Four decades ago, on June 5, 1981, the Centers for Disease Control and Prevention reported an unusual fungal infection of the lungs ( pneumocystis carinii pneumonia) in five gay men in Los Angeles. That was the first time the world learnt about the devastating infection caused by the Human Immunodeficiency Virus (HIV) in people with a weak immune system.
We are in June of another decade and another century, and another virus is haunting us. Clioepidemiology is the study of information from past epidemics for advice about the present. We have dealt with the HIV infection for 40 years. What stops us from drawing from the collective experience of the past and entering this new battlefield against COVID-19 well-armed?
Falling short of targets
It is widely acknowledged that India scripted one of the biggest success stories in fighting HIV/AIDS between 1997 and 2010, after the infection hit the shores in 1986. The achievement of “controlling AIDS” was flagged by the Centre in 2012 as a small victory in the long journey of accepting, understanding and fighting the disease. But soon, we fell short of our targets.
The aim of the World Health Organization, of which India is a member, was to ensure that 90% of the people living with HIV/AIDS are on anti-retroviral therapy by 2020. The target has been pushed by at least five years. Similarly, the 2017 National Health Policy and the UN Sustainable Development Goals aim to end AIDS by 2030. This goal too looks like it may take longer to achieve. Former Union Health Secretary and National AIDS Control Organization (NACO) Director, J.V.R. Prasada Rao, who helmed India’s AIDS response programme till 2017 as Special Envoy to the Secretary General of the United Nations on HIV/AIDS for the Asia Pacific region, fears that the country is at risk of losing hard-won gains.
When the COVID-19 outbreak shook the world last year, transferring the blame for unmet targets got easy. But AIDS had actually fallen off the radar long before. And if it is further flushed out of public memory, it will be difficult to check progress on controlling it.
How India slipped
After years of debate and hard work, India had everything going for it to escalate the fight against HIV/AIDS. The information and education campaigns of the 1990s helped to check the transmission of HIV infection through two routes: mother to child, and blood transfusions. Strict ante-natal protocols were established and blood banks were upgraded with superior testing facilities. The sale of blood was banned. Excellent awareness programmes and intensive follow-up action plans led to significant decline in incidence, but the reduced visibility of the disease led to plateauing of efforts. While politics let AIDS slip from being priority health news, arrogance and complacency of governments between 2013 and 2019 slackened the implementation of AIDS control programmes countrywide.
Post-2014 elections, the government was keen to show the world that it was close to beating AIDS, says Mona Mishra, strategic planning consultant (HIV/AIDS project), UNDP. The HIV infection diagnosis rate dropped from 60% in 2010 to 23% in 2019, the mortality rate doubled and new cases spiked five times more during the period. According to NACO’s annual HIV Estimates report of 2019, there were over 58,000 AIDS-related deaths and over 69,000 new HIV infections added to the pool of 2.3 million people living with HIV/AIDS, with 98% of new infections in the high-risk groups. This happened because the campaign to educate and empower the vulnerable communities — MSM (men who have sex with men), IDUs (Injecting Drug Users), migrant and sex workers, and truck drivers — was losing steam. An entire new generation had grown up on Internet knowledge. They were downloading dating apps and hooking up with no awareness of AIDS. Natural desires and sexual behaviour cannot be changed; yet discussions with adolescents on safe sex were buried.
Trusting the same formula
The pioneers of the AIDS movement understood that a strong political leadership, financial support, advocacy and activism were non-negotiable in the successful handling of the movement. “When the HIV reality was unfolding in India, we did not look at short-term interests but took a long-term view of AIDS beyond the health sector and the socio-economic impacts of the epidemic,” writes Mr. Prasada in his book Celebrating Small Victories: My Journey Through Two Decades of AIDS Response. India needs to keep the conversation going and focus on the broad coalition of economists, scientists, doctors, researchers, technicians, civil society representatives and policymakers, he says. He stresses on the need for a multi-sectoral and multi-pronged strategy to contain AIDS. To fight any medical crisis, we can trust the same formula of supporting science-driven responses, good quality data and empirical evidence; and consolidating guidelines.
“There is a road map for reducing new HIV infections by 2030; we only need to repurpose it,” says Ms. Mishra. Good data and information from scientific investigations have to be combined and the Centre needs to provide resources to scale.
The nationalised AIDS treatment plan is a perfect example of how early detection, diagnosis and treatment saved many lives. It gave a head start to the National AIDS Control Programme (NACP) when every State and Union Territory established its own AIDS control organisation and was given a free hand and funds to monitor the epidemic and work on integrated action plans under NACO’s supervision.
Universal precaution and prevention were NACP’s bedrock. Experts say the NACP’s experience in dealing with HIV needs to be tapped into. The existing workforce in 21,000 Integrated Counselling and Testing Centres (ICTC) is well-equipped. They can help in early detection of infections, provide basic information on modes of transmission, promote behavioural change, reduce vulnerability and link people with care and treatment services. A majority of the ICTCs has an excellent outreach in the interiors. The staff can also be easily utilised for dealing with COVID-19 now.
At the core of every exit strategy is a strong surveillance system. The government needs to rejig its priorities and re-energise the ICTCs along with the 32,000-plus primary and urban health centres to uphold the right to treatment and the dignity of individuals affected by diseases — AIDS, COVID-19 or any other. For that, acknowledging the existence and enormity of the problem is crucial. Using the available tools in the healthcare system is the best way to mainstream health crises. By integrating education and awareness outreach programmes and re-allocating and releasing funds on time, any chronic (TB/HIV/malaria), acute (cholera/plague) or new outbreak becomes easier to deal with.
There is no dearth of experiences to draw from if only we are inclined to learn from our past, rather than forget and be “condemned to repeat it”, in the words of writer-philosopher George Santayana. And that is also why AIDS needs to be back on the agenda.
soma.basu@thehindu.co.in
Published - June 29, 2021 12:15 am IST
