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Aids and maternity in India

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Patrice Cohen
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Suniti Solomon

Part 1. HIV/AIDS epidemic in India

1. An Overview of HIV/AIDS Epidemic and its Prevention in India

R.N. Gupta

Texte intégral

Background

1The year 1981 will never be forgotten for the human health tragedy which was revealed in some peculiar infections caused by the immunodeficiency syndrome. These infections were observed initially in homosexual males in the USA and later in other parts of the world. This gay-related immunodeficiency syndrome (GRIDS) was subsequently named AIDS by the Centre for Disease Control and Prevention, USA. The biomedical scientists’ curiosity and ingenuity soon succeeded in identifying the virus causing the immunodeficiency syndrome, termed human immunodeficiency virus (HIV) by the WHO.

2Within a couple of years, the spread of HIV assumed epidemic proportions. However, well before the mid-1980s, when it was engulfing Africa, Europe, the Middle East, Asia and other regions, the scenario had sensitized India. The anxiety and seriousness had become manifest among biomedical scientists and health care system managers. As a result, the Indian Council of Medical Research (ICMR), an apex biomedical research body in the country, set up a high- powered committee of scientists in 1985, known as the National Task Force on AIDS, which deliberated the problem and set agendas for prompt action to tackle the ensuing challenge of the dreaded infection causing AIDS, a disease stigmatized and met with discrimination. The Task Force called for serological testing for the HIV infection among some high-risk groups using ELISA procedures at its Pune based National Institute of Virology and Christian Medical College (CMC), and at the ICMR Centre for Advanced Research in Virology based in Vellore. These two institutions were made to serve as national AIDS Reference Centres for countrywide surveillance of the HIV infection. In 1986, the serological tests of commercial sex workers in Chennai (earlier Madras, in the state of Tamil Nadu) and subsequently in Mumbai (earlier Bombay, in the state of Maharashtra) established the presence of the HIV virus in the country.

3This discovery, which was to some extent a timely scientific achievement, sent a shock wave throughout the country and created an emergency-like situation. It stirred up the Indian health machinery and the people who used to perceive HIV/AIDS as a disease mostly confined to the gay community and prostitutes in the West, and to the African and South-East Asian countries.

  • 2 Details of the Phase-I and Phase-2 programme are available in Appendix 1.3 (Note from the Editors).

4The presence of the HIV infection in Chennai and Mumbai and the cumulative reaction of the concerned people led to the immediate formation of a high-powered National AIDS Control Committee to coordinate with government ministries, NGOs and other institutions for effective implementation of AIDS control programmes in the country. Subsequently, in 1987, the National AIDS Control Programme started such activities as the creation of public awareness, blood screening for transfusion, and sero surveillance. In 1989, a medium-term programme was planned with the US support of $ 10 million for the control of HIV/AIDS. It was implemented with WHO support in the states of Maharashtra, Tamil Nadu, West Bengal, Manipur, and Delhi. The programme activities included energizing the programme management capacity, targeted IEC activities, and HIV surveillance. The Task Force also recommended clinical surveillance among the patient population by medical colleges in certain states and serological surveillance among the asymptomatic persons from the high-risk groups in some areas. The programme received a further boost in 1992, with the support of the World Bank for five years (1992-97) and the establishment of the National AIDS Control Organization (NACO). The programme was designated Phase-I and made comprehensive with the inclusion and implementation of educational and awareness-creation activities, the introduction of blood safety measures, control of hospital infection, strengthening of clinical services for STD/HIV/AIDS and the promotion of condom use for safe sex2.

5The Phase-I programme was extended for another two years, to March 1999. In order to control the spread of HIV/AIDS-related morbidity and mortality, the programme followed the approach of intersectoral coordination and cooperation. The programme appraisal for this period (1992-99) was carried out and recorded relatively satisfactory achievements. This led to the initiation of the National AIDS Control Programme (NACP), Phase-II, for the next five years, from 1999 to 2004, with support from the World Bank, USAID and the Department for International Development (DFID).

Prevalence

  • 3 National AIDS Control Organization (NACO), 20002. Combating HIV/AIDS in India, 2000-2001. Ministry (...)

6There were 3.86 million people with HIV in India at the end of the year 2000. The cumulative figure for people living with AIDS was 20,304 (males: 15,563; females: 4,741 (NACO))3. Fifteen percent of these cases represent younger age groups (15-29 years). A nationwide sentinel surveillance survey carried out at 232 sentinel sites in different states and union territories, covering 109 STD clinics, 110 antenatal clinics, 11 IDU and 2 MSM areas, showed an increase in the prevalence of the HIV infection in the country. The survey indicated that the presence of the HIV infection among antenatal women increased from less than 1 % to more than 1 %, and from less than 5 % to more than 5 % among high-risk groups.

7The HIV infection among the antenatal women was reported to be more than 1 % in the states of Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, Manipur and Nagaland. In the states of Gujarat, Goa and Pondicherry, it was more than 5 % among the high-risk groups. However, in the remaining states of the country, the HIV infection among high-risk groups and antenatal women was reported to be less than 5 % and l % respectively.

