Activists working on gay and transgender rights feel the new guidelines from the World Health Organisation (WHO) on HIV services for key groups have not been very well thought out specially in the context of providing anti-retroviral therapy (ART) to men who have sex with men (MSM).
They also feel that priority to MSM is not appropriate in a country where women and children are much more at risk and in need of intervention. The WHO in a news release on July 11 for the first time strongly recommended that men who have sex with men consider taking antiretroviral medicines as an additional method of preventing HIV infection alongside the use of condoms. Rates of HIV infection among men who have sex with men remain high almost everywhere and new prevention options are urgently needed, the WHO said.
For the first time, WHO strongly recommends men who have sex w/ men to take antiretroviral meds as additional method of preventing >#HIV
— WHO (@WHO) >July 11, 2014The >“Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations" , was issued in the lead-up to the International AIDS Conference in Melbourne starting on July 20.
At the conference, WHO is expected to call on governments to re-energise and strengthen HIV programmes.
Dr. V.K. Subburaj, secretary, department of AIDS Control, told The Hindu that already 777,485 persons were receiving ART and in the case of MSM they will first have to be identified. In India, the numbers of MSM was much lesser than other countries, compared to the population size. Now ART is being given to those with CD 4 cell counts below 350 (CD4 cells or T-cells are the cells that send signals to activate your body’s immune response when they detect viruses or bacteria). There are plans to include those whose CD 4 counts are below 500 in the ambit of ART. This could mean an additional one lakh persons.
Any decision on preventive ART would have to take into account the numbers involved and identifying those who need it. The government is yet to take a decision on this issue, Dr. Subburaj said. The government is yet to cover all the 15 lakh identified as HIV-positive. The Rs 600 crore ART programme was introduced in 2004 and there are 1302 centres providing it. The National Aids Control Programme (NACP) IV aims to provide universal access to free ART to all those who require it.
The WHO warned that failure to provide adequate HIV services for key groups – men who have sex with men, people in prison, people who inject drugs, sex workers and transgenders – threatens global progress on the HIV response. In many countries they are left out of national HIV plans, and discriminatory laws and policies are major barriers to access.
Ashok Row Kavi of Humsafar Trust, which works with MSM and transgender communities in Mumbai, points out that this idea to cover MSM came up in the US where ART is cheap. While ART is effective, the question is an ethical one, he pointed out.
Mr. Kavi said that in meetings held on this issue, he had objected to the idea and pointed out that first of all women and children should be covered under ART specially since the age of male prostitutes and females was getting younger and younger. Women and children get very low priority and the male earning members of the family are usually given ART. Gay men and transgenders also have little access to ART and they are often kicked out at the gates of the centres by the security men. Is it fair in a patriarchal society to give men access and priority for ART? he asked.
Anjali Gopalan, Founder and Executive Director of The Naz Foundation (India) Trust, said that even as a preventive step, this is not so very well thought out and the government is still to provide ART to all those who are HIV-positive. There are many unresolved issues in providing ART to MSM. “While it is a good move, what about other forms of preventions like using condoms?” she asked. Also how does one ensure that ART gets to the right people and they take it? The WHO should have thought this out before issuing such guidelines, she added.
The WHO feels that preventive efforts are still lagging too far behind, particularly among key populations. It says there are still significant gaps in addressing their needs in national HIV plans.
Globally, just 70 per cent of countries surveyed explicitly address the needs of men who have sex with men and sex workers, while the figure for injecting drug users was 40 per cent. Transgenders are rarely mentioned in HIV plans. And even where policies exist on paper, it is hard for people to access services that can help them.
Clearly a balance needs to be achieved, depending on the country in question. Access in services to women and children, transgenders and other vulnerable groups must be improved first before introducing universal ART.
