Yes, you're positive, but there's nothing we can do for you
By Sandhya Srinivasan
What can the National AIDS Control Programme achieve in the
absence of integration of HIV-related services into the health
system as a whole? The second in a series assessing the
HIV/AIDS situation in India
When the National AIDS Control Programme was first set up in
1992 its first priority was to make people aware of HIV.
HIV is transmitted through unprotected sex, infected blood and
blood products and from an HIV-positive pregnant woman to her
baby either during pregnancy or through breast-milk. The
programme publicised these facts.
In some ways the programme took a bold step by starting to
talk about sex - the main route of transmission of HIV - in a
society which didn't like to talk about such things. Public
information campaigns were launched which actually spoke of
how HIV infection was acquired - and how it wasn't, through
casual contact, for example. These continue to meet with
resistance: some feel that talking publicly about sex corrupts
the young and is antithetical to Indian culture. Doubts have
also been expressed about the quality of information provided:
some messages seem to confuse and create fear more than they
The programme also sought to provide a bare minimum of
preventive services by protecting blood supply and setting up
an effective treatment programme for sexually transmitted
diseases (people who already have certain STDs are more
vulnerable to HIV if exposed to it through sexual contact, so
treating STDs would make people less likely to get infected
with HIV if exposed to the virus). Finally, the programme
worked at developing a system to monitor the prevalence of HIV
in various parts of the country by conducting unlinked
anonymous tests on STD clinic users, commercial sex workers,
injecting drug users, pregnant women attending antenatal
clinics, and gay men.
Phase II: More of the same
The second phase of the National AIDS Control Programme (1999
to 2004) tries to take all these activities one step further
and build on them.
The primary focus of the second stage of the programme has
been 'targeted intervention' to increase awareness among those
believed to be at high risk of infection, and to change their
behaviour. This includes the promotion of condom use among
Other activities include developing a safe blood supply
through the establishment of properly-equipped blood banks
where all blood is tested for HIV and other infections before
use; promoting blood Alternative Treatments and banning trade in blood;
setting up testing centres where people are encouraged to go
for testing which is preceded and followed by counselling;
further establishing STD treatment services, and setting up a
programme to provide a short course of anti-retroviral drugs
to pregnant women reporting to antenatal clinics who test
positive for HIV (called the PMTCT or prevent mother-to-child
Phase II of the NACP also has, as stated objectives, the
provision of decentralised services and strengthening of the
system's long-term capacity to respond to HIV.
Finally, the number of sentinel surveillance sites, conducting
HIV tests for monitoring purposes, increased dramatically in
the second phase. These were in STD clinics and antenatal
clinics and among groups of sex workers. As a result, it is
believed, surveillance data collected in the last few years
may present a more accurate picture of the prevalence of HIV
infection in India. (Still, the programme continues to be
plagued by queries about the quality of its data and many
limitations have been noted by public health experts and
NACP II was implemented at the state level using state AIDS
control societies, autonomous bodies headed by a senior civil
servant, but with independent financial authority. These
societies funded voluntary organisations to carry out
The targeted approach
Overall, the targeted approach dominates the second phase of
the National AIDS Control Programme. The targeted approach is
touted as a success story in states like Manipur and Tamil
Nadu where HIV prevalence has reduced among target groups such
as injecting drug users (in Manipur), commercial sex workers
and clients of STD clinics (Tamil Nadu). Indeed, surveillance
figures for 2000 and 2001 show a drop in HIV prevalence in
targeted groups in a number of states. However, it is not
clear if figures for the two years can be compared.
Interestingly, the NACO website does not contain any HIV
prevalence figures after 2001.
The programme quotes reports from successful AIDS control
efforts to argue that the best way to reduce HIV transmission
is to target interventions at groups most vulnerable to HIV.
These vulnerable 'core transmitter' groups are preferred for
interventions to groups that are more difficult to identify
and approach, such as clients of sex workers.