8In metropolitan cities like Mumbai in Maharashtra, the HIV infection has crossed 2 %, Hyderabad in the state of Andhra Pradesh, Bangalore in the state of Karnataka, and Chennai in the state of Tamil Nadu, have crossed 1 %. In Calcutta in the state of West Bengal, Ahmedabad in the state of Gujarat, and Delhi, it remains below 1 %.

  • 4 NACO, 2001. National Baseline General Population Behavioural Surveillance Survey. Ministry of Healt (...)

9What is more worrying than the prevalence of the HIV infection is its social epidemiology. The infection is spreading from high-risk groups to the general population and from urban areas to rural areas. The spread of the HIV infection among 20 304 AIDS cases reported from May 1986 to March 2001 has been mostly through the sexual route (82.6 %), followed by IDU (4.2 %) and blood transfusion (4.0 %). The perinatal route accounts for the lowest transmission (1.8 %). There are AIDS cases (7.5 %) whose histories do not provide information about the route of transmission of the infection (NACO)4.

10The co-existence of opportunistic infections among the AIDS cases is numerous. Tuberculosis accounts for 59 %, followed by candidiasis in more than half of the cases (51 %). More than one third (32 %) of the cases are reported to have a cryptosporidiasis infection, PCP 24 %, herpes zoster 18 %, toxoplasmosis 14 %, bacterial pneumonia 13 %, cryptococcal meningitis 9 %, Kaposi’s sarcoma and others 10.6 %. Although the HIV infection in some cases may be initially asymptomatic for quite some time, the common symptomatic presentation of HIV in India includes persistent generalized lymphadenopathy (PGL), herpes zoster (reactivation of the dormant chicken pox virus), oral thrush (fungal infection of the mouth), and prolonged diarrhoea where causative organisms remain unknown in many situations (Lanjewar, Rodrigues et al. 1996).

Awareness

11The data from National Baseline Behavioural Surveillance Survey recently carried out in thirty-five states and union territories (UTs) and covering a total sample of 84 182, an equal proportion of male-female and rural-urban in the age group of 15-49 years and about three quarters currently married, indicate that as many as 89.4 % respondents in urban areas have heard of HIV/AIDS, as compared with 72.3 % in rural areas. In most of the states, males accounted for a higher awareness than females. A majority of respondents in most of the states were aware that HIV/AIDS is transmitted through sexual contact (71.0), blood transfusion (72.5 %), sharing drug injection needles (77.6 %). Transmission from mother to child was found to be low in most of the states, except in Goa, which reported 90.0 %. The breastfeeding route was known to 54.4 % respondents. Awareness of safer sex or the correct and regular use of condoms was reported by 75.0 % of the respondents, but only in seven states, namely Delhi, Goa, Himachal Pradesh, Kerala, Manipur, and Punjab. A significant proportion of respondents also reported that monogamy, an infection-free partner, the regular use of condoms and abstinence prevent HIV/AIDS transmission (NACO, 2002a).

Prevention and Control

12Although HIV sero-positive cases were detected in India in the early part of 1986, a nationwide surveillance for detection of HIV incidence had begun as early as 1985. With the formation of the National AIDS Control Committee in 1986, the National AIDS Control Programme was launched in 1987. The Directorate General of Health Services under the Central Ministry of Health and Family Welfare was charged with HIV/AIDS control activities which included surveillance, the establishment of a central AIDS cell, statel-level AIDS cells, human resource development – training and equipping scientists and laboratory technicians to screen blood and blood products, the dissemination of preventive information, fostering health education and creating awareness among the people. As already referred to above, a medium-term programme was developed and implemented in five districts in 1989 with the the support of the US and WHO and progressed to a comprehensive Phase I, from 1992 to 1997, and was further exended to March 1999, with activities concerned with education and awareness, with the practice of blood safety measures and the control of hospital-based infections, and with the strengthening of clinical services for STD, HIV/AIDS and the promotion of condom use. The state AIDS cells were upscaled to state AIDS societies and technical advisory committees were constituted. In 1993-94 (S. Panda, 2002, G. Sethi 2002), the sentinel surveillance methodology was adopted. Its aim was to help in understanding the prevalence of HIV in different high-risk population sub-groups, like commercial sex workers (CSWs), IDUs, STD clinic attendees and others, and also among the antenatal women attending the clinic. The revised strategy suggested blood tests in the above population sub-groups once every year.

13The prevention programme is currently in Phase II. It became operational in November 1999 in thirty-two states and UTs for a period of five years. The main objectives are to reduce the spread of the HIV infection and strengthen the capacity of the government at the central and state levels in order to enable them to respond to HIV/AIDS on a long-term basis. The programme has been completely decentralized at the state and UT levels for speedy and effective implementation. The state AIDS control societies responsible for the control of HIV/AIDS in the concerned states are provided with adequate technical, managerial and financial support by the Indian government, Ministry of Health and Family Welfare, through NACO. The programme aims at containing HIV prevalence rates below 5 % in Maharashtra, 3 % in Andhra Pradesh, Karnataka, Manipur and Tamil Nadu, and 1 % in other states. Further, its endeavours are to keep the transmission levels of HIV below rates in India in 1985.

