We are not used to too many success stories in our battles against diseases. On the contrary, with our shambolic public health system and cavalier political attitude, we have become the leading light in most communicable and lifestyle diseases. But, India seems to be getting it right when it comes to the fight against HiV/Aids: infection rates have dipped by half over the last decade and we have also realised the advantages of working with affected communities.
There is another reason behind these improvements: there has been official receptiveness to work together with other countries to utilise the best practices than follow a go-it-alone strategy. Director-general of National Aids Control Organisation (Naco) Sayan Chatterjee, agrees on this united approach. He says that “researchers around the work must work collaboratively and strategically to identify and develop the best ideas for HiV vaccine design, whatever their provenance”.
Today, 30 years after the virus was first detected, African countries are trying to adopt the Indian model of combating it. The turnaround seems to have come in the National Aids Control Programme III (NACP III) in which a real effort was made by Naco to evolve a consensual model that involved all stakeholders: donors, civil society and those living with Hiv/Aids.
The Indian efforts have been focused on prevention. “It is still a huge health concern, so we cannot get away from prevention,” says MK Bhan, secretary, department of biotechnology. While he is all for the development of vaccines, he feels that when it comes to “neutralising viruses, whether HiV or malaria or others, we are working against nature, we have to rely on man’s ingenuity”.
In a happy development, targeted intervention programmes today cover over 70% of the populations at risk. There has been a quantum jump in the use of condoms and much more focus on access to prevention services. Similarly, there has been improvement in counseling, testing and an increase in the percentage of those receiving anti-retroviral drugs, all as a result of taking into account the situation on the ground rather than adopting a bureaucratic top-down approach.
But there are some factors that the NACP IV has to take into account as preparations before it begin next year. First, foreign funding for the fight against HiV/Aids is likely to decrease. The concessional funding from the World Bank will be reduced and organisations like the Gates Foundation have decided to put their money into other areas of communicable disease.
This means that there is likely to be greater reliance on domestic funding. And therein lies the rub. The health challenges that India faces today have proliferated from communicable diseases to lifestyle ones like diabetes, hypertension and cardio-vascular ailments. This means that there will be competing demands on even an enhanced funding. Former Naco director Sujata Rao says “this [the drop in funding] calls for a review of the programme so that these new factors can be taken into account from the beginning. Otherwise we may fritter away the advantages that we have secured.” Equally worried are the civil society organisations that work in this field.
In the prevention approach, there is no getting away from the simultaneous efforts to developing a vaccine. The department of biotechnology has created a centre in collaboration with the International Aids Vaccine Initiative for the development of a vaccine, which if successful will be manufactured in India. The secretary of the department of science and technology, T Ramaswamy, echoes this view that there is no need for India to strike out on its own and that we need to optimise our resources in collaboration with international efforts.
Today our seropositivity rate has come down from 0.36 to 0.31, a considerable achievement in a country with such a huge disease burden. But the efforts must be on to design a programme that will invite greater global funding. For this, donors have to be convinced that the programme takes into account all factors, including the views of those living with the virus or who have already contracted Aids. The focus on prevention is vital but there are four lakh people who are undergoing treatment and nothing can compromise their needs, especially the complex levels of care and support HiV positive people need.
The Bill and Melinda Gates Foundation’s Avahan package is a model which could be incorporated into the NACP IV that looks at prevention services like outreach, behaviour change, messaging on safe sex, free or socially marketed condom distribution, needle and syringe exchange for drug users and treatment for sexually transmitted infections. The other determinants it covers include stigma, violence, legal environment, medical infrastructure, mobility, migration, gender roles and barriers to accessing entitlements.
Stigma is a particularly difficult area in countering the virus as there is still so much ignorance surrounding it. This was clear from the manner in which two HiV-positive siblings were shunned by a school in enlightened Kerala as the parents of other students were against the idea of their children sharing the same space as them. Even more heartrending is the discrimination faced by marginal communities such as sex workers, transgender and injecting drug users. The antidote to this is to involve as many stakeholders as possible.
The experience of NACP III has shown that rather than become unwieldy, this actually helps to hone and focus interventions. We have reached a situation where we are being talked about globally as a success story in the fight against Hiv/Aids. We now need to build on this and today, which is World Aids Vaccine Day, would be as good a time as any to renew our pledge to do so.