made us confront social realities and inequities in unprecedented ways. It has also built bridges between the fields of medicine, science, development, law and human rights. Initially, the response to HIV/AIDS primarily revolved around changing individual behaviour, especially sexual and drug use habits, as well as screening of donated blood and on cleaning of surgical equipment between uses. Messages that narrowly focused on, negotiating safer sex or addressing injecting drug use, without adequate attention being given to the larger socio-economic context and the problem of human needs and deprivation, did not prove very effective.

The Larger Context

While the virus may affect people regardless of their socio-economic status, it is not entirely random in its spread. HIV/AIDS thrives in areas where poverty is rampant, inequalities – along gender, class and ethnic lines – abound, human development indicators – especially those relating to education and health – are woefully low, and physical and social infrastructure inadequate.

If human deprivation and inequalities increase vulnerability to HIV/AIDS, the epidemic itself further impoverishes people and sharpens social divisions. Apart from affecting people’s health, it also has a debilitating impact on national economies. Many countries in Africa which contracted AIDS in the eighties and nineties have seen their national growth rates severely reduced, their most productive men and women lost, and a huge increase in the burden on their societies of having to look after the aged and the orphaned left behind. Above all, HIV threatens rights as profoundly as it threatens public health and development work. The stigma attached to HIV/AIDS curtails the individual liberties of HIV-positive persons, restricting their right to employment, access to health care and right to movement. The people who are most vulnerable to HIV/AIDS such as – commercial sex workers, injecting drug users, migrant workers, men who have sex with men – largely belong to the economically deprived and socially marginalised sections of society whose basic rights are already curtailed. When they are diagnosed as HIV-positive, their persecution and social exclusion only increases. Though the isolating of HIV-positive persons may often be prompted by concerns about limiting the spread of the epidemic, such actions only fuel the epidemic, by preventing an open discussion of the epidemic and making it socially invisible.

The mutually reinforcing link between human deprivation and HIV/AIDS holds particularly true for South Asia because of the presence of the structural factors that fuel the pandemic. South Asia’s most persistent and urgent problem today is its widespread poverty. The region is home to 515 million income-poor, or nearly 40 per cent of the 1.3 billion people who live in absolute poverty i.e. below $1 a day, globally.

Poverty makes people less able to control the circumstances in which they live and work, making them vulnerable to ill-health and diseases in general and HIV/AIDS in particular. Between 30 and 60 per cent of the residents of urban centres in South Asia live in slums and squatter settlements, where basic civic amenities and health infrastructure are near-absent, and as a result of which people live in unhygienic environments.

The region has a large mobile population. These include migrant workers looking for economic opportunities; refugees fleeing from civil and military conflict; trafficked women and girls; and armies and security forces on the move. Women migrants are more vulnerable to sexual exploitation and are less able to negotiate safer sex. Women from poor families are often lured with false promises of employment and even marriage and may be forced into slavery or the sex trade. This only makes them more susceptible to HIV/AIDS. Without blaming these groups for the spread of the pandemic, it needs to be acknowledged that each of them is particularly vulnerable to HIV.

The relatively low status of women in South Asia has meant that it is they who are the most adversely affected. As it is, women are more susceptible to sexually transmitted infections than men, and this problem is only exacerbated by patriarchal social norms and unequal gender relations. Seventy per cent of the rapidly rising new transmissions of HIV/AIDS in this region are through heterosexual intercourse, and women from all walks of life are increasingly being infected.

As a result of their general state of disempowerment, most women in South Asia are less able to protect themselves from HIV. And when they are infected, there is the very real danger of their passing the disease to the children they bear. World-wide there are estimates that 35 per cent of the children born to HIV-positive women contract HIV/AIDS. In 1998, one in ten of all new infections were children, and the vast majority of them acquired the virus from their infected mothers.[1] Across South Asia, too, there is an increase in the mother-to-child transmission rates.

But women have to bear the burden of HIV/AIDS regardless of whether or not they are infected. They take on a greater share of the psychological, social and economic burdens related to discrimination, alienation, violence, loss of livelihoods, assets and rights and caring for the sick. When women are found to be HIV-positive, they are often abandoned by their families and ostracised by the community. Even when they are not diagnosed with HIV/AIDS, they have to bear the burden of care within the household, fend for the family when the male members are unable to work or die of AIDS, and at the same time be blamed for their husbands illnesses.