14The Prime Minister appealed in his Independence Day speech, on 15 August 2000, to the people and again during his meeting with business leaders, on 1 December 2000, to join in the fight against HIV/AIDS. On 22 May 2001, the Prime Minister met with the Chief Ministers of high-prevalence states and urged them to intensify the fight against HIV/AIDS. The Union Health Minister also talked to the Chief Ministers. The Chief Ministers registered their intentions to intensify their efforts in combating the spread of the infection in their states. The Union Health Minister and opposition leader in Parliament addressed the UN Special Session on HIV/AIDS, held in New York in June 2001, and gave the assurance of India’s commitment and efforts in tackling the epidemic: to keep the transmission through blood and blood products below 1 %, to raise awareness among the youth to 90 %, and to increase the use of condoms among high-risk groups like CSWs to 90 %. Thus, the high-risk groups have targeted interventions, while the general population have intervention components like IEC awareness campaigns, VTC, etc., besides the provision of low-cost AIDS care based on the best guidelines for practice and the use of appropriate drugs for the treatment of opportunistic infections at district hospitals, and on the training of staff for referral services (NACO, 2002-b).

Political Will

15The health and socio-economic impact of HIV/AIDS is well realized at the political and industrial levels. HIV surveillance began in the country at the personal instance of the Prime Minister.

National AIDS Prevention and Control Policy

  • 5 Details of creation of national AIDS control policy at the States and Union Territories scale are a (...)

16The Indian government has been quick to act to prevent and control the spread of HIV/AIDS in the country, right from the time the infection was detected in Chennai, in 1986. It not only formulated the National AIDS Prevention and Control Policy,5 but also prepared separately and implemented a National Blood Policy. Conforming with the global strategy, its policy provides for programme management, surveillance, IEC, control of STD, blood safety by modernization and strengthening of blood banks, impact reduction, promotion of condom use, and research, besides training and support facilities. The policy reiterates the commitment of the government to the control and prevention of the epidemic, the involvement of NGOs, and inter-sectoral and financial support of prevention programmes (NACO, 2002-c).

IEC Strategy6

  • 6 IEC: Information Education Communication.

17The scope of the national HIV/AIDS-related IEC strategy is very wide. Its focus is on political and media advocacy, on the one hand, and on the development of an environment at field-level of the general population which is conducive for awareness creation, the removal of discrimination and stigma attributed to HIV/AIDS, behavioural change and the utilization of the services provided for combating and preventing the spreading of the epidemic of the dreaded infection through the country, on the other hand. NACO has done commendable work in the area of IEC, particularly in making it need-based and effective. It has involved the State AIDS Societies in the assessment of the communication needs in their respective states so as to address them effectively in the development and implementation of the state IEC programme. Guidelines for focused, effective and cost-effective IEC programmes have been provided by NACO.

18A number of government and private agencies have been involved in the development and implementation of IEC programmes in the country. Training, research, advocacy, use of electronic media, youth programmes, school AIDS education programmes, family life education and responsible sexual behaviour among rural youth through Nehru Yuvak Kendras (youth centres), university AIDS programmes for the creation of awareness among university students of HIV/AIDS, telephone help lines, street plays, songs and drama, press advertisements for voluntary blood donation, involvement of political and religious leaders and industrialists and popular film stars for the dissemination of important messages to prevent HIV/AIDS and to remove stigmatization and discrimination, etc., are important components of the IEC strategy.

Monitoring and Evaluation

19The implementation of the national HIV/AIDS prevention and control programme, including training, strengthening services, quality control, coordination, etc., is monitored centrally and at the state level through state AIDS societies. For the evaluation of programme performance and corrective measures, a computerized management information system (CMIS) is being created at the state and central levels. Baseline, mid-term and final evaluations have been devised by an independent agency. The provision of the annual programme performance and a review of national performance under the National AIDS Control Board has also been made.

Social and Behavioural Research

20The need for social and behavioural research emerged long after the detection, in 1981, of homosexual males with HIV seropositive in the United States, and subsequently in other countries. While serological test and surveillance facilities were being established and updated and the epidemiology of the infection, in both the developed and developing countries, was being studied in the 1980s, it became imperative to understand the mode of infection transmission for treatment and prevention.

21These were the priorities for clinicians and bio-medical scientists. Thus, the programme of antiretroviral drug and vaccine development became the major thrust. The prevailing situation, therefore, could not project the need for social and behavioural research in order to bridge the knowledge gap, on the one hand, and so as to inform interventions for the behavioural prevention of HIV, on the other hand. However, the rapid spread of the infection assumed epidemic proportions in some states and later spread to several non-endemic areas, making a compelling case for taking the measures necessary to contain it.

22Thus, social and behavioural research came to the fore, with first generation studies assessing the high-risk population sub-groups, awareness and knowledge, the profiles of people who had contracted the infection and those with high-risk behaviours, as well as the determinants of infection and high-risk behaviours.

