Without any evaluation of how its AIDS control and prevention programme has worked in the past decade, India is plunging into the second phase of the programme bent upon repeating the same mistakes. With many questions still remaining unanswered about HIV/AIDS, the disease is being given top ranking status, eclipsing all other killer diseases, and skewing India’s health policy.

AIDS is a unique disease because it is linked to a range of opportunistic infections that arise with its onset. It provides a window to look at what is going wrong within the health system, in our patterns of social and economic development. It provides impetus for change.

By pouring money into a narrowly conceived AIDS policy, India is yet again missing the bus. The past decade’s experience reveals that an AIDS programme cannot stand in isolation, while general primary health care remains in a state of shambles.

In the first phase of the programme (1992-1999) the AIDS programme received Rs 320 crore; the second phase will see an unprecedented Rs 800 crore assured through World Bank loans (1).

Three questions

Over the past decade, three questions have consistently been asked by public health experts in India. While donor agencies and the Indian government have spoken of ‘projections’ and ‘estimates’ about the AIDS epidemic sweeping India, where is the epidemiological data supporting those claims? Secondly, AIDS is connected with a range of diseases like TB, diarrhoea, malnutrition or malaria (the presence of these factors depress the immune system leading to the faster onset of AIDS). Why then are we seeing the eclipse of all other disease programmes and a major portion of the ‘AIDS funds’ poured into a ‘targeted’ intervention programme, geared at condom promotion and sex education? Thirdly, the hysteria and scare tactics being used to create awareness about AIDS are wreaking social havoc. In the past months, reports have poured in from across the country about incidents of lynching and ostracism by entire communities against AIDS patients.

To date, the National AIDS Control Organisation records 5,204 AIDS cases in India, primarily reported from four states. Meanwhile, those testing HIV positive number 75,000. Until 1997, these samples were drawn from 55 ‘sentinel surveillance sites’ — blood banks, sexually transmitted disease clinics and ante-natal clinics — that are not uniformly spread across the country. Bihar, for instance, has none, and its one testing centre in Patna reports 29 HIV cases and three of AIDS. Meanwhile Maharashtra reports 46,000 testing HIV positive and 2,518 AIDS cases. Such uneven trends, drawn from selectively chosen groups in a few urban areas, are being extrapolated to the general population across the country (2).

Despite the absence of epidemiological data, India unquestionably follows the diktat of donor agencies in pursuit of a vertical AIDS programme. Countries like Thailand have integrated AIDS into a strong primary health system. They are now seeing results in AIDS prevention, and simultaneously in malaria control. India’s primary health services remain in shambles. A vertical AIDS programme cannot work when there is no primary health base it can stand upon. Indian health experience offers one key insight: when the community receives a comprehensive package of curative service it needs, only then does it become receptive to the prevention message.

Comprehensive care

Meanwhile, a fundamental debate rages on internationally on whether HIV is the sole cause of AIDS. Is AIDS related to abuse of lifestyle rather than a virus? Do factors such as antibiotic and recreational drug abuse, anal sex, nutrition and stress disorders play any role in immune system suppression? Does AIDS research need to look at drugs that modulate or boost the immune system response? When so many questions remain unanswered about HIV/AIDS, shouldn’t our interventions be as broad-based as possible?

There are also questions about whether public policy should encourage HIV testing when there are doubts about the accuracy of the kit and whether the virus itself has been isolated. If HIV exists, but is ‘constantly mutating’, can the HIV test show a false negative result? When the HIV test is conducted on persons suffering from malaria,TB, malnutrition and other common infections, can there be a cross-reaction, leading to false positive results?

After (more than) a decade of living with AIDS, maybe this disease needs to be teach us that there is more to it than condoms, and sex education. AIDS is about creating responses to social and economic needs, comprehensive health care and education.

The Times of’ India, September 2, 1998.