Since the first case of HIV infection was reported in India in 1986, AIDS has devastated the country with approximately four million cases currently (1).

Social empowerment

Though prevention is more cost-effective than treatment (2, 3, 4), 48.6% of pregnant women surveyed in New Delhi preferred to get information on AIDS from doctors rather than the mass media (5), 39.3% of the subjects had not even heard of AIDS; only 45% were aware that AIDS is not transmitted by mosquito bites (5). Clearly, there is an unmet demand for HIV risk assessment and prevention counselling.

Samraksha (a Bangalore-based non-governmental organisation) and ActionHealth (a UK-based charity) joined hands to form a Well Woman Clinic in 1997 (6). The clinic operates on a walk-in basis on two afternoons per week. Gynaecological examination, along with screening and treatment is done for gonorrhoea, and infection with Chlamydia and Trichomonas vaginalis. Each patient is then interviewed by a trained health advisor who discusses safer sexual practices and distributes condoms with detailed usage instructions. Management of partners is discussed and arranged, when appropriate. The emphasis is on risk reduction.

Solomon et al. have identified some factors that make Indian women vulnerable to HIV infection: the culture of silence surrounding women’s sexuality, the willingness to risk acquiring HIV to conceive a child, and the inability to negotiate safer sex practices (7). Primary prevention delivered through routine clinical encounters thus offers a means of reaching out to a particularly vulnerable population.

Community mobilisation

Another primary preventive intervention is more localised and aimed at mobilising community members. VISIONS Worldwide, Inc., formed in 1995, uses peer education to fight the spread of HIV infection among Indian youth who have the highest number of HIV infections (1) and lack AIDS awareness (8, 9). A delegation of US college students was trained and sent to India where they established local chapters in Bangalore, Mumbai and New Delhi. They conduct personalised risk assessment and counselling, dispel misconceptions about modes of transmission and enable behavioural modifications. The local chapters reach out to secondary schools to disseminate knowledge on HIV/AIDS. The message has been delivered to over 40,000 individuals. The efficacy of these interventions have not been formally evaluated.

Ethical considerations

An international approach to responding to HIV/AIDS must acknowledge interdependence and, while providing aid, respect individual and national autonomy. By mobilising the community and individuals, it works towards sustainability. Passive global funding of treatment and prevention programmes falls short of such mobilisation. A national system of risk assessment and prevention counselling needs to be built into the primary health care system. Local community-based programmes that empower individuals need to be complementary to such an integrated system of primary health care.