23The second generation studies, epidemiological in nature, including HIV/AIDS prevalence and incidence and sexual behaviour, began later, except for a few concurrent but sporadic efforts.

24There soon appeared a shift in the research focus characterizing the third generation studies, in which the social context of the infected cases, people with risk behaviours including sexual behaviour, particularly of adolescents, and cultural practices got preference around the mid-1990s, apart from some efforts which had already begun in the early 1990s along with studies on sexuality. But because of their limited scope, such as the use of condoms as a preventinve measure against HIV infection, they could not demonstrate the efficacy of the strategy or show the sustained change in the people exhibiting risk behaviour.

25Thus, in the second half of the 1990s, social and behavioural research crossed over to the fourth generation, in which behavioural prevention interventions could aim at bringing about change in risk behaviour by enforcing social norms for safer sexual behaviour and the conformity to them by individuals and groups, and sustaining the changed behaviour, besides reinforcing the cognitive, motivational and self-efficacy skills. Kelly, Murphy, et al. (1993) seem to view those studies as second generation approaches to behavioural change.

26Nadkarni and Subadra (1995) have reported three phases of social science research, i.e. risk behaviour and its determinants during the first seven to eight years of the AIDS epidemic, cultural meanings and responses in later years, and socio-economic and HIV-related inequalities. Whatever may be the generation or stage of social and behavioural research in the present scenario of HIV/AIDS, research into behavioural prevention intervention assumes greater responsibility, especially in the wake of the absence or delay in medical interventions.

27Some of the studies conducted in different countries have shown that high-risk behaviour could be changed. Individuals and groups may conform to social norms and practice safer sex by using condoms and reducing multi-partnership.

28The US project, Respect and Light, suggests that intensive education and counselling may change risk-behaviour. Fenway Community Health Centre (FCHC) studies indicated a high association between anal intercourse and HIV transmission, and the risk of oral exposure to ejaculate (YRG Care, 2000).

29Studies of homosexual men have shown a relationship between alcohol and HIV infection, and a reduction in HIV risk behaviour by safer sexual practices. Weinhardt, Michael, Carey et al. (1998) have shown in their study that assertiveness training for women living with a serious mental illness can serve as one part of a comprehensive HIV risk eduction programme for this vulnerable population. Kelly, Murphy et al. (1997) have shown the success of community-level intervention in preventing sexual risk behaviour among homosexual men in US cities. Assessments of behavioural skills intervention among patients with severe mental illness have shown an improvement in knowledge regarding HIV, as well as in attitude and intention to use condoms, and reported a reduction in unsafe sexual practices (Kalichman et al. 1995).

30In one study, women who received skill-based AIDS prevention intervention considered themselves more vulnerable to HIV than did the control group, and thus reduced their risk behaviour (Kelly et al. 1994).

31The NIMH (1998) multi-site HIV prevention trial tested three high-risk populations and found that behavioural interventions can reduce sexual risk behaviour among low-income women and men. In an HIV prevention intervention based on the education of adults with severe mental illnesses about risk reduction skills and encouragement to advocate behaviour change to others, the adults were motivated and encoursged to change their behaviour to reduce HIV risk (Kelly et al. 1997). Bhawe et al. (1995) have demonstrated among Mumbai (India) commercial sex workers (CSWs) a partial increase of condom use. Kumar et al. (1998) observed a significant change in risk behaviour in Chennai. The AIDS prevention and control (APAC) project of USAID and Voluntary Health Services (VHS), Tamil Nadu, (1998) have shown the impact of its intensive outreach programme using specific information, education and communication (IEC) materials to promote condom use. Non-regular sex partners among CSWs, truckers, and male factory workers showed an increased use of condoms, and thus the adoption of safer sexual practices.

32A rapid assessment study by NACO India (1998) succeeded in identifying and mapping high-risk sexual patterns and their concentration in eighteen cities. The results were to benefit intervention programmes with the goal of behavioural change.

33Similarly, ICMR (2001), in a multi-site study, assessed awareness of school-going adolescents (boys and girls) regarding different reproductive health aspects and sexual behaviour, and teachers’ and parents’ views, particularly about sex education for children in different cultural settings, and led the design of an intervention study. Another multi-site study by UCLA-ICMR investigated married HVI-positive and HIV-negative women in diverse cultural settings and found significant results to pilot intervention.

34A WHO study carried out in five countries, the Dominican Republic, India, Mexico, Tanzania and Thailand, offers, through community responses to HIV/AIDS and coping patterns, information about socio-cultural mechanisms that could be used to help design household and community-level control and prevention interventions.

35In India, this study was carried out in the Greater Bombay area where sexual activities among boys were reported to have been performed at the age of 13-14 years. The study detected the impact of the company of older males and peer pressure on boys’ sexual behaviour. Bharat reports that 50 %, or, in one slum community, 80-90 %, of the males aged 14 years and above were said to visit CSWs. An independent source of income of males, including school dropouts, the lack of privacy at home, etc. were reported as factors influencing sexual behaviour. Interestingly, women reported the presence of children or adults, exhaustion from daily chores, and constant child-bearing as factors for not having sex or lack of interest in sex. Some women feared that the continued avoidance of sex could make husbands go out for sex. Some women viewed sex as an obligation on their part which had to be endured (Bharat & Aggleton 2002).

