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AIDS control priorities

A new study reported in this newspaper indicates that the present estimate of 5.2 million people living with HIV in India is an overestimate, and that the actual number may be closer to 3.5 million. Whatever be the best estimate, it is clear that India faces a complex set of challenges. Social attitudes remain largely unchanged despite the high profile response to the pandemic over the last decade. Hope hinges on the five-year National AIDS Control Programme III, which is due to start in 2007 with a budget of about $ 2.5 billion, embellished by voluntary efforts. At the XVI International AIDS Conference in Toronto, Union Health Minister Anbumani Ramadoss made a welcome departure from the mostly conservative approaches of the past by accepting ground realities. The proposal to amend the law to decriminalise certain behaviour that leads to the spread of HIV (such as men having sex with men) is bold and progressive; the positive results of the needle exchange programmes for injecting drug users in some parts of the Northeast have been acknowledged. Criminalising and driving vulnerable groups such as sex workers and drug users underground puts them out of reach of health workers and at higher risk of acquiring and transmitting HIV.

While the search for an HIV vaccine goes on, global attention has turned to new interventions for prevention such as circumcision and the use of microbicides and prophylactic medication for those at risk of exposure. These are under scientific scrutiny and will need validation. Proven approaches to check HIV rely on safe sexual behaviour, universal access to anti-retroviral (ARV) drugs, and, as Dr. Ramadoss has proposed, removing stigma and discrimination through effective laws. The experience in South India, where a high proportion of Indians with the virus are thought to live, is revealing. The Lancet reported recently that between 2000 and 2004, there was a one-third reduction of new infections among women attending clinics in South India, a breakthrough enabled by increased condom use by men visiting sex workers (thus protecting the wives of these men). Women empowered are better able to protect themselves against HIV. For the infected of course, hope lies in access to the best drugs. There is growing concern that India's response to the challenge of providing universal access to treatment is inadequate. The Lancet article cites a worrying inadequacy of data on infection rates in some northern States. It is imperative that the national plan goes for wider testing and universal ARV treatment coverage. It must also provide the more expensive second line drugs to those who have developed resistance to first line medication. The health workforce needs to be expanded to give the HIV campaign greater reach. The World Health Organisation has made the excellent suggestion that some of this augmentation can come through treating and recruiting HIV positive people themselves.

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