India can’t be complacent in the battle against HIV/AIDS
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India can’t be complacent in the battle against HIV/AIDS

Six Indian states have HIV prevalence that is more than double the national average

analysis Updated: Nov 30, 2018 17:07 IST
Ashok Alexander
Ashok Alexander
The situation in three north-east states of Mizoram, Manipur and Nagaland, driven primarily by injecting drug use, is particularly worrying. We ignore the threat of HIV at our own peril, even as we celebrate what we have achieved.(REUTERS)

Fifteen years ago, there were global fears that the HIV/AIDS epidemic in India could spin out of control. Today, India ranks among countries with the lowest HIV prevalence. The control of HIV is one of India’s greatest public health achievements. Sadly, it has not received the recognition it deserves in India, because of the high levels of stigma that still surround this cruel disease.

Consider the following facts. In 2002, India’s National AIDS Control Organisation (NACO) estimated 4.8 million people living with HIV in the country (revised to 2.7 million later based on a new methodology), with 150,000 new infections each year. The prevalence of HIV among female sex workers was more than 25 times that in the general population. There were global fears that the epidemic would spiral out of control.

Today, new infections per year have come down to 88,000 as per NACO data. HIV prevalence in India has been declining steadily. At 0.22%, India’s HIV prevalence today is one of the lowest in the world, less than that in the United States. In 2000, most countries committed to meeting four health-related targets by 2015 — reduce the under-five mortality rate, reduce the maternal mortality ratio, halt and begin to reverse the spread of HIV/AIDS, and that of malaria and other major diseases. India achieved only two among these — the target for HIV/AIDS, and for malaria and other diseases.

From 2003-2013, I had the honour of leading the building of Avahan, the India HIV prevention programme sponsored by the Bill and Melinda Gates Foundation. Avahan worked primarily with communities most at risk of contracting the HIV virus. There were female and male sex workers, transgenders, injecting drug users, and long-distance truck drivers. Female sex workers were our largest target group.

Thousands of people most vulnerable to the HIV virus, mainly brave female sex workers, fought at the frontline of the war against HIV, driven by a huge sense of community. Avahan worked in six states in India: Manipur, Nagaland, Maharashtra, Tamil Nadu, Andhra Pradesh and Karnataka.

Avahan expanded rapidly, and soon established itself as the world’s largest ever privately sponsored HIV-prevention programme. The programme covered all but one of the 78 high prevalence districts in India (HIV prevalence of 1% or more). At its peak, Avahan delivered prevention services across 672 towns within 83 districts in six states. It reached out to more than 250,000 people from highest-at-risk communities and was distributing 13 million condoms a month. In 2013, Lancet credited Avahan with having averted over 600,000 HIV infections.

The fact that we could mount such a large campaign, so quickly, is not because of any great aptitude on our part. The smartest thing we did really was to ask the communities of sex workers to point the way to the solution. I remember how a year into my journey in HIV prevention, I met Theny, a 25-year-old street based sex worker, in a small town in Tamil Nadu. As I explained to her the dangers of unprotected sex, she said, “You are telling me that if I get HIV I will die in ten years’ time. But sir, ten years is a lifetime for me. I have other more serious things to worry about now.” From women like her, we learnt that sex-workers’ biggest need was freedom from violence. We then appreciated that violence was strongly linked to unprotected sex. When sex workers came together to tackle that menace, the Avahan programme spread rapidly, and developed its own momentum. This was my first big learning — that even highly marginalised women, working together, have the power to tackle some of their toughest problems.

Sex workers across six states then went on to lead the effort of identifying and mapping every single member of their community by risk category. They used innovative ways to mark hot spots on street maps, create social networks to generate awareness, and prepare elaborate monitoring tools for beneficiary-level tracking. Groups of women sex workers across states shared hard data about incidence of violence with police and media, collaboratively combatting the issue. This was the second learning — that smart data use by front line health workers to achieve focus — was critical for effective response

At Avahan, we always knew that we were playing a temporary role, and so we made every effort to work with and through government, within the framework of the national AIDS control programme under NACO. Once we had played our role, we successfully transitioned our programme to the government, and stepped back after 10 years. This was the third lesson: that it is necessary for any outside agency to work with and though government to achieve scale and sustainability. More important, that the transition of a massive privately sponsored programme to government was feasible.

Having come so far in the battle against HIV, it will be a fatal mistake to declare victory too soon. Several nations made the mistake of being complacent when AIDS-related mortality decreased. Six Indian states have an HIV prevalence that is more than double the national average. The situation in three north-eastern states of Mizoram, Manipur and Nagaland, driven primarily by injecting drug use, is particularly worrying. We ignore the threat of HIV at our own peril, even as we celebrate what we have achieved.

For me, participating in the campaign against HIV in India was a life-changing experience. Coming from McKinsey, where we would deliver smart solutions to clients’ issues, into a world where consumers knew far more than the supposed experts, was sobering. Working closely with communities of sex workers to find answers to complex problems in HIV prevention, I was humbled and inspired by their leadership, courage and selflessness. Those were the best years of my life.

Ashok Alexander is Founder-Director of the Antara Foundation.

The views expressed are personal

First Published: Nov 30, 2018 17:07 IST