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International Health Organization (IHO)'s 3rd AIDS-in-India Conference - India, the Next Epicenter of the AIDS Pandemic?

submitted by Bikash Verma and Pramila Vivek

"4.2 million are infected with the AIDS virus now in India", said Salim Habayeb of the World Bank. Siddharth Dube of UNICEF and author of the best seller, "Sex, Lies and AIDS" said, "In 4 to 5 years, India will face (the end of) Kali Yug, a cataclysm. 2 to 2 million have already died, (which is) more than one hundred times the death toll in the Gujarat earthquake. 1 million will die each year from AIDS."

The dismal prophecy along with voices of optimism, passionate exhortations along with the calm evaluations were presented at the IHO (International Health Organization) 3rd AIDS in India Symposium cosponsored by AAPI (American Association of Physicians of India Origin) and Harvard University South Asian Association hosted at Harvard School of Public Health on December 7, 2001.

The faculty, a veritable Who is Who on prevention, control and treatment of AIDS in India, included Dr. Prabhat Jha (World Health Organization), Dr. Salim Habayeb (World Bank), Eliot Putnam (USAID), Dr. Bruce Walker (Harvard Medical School), Siddharth Dube (UNICEF) and Ms. Sujatha Rao, Joint Secretary, Ministry of Health, Government of India. Dr. Barry Bloom, Dean of Harvard School of Public Health welcomed all and set the tone. Dr. Bikash Verma, Director of IHO laid out the issues and problems as he launched the conference. Ms. Pramila Vivek, Vice President of IHO presented the welcome comments and an overview of IHO's programs in India and Nepal. Mr. Joe D'Amour, Advisor, IHO, moderated the afternoon session.

Dr. Bloom through his opening remarks shared his views how AIDS has attained epidemic proportions and the devastation it continues to cause especially in developing countries, with more 40 million people living with HIV/AIDS.. While scientist are working for more effective treatment and a vaccine against HIV, the key to the current problem lies in utilizing the currently available and scientifically proven models of AIDS prevention, he said. Recalling his experience of working in India more than three decades back when he was providing some of the earliest advanced training in immunology, Dr. Bloom mentioned that India has an excellent pool of scientists and researchers who are fully capable of addressing the AIDS epidemic in India. He mentioned that for a country like India with a population of one billion, a massive health sector infrastructure will be needed which will help in not only fighting the AIDS epidemic but many other infectious diseases as well. He emphasized therefore, the role of integrating AIDS programs with other conditions commonly present among AIDS patients such as tuberculosis. Dr. Bloom recalled that India has the largest number of some diseases such as TB and leprosy which have been well controlled in other parts of the world, and the country needed massive investment of resources to better the lives and living conditions of its citizens. Dean Bloom said he looks forward to the opportunity to work in India and mentioned some of the projects he is helping with through the Indian Council of Medical research (ICMR).

Ms. Rao spoke of the evolution of AIDS control program in India and the current surveillance methods and control programs implemented through both governmental and non-governmental organizations (NGOs). Some of the achievements included 50% increase in condom distribution and in one target population increase of condom use from 10% to 50% and in another group in Calcutta (Songachi) condom use jumped from 0% to 70% between '92 and '94 following prevention and education interventions. Ms. Rao presented a detailed background of Government of India's AIDS control programs starting from 1986 when the first few HIV/AIDS cases in the country were reported. Soon after the government took a series of important measures to tackle the epidemic. By this time AIDS had already attained epidemic proportion in the African region and rapidly in many countries of the world. Government of India initiated steps and started pilot screening of high risk population. A high powered National AIDS Committee was constituted in 1986. In 1987 the National AIDS Control Programme was launched followed by the development of a medium term plan for HIV/AIDS Control in 1989 with a US $10 million budget provided by WHO.