All this only reinforces the need to see HIV/AIDS as a larger development issue. We cannot win the battle against HIV/AIDS without a comprehensive approach.

A multi-sectoral approach

An emphasis on a preventive and multi-sectoral approach to HIV/AIDS is particularly important in South Asia because of the complexities and prohibitive costs of managing this epidemic at the personal, community and national levels.

Experiences of countries like Thailand show that effective responses can contain the spread of HIV and its impact. In Thailand, where the epidemic started long before other countries in South and South East Asia, strong government commitment and a focused national AIDS programme has brought about a significant decline in incidence of HIV/AIDS. The National AIDS Committee was chaired by none less a person than the Prime Minister himself. A purely epidemiological approach was combined with programmes to deal with the social consequences of the epidemic and the active involvement of civil society and people living with HIV/AIDS as well as preventive programmes aimed at educating people about the causes of HIV/AIDS.

It is necessary to set up inclusive and participatory processes that foster broad-based partnerships among governments and civil society organisations – be they community-based organisations (CBOs) or networks of HIV-positive people or women working together. NGOs have been at the forefront of efforts to address HIV/AIDS and a host of related issues like sexual health, curtailment of individual liberties, stigma and discrimination. It is essential to draw on their collective experiences when policies to tackle the pandemic are being formulated. There are examples from India and Bangladesh of partnerships between sex workers organisations and NGOs on gender issues. Such collaborations can be replicated for designing approaches to HIV/AIDS as well. In addition, it is necessary to work out innovative partnerships which also involve the media, the private sector, donor organisations, and UN organisations. Similarly, there are a few examples from India of private companies addressing the problem of HIV/AIDS at the workplace. One of the larger Indian companies, Tata Steel, was awarded the prestigious Global Business Collation Award for business excellence in the community for its outstanding HIV/AIDS awareness programme in the town of Jamshedpur in India.

The Resource Conundrum

It is only when we work together as partners that we can respond most effectively in finding creative solutions to combat HIV/AIDS. Certainly in India, with an estimated 3.97 million HIV-positive people, the UNDP and its sister UN organisations are determined to join hands to fight HIV, not only through various ongoing programme modalities, but also under the joint UN Development Assistance Framework (UNDAF) for India.

In consultation with Government, development partners and civil society, the UN Family has agreed that the strategic focus of this new joint framework will be on gender equality and decentralisation – both themes that are part of the daily vocabulary of any HIV/AIDS worker or activist. CHARCA (Coordinated HIV/AIDS and STD Response through Capacity Building and Awareness) – the first joint UN system programme on HIV/AIDS – attempts to do precisely this.

With UNAIDS in the lead, the UN system is striving to move away from a series of independently conceived and negotiated inputs to a strategic contribution building on each organisation’s comparative advantage. Working closely with the National AIDS Control Organisation (NACO), the UN system in India initiated a dialogue with the National Planning Commission to give explicit recognition to HIV as a major development concern in the country’s Tenth Five-Year Plan. UNDP in India is committed to integrating HIV in the planning processes through the Human Development Reports, whether at the regional or state level. The first Regional Human Development Report on HIV and Development in South Asia, published in June 2003, was a step in this direction.

As a follow-up action to the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), UNDP has launched a Leadership for Results Programme globally. The Programme attempts to mobilise a critical mass of leaders and change makers in various constituencies like media and arts, people living with HIV/AIDS, local political leaders and the bureaucracy. It is hoped that this critical mass of leaders will not only influence local and national policies to address the HIV epidemic, but will also facilitate sustained, committed leadership in the region to raise concerns regarding HIV in global fora, in order to muster international support and garner resources

Innovative Approaches

UNDP, in close collaboration with NACO and UNAIDS, is also exploring possibilities of setting up an incentive fund to support innovative projects by NGOs and CBOs. This fund would not only provide a platform for bringing in other multilateral and bilateral partners for a better national response but would also be able to offer a menu of options of effective interventions which could be scaled up and replicated.

In India, the epidemic has moved fast. With an estimated 3.97 million HIV infected people, India has more people living with HIV than any other single country in the world. Unfortunately, given the total population size, the national HIV prevalence rate of less than 1 per cent often masks the seriousness of the problem. Most of the HIV-positive people are concentrated in four states – Tamil Nadu, Maharashtra, Andhra Pradesh, Manipur. The groups that are particularly vulnerable include migrant workers scattered within the country and their families; rural families clustered in urban slums; and women and children living and working under unhealthy conditions. These are the people who do not have access to quality health care, or information about how to protect themselves from the epidemic. The initial cases were reported from among commercial sex workers and self-injecting drug users, but the epidemic is now spreading from the urban into the rural areas, and from vulnerable groups into the general population. Also, youth and women are two groups to whom special attention needs to be paid.