It is true that in the US and Australia, for example, well-organised
information programmes for gay men, by organisations of gay
men, are believed to have brought a sharp reduction in HIV
prevalence relatively soon after the appearance of HIV
infection in these groups.
What about those outside the target group?
A number of activists have complained that the targeted
approach misses people who are outside the target group. So,
for example, messages on the risk of unsafe sex between men
are presented only in situations where men congregate to have
sex with other men, or to groups self-identified as having sex
with other men. Since messages on the risks of gay sex are not
presented to the general population, those who do not identify
themselves as gay are excluded from important information.
Likewise, partners of injecting drug users risk acquiring HIV
but there are few efforts to speak to them as a group.
Targeting groups for interventions also stigmatises these
Surveillance figures in recent years indicate that HIV
infection is not confined to the 'target groups' of people
with high risk behaviour. A number of women who are HIV
positive report having had sex with only one partner -- their
husband. However, there is no effort to reach the 'low risk'
woman and discuss how she might protect herself from
Need for quality counselling
The general call for people to get themselves tested for HIV
is not supported by counselling services before and after
testing. The voluntary counselling and testing centres (VCTCs)
set up by the programme are reportedly under-staffed and
counsellors are often poorly trained. There are too many
reported incidents of people being informed of their HIV
status in front of other patients, of little or no effort
being made to educate those who test negative of how to avoid
Yes, you're positive, but there's nothing we can do for you
It must seem particularly unjust to those who are encouraged
to test themselves and find themselves HIV positive, that they
have nowhere to go.
A few voluntary organisations do provide treatment and support
but they can meet just a fraction of the demand for such care.
In general, both private and public health services are
completely unprepared to respond to the growing need to care
for people with HIV. Private services generally refuse
treatment, or provide it at exorbitant costs to those who can
afford it. Very few public health services are equipped to
provide treatment of any kind. Drugs are in short supply, as
are protective materials to be used for all patients
(following universal precautions). And few personnel have been
trained in standard procedures to prevent transmission of HIV
or other infections. The kind of resource allocation,
education and regulation needed to ensure treatment to people
with HIV-related health problems do not exist.
In such a situation, there is no scope for treatment with
anti-retrovirals through the public health system, a demand
made by some groups working with people with HIV.
A weakened health system
There is much talk about integration of HIV prevention and
treatment into the system. However, not only are preventive
programmes patchy and integration poor, there is no
integration of HIV-related services into the health system as
Further, public health services in India have deteriorated
steadily over the last few decades. There is no evidence of
efforts being made to strengthen the health system and prepare
it for a growing burden of ill people. Barely 20% of all
health-related expenditure is made by the government; the rest
is within the private sector, where payment is made by
individuals spending their own money since health insurance is
available to a negligible percentage of people in India. The
increase in HIV-related problems calls for increased
government spending on health. As more awareness is generated
and more people test positive, this demand is bound to grow.
This increase in government spending on health is a
decades-old demand. Instead, the amount spent on health has
gone down, not up. There are innumerable instances
illustrating the collapse of health care through the
government, from the rural primary health centre all the way
up to the municipal hospital representing the tertiary level
of care. Equipment does not work, drugs and other materials
are not available, staff are absent, and so on.
In fact this general deterioration of public health services
actually increases people's vulnerability to HIV as shortages
encourage the reuse of unsterilised equipment.
Further, the absence of treatment may in fact exacerbate the
stigma attached to HIV.
HIV is driven by inequities
HIV is intrinsically linked to poverty and to inequalities of
all kinds - social, economic and gender. However, awareness
and other preventive programmes do not address inequities that
are intrinsic to the problem. The married woman is unable to
refuse her husband unprotected sex. The commercial sex worker
will not insist on her client using a condom if he threatens
to go elsewhere. The national HIV programme fails to take into
inequities into account.
(InfoChange News & Features, July 2003)