36An ethnographic study of men who have sex with men (MSM) in Chennai was carried out in 1993, with the objective of assessing the need for targeted prevention interventions in particular settings. The study mapped over seventy cruising points or public sex environments (PSEs) like parks, beaches, deserted rail tracks, theatres, etc. where cruising MSMs peak during weekends for homosexual contact. Some of these PSEs get 150-400 MSMs on Saturdays and Sundays. Such contacts occur in the broader context of the limited awareness of HIV/AIDS. Based on situation analysis, an outreach encounter programme was designed. MSMs were recruited and trained and then fanned out to their sexual partners with objectives of establishing rapport, making them aware of the risks of HIV/AIDS associated with sexual practices and of the use of condoms. Using a model, they also demonstrated the use of condoms, with which their clients were supplied. The intervention also included the referral of cases to service centres for required care, particularly for STDs. The project office also provided counselling to MSMs and support activities for HIV-positive people (Pradeep 2002).

37Interventions targeting injecting drug users (IDUs) were carried out in different parts of the country and showed good results. In 1991, SAHAI Trust implemented an outreach service programme in Chennai. The team of professional social workers and ex-IDUs conducted street outreach programmes. HIV/AIDS education, information on decontamination of syringes and needles, distribution of bleach and condoms were some of the major activities carried out under the outreach programme. SHARAN, an NGO in Delhi, has been conducting an outreach programme since 1995. An NGO which evolved out of a research project of ICMR is conducting an outreach programme for the IDUs in Kolkata. The intervention includes street-based outreach with drug users as outreach workers, peer education, needle exchange, distribution of other risk reduction materials like antiseptic cotton wipes, bleach, condoms, information material, dressing for abscesses and limited facilities for primary health care, as well as referral for drug and STD/RTI treatment (Chatterjee, Kumar and Abdul-Quader 2002).

38An intervention project targeting CSWs was implemented, in 1992, in Sonagachi, one of the oldest and largest red-light areas of Kolkata city, where about 370 brothels and 4 000 CSWs are estimated to be active. The intervention had major components like IEC, condom programmes and STD treatment, but the project also helped the CSWs realize and articulate their own needs for better living. Thus, non-formal education began for them and later for their children. The educational programme started with twelve peer students and rose to 247 while expanding to another eight centres. The programme’s scope enlarged from reading-writing to advanced non-formal education that includes health, language and communication. The CSWs created their multi-purpose cooperative society in 1995, which liberated them from moneylenders. The society was registered and enrolled 3 528 members. It trained a group of CSWs who carry out social marketing of condoms in forty-five red-light areas. It runs an evening/night creche for the children of CSWs and plans to have its own department stores and other utility units in the future. Under the project, the CSWs have started their own forum with sixty-two branches and 65 000 members from different areas of West Bengal. It is known as the Darbar Mahila Samanwaya Committee (DMSC). The project has introduced another innovation, Positive Hotline; this is a telephone hotline to help HIV-positive people, AIDS patients and their family members. A group of volunteers (doctors, nurses, counsellors and legal experts) receive calls, provide information, make domicilliary visits and provide medical and legal assistance.

39The project has helped the CSWs in building confidence, self-respect, social identity, earning for themselves, learning skills and non-formal education, educating their children, and taking health care measures (Jana et al. 2002).

Bibliographie

References

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Bharat, Shalini and Peter Aggleton, 2002. “Community Responses to HIV/AIDS in Mumbai City”. In S. Panda, A. Chatterjee and A.S. Abdul Quader (eds.), Living with the AIDS Virus. Sage Publications, New Delhi.

Bhawe, G., C.P. Lindan, et al., 1995. “Impact of an Intervention on HIV, Sexually Transmitted Diseases, and Condom Use Among Sex Workers in Bombay, India”. AIDS (: 1, 521-530).

Chatterjee, A., M.S. Kumar and Abu, S. Abdul-Quader, 2002. “Targeted Interventions in Injecting Drugs Users: Some Experience”. In S. Panda, A. Chatterjee and A.S. Abdul-Quader (eds.), Living with the AIDS Virus. Sage Publications, New Delhi.

Kalichman, S.C., K.J. Sikkema, J.A. Kelly, et al., 1995. “Use of a Brief Behavioural Skills Intervention to Prevent HIV Infection Among Chronic Mentally Ill Adults”. Psychiatric Services 46: 275-280.

Kelly, J.A., D.A. Murphy, et al., 1993. “Psychological Interventions to Prevent HIV Infection are Urgently Needed: New Priorities for Behavioural Research in the Second Decade of AIDS”. American Psychologist 48: 1023-1034.

Kelly, A.J., D.A. Murphy, et al., 1994. “Effects of HIV/AIDS Intervention for High-Risk Women in Urban Primary Health Clinics”. American Journal of Public Health 82: 372-377.