The National Context

India’s capacity and will to respond to the growing epidemic has developed dramatically in recent years. Much of the credit for this goes to the efforts of the National AIDS Control Organisation (NACO) within the Government’s Ministry of Health and Family Welfare.

India is one of the few countries that have been able to generate political commitment from the highest level. In 1995, the President, Prime Minister and Health Minister shared a platform to speak on HIV/AIDS at the Global AIDS Law Conference. In December 1998, Prime Minister Atal Bihari Vajpayee, in his address to parliamentarians noted, “the most serious public health challenge facing the country is HIV/AIDS. …which is a global problem with a strong Indian dimension.” While acknowledging the potential consequences of the spread of AIDS in India, he urged political commitment and support at various levels – state, district and local.

By building upon the lessons learned from past experiences, India has developed a decentralised and multi-sectoral national response to the epidemic.

Decentralisation and Multi-Sectoral Approaches

Authority and accountability for HIV prevention have been devolved to the States. Plans are in place for a new and decisive impetus in each of India’s 35 States and Union Territories. At the State level, there have been innovations in organisational structures that promise to break through some of the obstacles that have hampered progress in the past. In order to make decentralisation successful, there is constant dialogue with state-level partners, including those from civil society. Consultations have helped to open a two-way dialogue between stakeholders such as State AIDS Control Societies (SACS), NGOs, people living with HIV/AIDS (PLWHA) and NACO. This has had a salutary impact on the overall programme. The SACS, modelled on the path breaking adult literacy campaigns of the 1980s and 1990s, provide the flexibility needed for the evolving epidemic, and the means to engage a wide range of stakeholders including NGOs. Key officials and partners from the district and local level are playing an important role in the campaign against HIV/AIDS.

In line with the multi-sectoral approach, different Government Departments and Ministries, like Women and Child Development, the Railways, Defence, Social Justice and Empowerment, Education, Youth Affairs and Sports have joined hands with the Health Ministry to reach out to the people in various ways. Some 735 targeted intervention projects have been undertaken by the SACS through NGOs across the country. More than half of these projects are located in the high prevalence states of Andhra Pradesh, Maharashtra, Tamil Nadu, Karnataka, Manipur and Nagaland.

Testing of all donated blood samples for HIV, Hepatitis B, malaria and syphilis has been made compulsory. All blood banks must be licensed; the Government is phasing out donation of blood by professional blood sellers and is taking up campaigns to encourage people to donate blood voluntarily. The Government has also approved a National Blood Policy which attempts to ensure the availability of safe and good quality blood and the setting up of modern blood collection facilities.

The Government is sponsoring research in the Indian systems of medicine and homeopathy for the development of drugs that will have an anti-retroviral effect. At the same time, awareness campaigns are educating people on the dangers of falling prey to the claims and medication of unqualified and unscrupulous persons.

Addressing Drug Use

India has one of the most progressive policies on harm reduction and drug use, based on the lessons and experiences of the intravenous drug users in the North-Eastern State of Manipur, where injecting drug use is the main route of transmission of HIV. The Manipur Health Minister noted “in the beginning of the epidemic we thought HIV is a problem of drug addicts alone and the addicts deserved punishment. The community including parents and women activists organised mass arrests, compulsory testing, and control… We have however realised that this 'police model’ does not work”. The Needle and Syringe Exchange Programme (NSEP) was launched in 1995, as a pilot project in some districts and implemented with the help of NGOs. Though the programme was frowned upon initially, since it was seen as indirectly sanctioning drug use, it now receives national and international funding. The Manipur State AIDS Control Society has also taken it up under its Rapid Intervention And Care (RIAC) programme.[2] The programme certainly has been a success going by the decline in HIV prevalence rates among injecting drug users from 80.7 per cent in 1997 to 58 per cent in 2000.