Project documents for the implementation of this plan were developed and implemented in 5 states and UTs which were most affected, namely Maharashtra, Tamil Nadu, West Bengal, Manipur, and Delhi. In 1992, National AIDS Control Programs were set up in the remaining states & Union territories. This led to the impressive Phase 1 of the national AIDS control program extending over 1992-1999. Currently the Government of India is implementing its Phase II which started in 1999 and will continue till 2004. Continuing furtheron, Ms. Rao mentioned that the goal of NACO was to develop a national public health program in HIV/AIDS prevention and control while its objectives: 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. The five basic components of NACO's programs have been : (a) strengthening management capacity for HIV/AIDS control; (b) promoting public awareness and community support; (c) improving blood safety and rational use; (d) controlling sexually transmitted diseases; and (e) building surveillance and clinical management capacity. Ms. Rao said that in spite of the massive task at hand and the initial lack of experience in developing and implementing AIDS programs given that it was a new disease, NACO's achievements have been quite impressive, such as: *Nationwide capacity building in managerial and technical aspects of the program in all 32 States and Union Territories (UTs). *There was a 50 percent increase in the volume of condom distribution *Condom use in targeted risk groups increased from less than 10 percent to a range of 50-90 percent. *In selected major States, awareness about prevention of HIV infection reached a range of 54-78 percent. *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. *Two-third of the 32 States/UTs performed satisfactorily.

Ms. Rao ended her presentation with the comments that the threat of HIV/AIDS in India will remain a major and potentially catastrophic issue, and it calls for an urgently enhanced response. Dr. Jha from WHO focused upon "Global Evidence and Local Action: HIV/AIDS Control in India" presenting his findings from the WHO Working Group of the Commission on Macroeconomics and HealthTalking about macroeconomic and poverty consequences of HIV/AIDS, Dr Jha outlined some of the effects such as: the direct cost from lost lives and loss of productivity (that can be as high as 12% of GNP); indirect costs higher from intergenerational, life cycle and spillover effects; security effects from poor health; poverty dimension of poor health of HIV/AIDS. Based upon the results of his findings, Dr. Jha outlined some of the reasons for the explosive growth of HIV in southern parts of India, namely: about 1 in 5 men report paid sex; sexually transmitted infections are common: 6% male and 13% female prevalence in Tamil Nadu; condom use rates with non regular partners are low-30%; male circumcision, which may protect against HIV is common only to 12% of Indian males.

He mentioned various measures needed to address the AIDS epidemic including: that large scale implementation of highest impact interventions in each district; aim for high coverage and high quality of effective prevention services; build capacity and train HIV/AIDS control officers; create new evidence; advocacy and public debate; HIV/AIDS care and support; incremental and sustained spending of $7-11 billion per year in South Asia is required for a set of priority diseases, including HIV/AIDS; enormous health and poverty benefits of scaled-up interventions; need for regional programs for surveillance, operational research and training; need to accelerate vaccine development; in service training for health providers; training courses in effective interventions through the Regional AIDS Training Network; development of leadership cadre through more long term training and the development of individuals. Dr. Jhaspoke of the proven interventions (in Thailand, Cambodia and Tamil Nadu, where there has been success), "Peer education for condom use, better STI (sexually transmitted infection) management, intervention in high risk males (e.g. truck drivers) and decrease mother to child transmission." He added that antiretroviral treatment (drug treatment of AIDS) is ineffective in preventing the transmission of AIDS virus From the days of AIDS not being really considered a problem in India and calling it a "World Bank Disease, India has made good progress, yet the outcomes are not good so far," said Habayeb. Perhaps reaching more of the population through these programs is what is needed to make the good programs show large-scale results.

S. 'Jay' Jayasankar, MD, President of the AAPI (American Association of Physicians of Indian Origin), a cosponsor of the program said, "AIDS is real and deadly and you cannot see it till it is too late; Prevention is simple; Use a condom! It is effective delivery of the message through peers and other trusted people that is the real challenge. NGOs are an integral part in doing it while general messages through popular figures such as entertainers would sink in more effectively." Dr. Anil Purohit of the Francois Xavier Bagnoud Foundation spoke of using barbers, auto rickshaw drivers and such to spread the message. Dr. Walker emphasized that while the bulk of the effort should be aimed at prevention measures, some effort should also be directed at treating the 40 million people living with HIV/AIDS for whom treatment is the only option. The issue of prioritizing allocation of limited resources was discussed. Given the high cost of treatment and the trained resources needed to monitor and help the treatment program and the fact according to Habayeb, that, "the number (of HIV infections) is expected to double every two years," it appears that the prime efforts need to be focused on prevention if a dent is to be made in the AIDS epidemic. IHO is a Boston based non-profit organization developing and implementing health programs integrated with development programs in India since 1992 to make successful and sustainable changes. IHO has been implementing larger scale AIDS prevention and control programs in collaboration with Government of India and other non-governmental agencies in India and Nepal. For details about IHO's AIDS and other programs in India, please contact: IHO, 60 Birmingham Parkway, Suite 105, Brighton, MA 02135 or call (508) 229 2988.

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