Kelly, A.J., D.A. Murphy, et al., 1997. “Randomized, Controlled, Community Level HIV Prevention Intervention for Sexual Risk Behaviour Among Homosexual Men in US Cities”. Lancet 350: 1500-1505.

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Annexes

Appendix 1.1 HIV/AIDS Surveillance in India7

AIDS cases in India Cumulative March 2003
MALES 36,411 3,366
FEMALES 12,522 1,292
Total 48,933 4,658
Risk/Transmission Categories No. of cases Percentage
Sexual 41,633 85.08
Perinatal transmission 1,299 2.65
Blood and blood products 1,363 2.79
Injectable Drug Users 1,287 2.63
History not available 3,351 6.85
Total 48,933 100.00
Age group Male Female Total
0-14 yrs 1,138 711 1,849
15 - 29 yrs. 11,502 5,806 17,308
30 - 44 yrs 20,942 5,289 26,231
> 45 yrs. 2,829 716 3,545
Total 36,411 12,522 48,933

Appendix 1.2 National AIDS Control Policy in the States and Union Territories8

State-Level Strengthening

In order to strengthen the programme management at the state level, the state governments have established their own managerial organisations which include State AIDS Control Societies (formerly State AIDS Cells), technical advisory committees and empowered committees as per the guidelines of the strategic plan. The structure of the State AIDS Societies is shown below. Progress in the development of state management teams has been satisfactory, although some states have responded more effectively than others.

Empowered Committee

At the state level, an empowered committee has been constituted by the states either under the chairmanship of the chief secretary or additional chief secretary at par with the National AIDS Control Board at the central level.

This committee takes the policy decisions for implementation of the HIV/AIDS control programmes in the respective states and approves administrative and financial actions which otherwise would have been approved by the state Department of Finance.

State AIDS Control Societies

State AIDS Cells were created in all the 32 States and UTs of the country for the effective implementation and management of the National AIDS Control Programme. However, over a period of time, it was realised that due to many cumbersome administrative and financial procedures, there was a delay in the release of financial outlays sanctioned by the Government of India, due to which the implementation of the programme at different levels suffered. In order to remove the bottlenecks faced by the programme implementation at the state level, the Ministry of Health and Family Welfare advised the state governments/union territories to constitute a registered society under the chairmanship of the Secretary of Health. The society should be broad-based with it members representing various ministries like social welfare, education, industry, transport, finance etc., and non-governmental organisations. On an experimental basis, the Tamil Nadu AIDS Control Society was created, which was followed by Pondicherry. The successful functioning of these societies led the Government of India to advise other states to follow this pattern for the implementation of the National AIDS Control Programme.

Appendix 1.3 National AIDS Control Programme Phases9

National AIDS Control Programme Phase - I (1992-99)

The National AIDS Control Project was the first project in India to develop a national public health programme in HIV/AIDS prevention and control, and was implemented between 1992 and 1999.

Project Objectives

1. The ultimate objective of the project was to slow the spread of HIV to reduce future morbidity, mortality, and the impact of AIDS by initiating a major effort in the prevention of HIV transmission. It constituted a start-up investment to launch expanded preventive activities. The specific objectives were to:

  1. involve all States and Union Territories in developing HIV/AIDS preventive activities with a special focus on the major epicentres of the epidemic;
  2. attain a satisfactory level of public awareness on HIV transmission and prevention;
  3. develop health promotion interventions among risk behavior groups;
  4. screen all blood units collected for blood transfusions;
  5. decrease the practice of professional blood donations;
  6. develop skills in clinical management, health education and counselling, and psycho-social support to HIV sero-positive persons, AIDS patients and their associates;
  7. strengthen the control of Sexually Transmitted Diseases (STD); and
  8. monitor the development of the HIV/AIDS epidemic in the country.

2. The project objectives were clear and specific. They were in line with the broad sectoral strategy of the Government, and initiated the development of sub-sectoral strategies on HIV/AIDS. The expected outputs and outcome indicators proposed in the Staff Appraisal Report were used to assess the project’s performance. At start-up, the limited national capacity to deal with HIV/AIDS called for a simple, realistic and flexible framework. The design included five basic components:

  1. strengthening management capacity for HIV/AIDS control;
  2. promoting public awareness and community support;
  3. improving blood safety and rational use;
  4. controlling sexually transmitted diseases; and
  5. building surveillance and clinical management capacity. After the development of a programme framework, the central Government pursued incremental efforts to generate state responses and commitment. At the mid-term review, it was concluded that the objectives of the project remained valid and attainable.