NACO has received a $ 100 million grant from the Global Fund for AIDS, TB and Malaria (GFTAM). Spread over a five-year period, this grant provides chemoprophylaxis to HIV-positive mothers in order to prevent parent-to-child transmission. Besides, it will also enable NACO to provide, for the first time in India, Anti-Retroviral Therapy (ART) to infected parents. The experience gained will strengthen the capacity of the government to manage ART in the country. In addition, ART will be administered to 15,000 persons through public-private partnerships in four cities – Bangalore, Hyderabad, Mumbai and Chennai. Although the costs of the anti-retroviral (ARV) drugs continue to be beyond the reach of most households, the Union government has exempted the drugs from excise duty, and the states have been requested not to levy sales tax and other local duties on them.

UN System Partnership

This national response to the epidemic is being actively supported by the UN organisations, the World Bank, bilateral agencies and international and national NGOs. First, the work of the World Health Organization (WHO) in the early days of the epidemic in India needs to be commended. The WHO, with its Global Program on AIDS, made a significant contribution in designing and implementing the first phase of the National Programme.

The UN system has been working also to strengthen partnerships between civil society, academic institutions, SACS and NACO. Some of the significant UN-supported interventions which are geared towards strengthening the ongoing National Programme and forming the basis of the next programme include the following examples, involving the relevant UN organization in each case: a school AIDS education programme; a study of the economic burden of HIV/AIDS and its socio-economic impact in each of the six high-prevalence states; a field-level study to assess the community prevalence of major sexually-transmitted diseases (STIs); mainstreaming HIV in drug-demand reduction programmes; a pilot programme to strengthen women’s organizations to address HIV/AIDS, especially for those women living with HIV/AIDS, in a gender-sensitive manner; initiatives at the regional and national levels to help combat the trafficking of women and girls and their vulnerability to HIV/AIDS; work with existing networks of HIV-positive people and provide them with leadership training for a more effective voice in policy-making.

The joint initiative of NACO and WHO/Global Programme on AIDS in Sonagachi, Kolkata, demonstrates how the right combination of information and community mobilisation can make a significant difference. The STD/HIV Intervention Project (SHIP) among commercial sex workers in Sonagachi started in 1992, initially focussed on disease prevention, mainly through distribution of condoms. The initiative later evolved into a community mobilisation exercise for managing a range of community-led activities.

Through capacity building and empowerment processes that focused on peer learning, collective action and information sharing, the community of sex workers – stigmatised and marginalised by society – is able to influence policies related not only to HIV/AIDS but also issues related to sexuality, rights of women and right to livelihood.

Nearly one million elected women representatives have been brought into the political arena under Panchayati Raj. It has allowed for a strong movement of women eventually able to guide policy. These women represent a tremendous resource for changing attitudes on HIV and gender as well as preparing the community for the impact of the epidemic. Several ongoing UN family initiatives are advocating for, and strengthening the leadership capacities of these elected, women in order to widen the discourse on gender, HIV and development.

The Lessons Learned

One has come to the realization of how important it is to work in partnership with other Development Organisations UN partners have eventually formed hands with other multilateral and bilateral agencies, CSOs, NGOs and the corporate sector, to support the Government's lead in building a more unified, equitable and mutually caring environment in India and this region. An important feature of the work of UNAIDS and UNDP is the effort to involve NGOs, the corporate sector and HIV-positive people. This is breaking new ground and is changing the way the UN works.

Next, the empowerment of people themselves, through networks of positive people or other community-based collectives is most needed in order to meet the challenges posed by the epidemic. In particular, the challenge is to reduce the stigmatisation and discrimination of positive and other marginalised people, including women. Responses to the epidemic must put people at the centre of the analysis.

Finally, HIV must be part of the wider development debate, so that it is not seen as a stand-alone initiative. This is a unique contribution of the UN System of jointly addressing the broader canvas of poverty reduction, gender equity, decentralisation of development, and drawing lessons from these for concerted action on HIV. The Human Development Report on HIV/AIDS and Development in South Asia, provides ample evidence of the two-way link between human development and HIV.

Overall, it needs the country’s political leadership to keep empasizing the priority importance of combating HIV/AIDS for the future survival of India. It also needs people from all walks of life to volunteer and join hands to 'break the silence', along with the media and the local communities and households already living with the epidemic and its consequences.

[1]http://www.unaids.org/publications/documents/mtct/qaweb99.html

[2] Yumnum Rupachandra, “Harm Reduction Among Drug Addicts: Manipur shows the way.”

http://www.youandaids.org/news/states/manipur.asp