Achievement of Project Objectives

1. The project achieved its main purpose and specific objectives after overcoming the initial challenges faced by the Union and State Governments. These ranged from severely limited capacity across sectors to denial and low commitment in many states. During the implementation periods, the project substantially achieved its specific objectives and often exceeded the original targets. This included nationwide capacity building in managerial and technical aspects of the programme in all 32 States and Union Territories (UTs). Multi-sectoral involvement was gradually built up. Project activities were integrated to the maximum extent possible with the existing health care system. Efforts to target vulnerable risk groups gradually increased after a slow start, when the capacity of NGOs to deal with the HIV/AIDS was still limited except in a few areas. There was a 50 per cent increase in the volume of condom distribution through social marketing. Condom use in targeted risk groups increased from less than 10 per cent to a range of 50-90 per cent. In selected major States, awareness about prevention of HIV infection reached a range of 54-78 per cent. Screening of donated blood became almost universal by the end of the project. Professional blood donations were banned by law. Under the project, 504 STD clinics were strengthened with improved effectiveness and quality of STD management. The syndromic approach for STD treatment was developed beyond initial project plans. Surveillance capacity was developed in 62 centres and 180 sentinel sites nationwide. However, the capacity to implement programmes was uneven across the States, due to varying capacity and commitment. The centre and the major project target epicentres of Mumbai and Chennai showed high overall performance in implementing the programme. Two-thirds of the 32 States/UTs performed satisfactorily and the remaining one-third of the States did not perform effectively.

2. In contrast with other project objectives that can be readily measured, it is difficult to assess the project’s contribution to slowing the spread of HIV. Nonetheless, the 1998 HIV sero-prevalence in the adult population of India was estimated at about 0.7 per cent

National AIDS Control Programme Phase - II (1999 - 2004)

(1) The Phase II of the National AIDS Control Programme became effective from 9th November, 1999. It is a 100 % centrally sponsored scheme implemented in 32 States/UTs and 3 Municipal Corporations namely Ahmedabad, Chennai and Mumbai through AIDS Control Societies.

(2) Project formulation for Phase II, National AIDS Control Programme followed a truly participatory process at the State and Municipal Corporation levels. Between April and June 1998, the Technical Liaison Officers (TLOs) of NACO, in collaboration with State AIDS Control Programme Officers, conducted State Level Planning Workshops in all the States and the cites of Mumbai, Chennai and Ahmedabad. Each of these workshops was conducted for 2 days in which all major stakeholders such as senior officials of the Government departments, NGOs, private sector, medical professionals and district-level officials participated. On an average, around 100 stakeholders participated in each of these workshops. In addition to serving as a tool preparation, these workshops also turned out to be a major advocacy effort. In the formulation of the State Implementation Plan (IPs) the following steps were taken:

Step 1 Holding of state-level workshops in which participants from Government departments, NGOs etc. discussed the various issues under several components and came out with recommendations
Step 2 Constitution of Core Team to finalize the specific programmes for AIDS Control Project II based on the recommendations made under seven components
Step 3 Core Team held three sittings in June-July, 1998, examined the recommendation to identify and select programmes/activities which needed to be given priority and focus.
Step 4 The activities suggested were listed and prioritized by the Core Team based on the recommendations at the workshop.
Step 5 At the end of July 1998, the World Bank prescribed cost codes were received. A special Task Force was constituted and the activities were regrouped under five components as per the revised guidelines from NACO and World Bank
Step 6 The various activities were divided into sub-activities, cost codes were assigned for each sub-activity. The implementation plan was prepared indicating the process, sub-process, activities, implementing agency, assessment parameters and risk.
Step 7 The unit cost and the number of units under each activity were finalized by the Special Task Force and the outlay was worked out. Discussions were held with officials of USAID and VHS-APAC to assess the extent of the bilaternal’s involvement in Tamil Nadu.
Step 8 The Technical Liaison Officers, World Bank Consultants and the PD, NACO, reviewed the draft Project Implementation Plan (PIP) prepared and suggest scaling down of outlay, taking into account the past and current expenditure and the absorptive capacity funds in the future. At this stage, the Procurement Plan and the Training Action Plan were prepared simultaneously
Step 9 The special task force held several sittings to review the no. of interventions and units of various activities. After the southern states PIP workshop at Bangalore in the first week of Sept., 1998, it was decided to restrict the interventions and the no. of other units/activities and the outlay was revised. The procurement plan was finalized after excluding the cost of equipment to be procured and supplied by NACO. The training action plan was also revised and finalized based on the modified outlay.

(3) In the month of September-October 1998, the National AIDS Control Organisation organized regional workshops for State ADS Programme Officers for finalization of the State PIP. On the basis of the State PIPs, the National Project Implementation Plan was prepared.

(4) The Mission of the International Development Association (IDA) visited during 14-22 December 1998 and appraised the project in collaboration with officials of the Government of India. The Mission recommended an overall assistance of US $ 191 million with the Government of India’s contribution of US $ 38.8 million. The total project cost was estimated at US $ 229.8 million (Rs.1 155 crores). The detailed project document was considered by the Expenditure Finance Committee (EFC) in its meeting held on 29 April 1999 along with USAID and DFID assisted projects. The EFC recommended 3 projects for approval - NACP II (National AIDS Control Project) for Rs.1 155 crores, US assisted AVERT project in Maharashtra for Rs.166 crores and DFID project for AP, Orissa, Kerala and Gujarat for Rs.104 crores for the period of 5 years from 1999-2004, except the US assisted AVERT Project, which will be for a period of 7 years.

The World Bank and DFID projects are for a period of 5 years (1999- 2004), while US assisted AVERT project is for 7 years (1999-2006).

The negotiations for an IDA Project NACP II were held between the representatives of the Government of India and the IDA in Washington from 7-12 May 1999. The AIDS II project was approved by the IDA Board in its meeting dated 15 June 1999. The NACP II project was approved by the Cabinet on 26 August 1999.

The National AIDS Control Project, Phase II is aimed at -

(i) Shifting the focus from raising awareness to changing behaviour through interventions, particularly for groups at high risk of contracting and spreading HIV;

(ii) Supporting the decentralization of service delivery to the States and Municipalities and a new facilitating role for National AIDS Control Organisation. Programme delivery would be flexible, evidence-based, participatory and rely on local programme implementation plans;

(iii) Protecting human rights by encouraging voluntary counselling and testing and discouraging mandatory testing;

(iv) Supporting structured and evidence-based annual reviews and ongoing operational research; and

(v) Encouraging management reforms, such as better managed state-level AIDS Control Societies and improved drug and equipment procurement practices. These reforms are proposed with a view to bring about a sense of ’ownership’ of the programme among the States, Municipal Corporations, NGOs and other implementing agencies.

The National AIDS Control Project has two key objectives namely:

(1) To reduce the spread of HIV infection in India; and

(2) To strengthen India’s capacity to respond to HIV/AIDS on a long-term basis. Operationally, the project interventions would seek to achieve the following by the end of the project:

  • to keep the HIV prevalence rate below 5 % of the adult population in Maharashtra, below 3 % in Andhra Pradesh, Karnataka, Manipur and Tamil Nadu, where HIV prevalence is moderate, and below 1 % in the remaining states, where the epidemic is still at a nascent stage;
  • to reduce blood-borne transmission of HIV to less than 1 %;
  • to attain an awareness level of not less than 90 % among the youth and others in the reproductive age group; and
  • to achieve condom use of not less than 90 % among high-risk categories such as Commercial Sex Workers.

Project Targets

The programme has the following firm targets to be achieved during the project period:

  1. To reduce blood-borne transmission of HIV to less than 1 % of the total transmissions.
  2. To introduce Hepatitis-C as the fifth mandatory test for blood screening.
  3. To set up 10 new modern blood banks in uncovered areas, upgrading of 20 major blood banks, setting up of 80 new district-level blood banks in uncovered districts, establishing another 40 blood component separation units, promotion of voluntary blood donation and increase its share in total blood collected to at least 60 %. The total blood collection in the county, which is now around 3-3.5 million units, is sought to be raised to 5-5.5 million units by the end of the project.
  4. To attain an awareness level of not less than 90 % among the youth and those in the reproductive age group.
  5. To train at least 600 NGOs in the country in conducting targeted intervention programmes among high-risk groups and through them promote condom use of not less than 90 % among these groups and control of STDs.
  6. To conduct annual Family Health Awareness Campaigns among the general population and provide service-delivery in terms of medical advice and provision of drugs for control of STDs and Reproductive Tract Infections (RTIs). These campaigns will be conducted jointly by NACO and RHC programme managers at the state-level.
  7. Promotion of voluntary testing facilities across the country at the end of the project. It is visualized that every district in the country would have at least one voluntary testing facility.
  8. Awareness campaigns will now be more interactive and use of traditional media such as folk arts and street theatre will be given greater priority in the rural areas. It is proposed to cover all the schools in the country, targeting students studying in Class IX and Class XI through school education programmes and all the universities through the “Universities Talk AIDS” programme during the project period. Organizations of people living with HIV/AIDS are to be promoted and given financial support to form self-help groups.

Notes

2 Details of the Phase-I and Phase-2 programme are available in Appendix 1.3 (Note from the Editors).

3 National AIDS Control Organization (NACO), 20002. Combating HIV/AIDS in India, 2000-2001. Ministry of Health & Family Welfare, Govt. of India, New Delhi.

4 NACO, 2001. National Baseline General Population Behavioural Surveillance Survey. Ministry of Health & Family Welfare, Govt. of India, New Delhi.

5 Details of creation of national AIDS control policy at the States and Union Territories scale are available in Appendix 1.2: See Empowered Committee, State AIDS Control Societies (note from the Editors).

6 IEC: Information Education Communication.

7 These data are published by NACO on March 2003 and are available on its website: http://www.naco.nic.in/indianscene/overv.htm. as in July 2003.

8 Excerpt from Naco website proposed by the editors, as in August 2003: www.naco.nic.in/nacp/nacobkg.htm

9 Excerpt from the NACO website proposed by the editors: see the following pages: www.naco.nic.in/nacp/phase1.htm., and /phase2.htm

Auteur

Ph.D. in Sociology, is Emeritus Medical Scientist and Chief of Social & Behavioural Research Unit at the Indian Council of Medical Research, H.Qrs. Office, New Delhi, India.

© Institut Français de Pondichéry, 2004

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