Cross out HIV stigma

Had John Lennon been alive, he may have repackaged his famous Christmas song for today.
“So this is December 1
And what have you done
Another year over
And a new one just begun…”

There is the ceremonial part of World AIDS Day: Speeches, slogans, statements, songs, candle-lit vigils, all aimed at raising awareness about HIV and AIDS. Then there is the stock-taking when one not only celebrates the victories in the battle against AIDS but also flags the jobs not done, the concerns and the challenges ahead.
Needless to say, the second part is tougher than the first.
Twenty-six years after the first case of AIDS was diagnosed in the country, affecting a female sex worker in Chennai, India can proudly say that it has come a long way in fighting the disease. But we also have to admit that despite all efforts, AIDS continues to be a word that generates more anxiety than awareness. Stigma and discrimination against those living with HIV and AIDS remain the grim reality. Many still believe that it is something that happens to “others” — those who are on the margins of society. This refusal to confront reality masks the fact that India still has over 20 lakh people living with HIV and AIDS — the third largest number in the world. Unprotected sex continues to drive the epidemic in most parts of the country.
First, some feel-good data: According to National AIDS Control Organisation’s (Naco) latest figures, there has been 57 per cent reduction in new HIV infections (among the adult population) in India during the last decade. Clearly, the scaled-up prevention strategies are yielding results — some 1.5 lakh lives have been saved due to the scale-up of free aniretroviral (ARV) treatment since 2004.
However, there are many “buts”.
Loon Gangte, founder-member of the Delhi Network of Positive People, says though there are medicines, money and infrastructure, antiretroviral medicines are sometimes not available in many parts of the country, due to “poor supply chain management”. This has serious implications: Breaks in treatment can trigger drug resistance and eventually push many of those currently on ARV treatment towards the more expensive second-line drugs.
To stay with the mood of Lennon’s song, a lot more needs to be done. The old divide between “high-prevalence” and “low-prevalence” states is breaking down. The latter shows an increase in the number of new infections over the past two years. Of the 1.16 lakh estimated new infections in 2011, among adults, the six high prevalence states (Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra, Manipur and Nagaland) account for 31 per cent of new infections, while new pockets of high HIV prevalence are being reported from states where HIV was not a big issue earlier like Orissa, Bihar, West Bengal, Uttar Pradesh, Rajasthan and others.
One major reason is that more and more people from poor “low-prevalence” states are moving towards the poles of economic growth — Western and Southern India — where HIV has had a higher prevalence. A Planning Commission report points out, “Though prevalence is low in many states, the HIV trends are rising and number of new infections in some states is large. So considering only the prevalence may mask the attention to be given to the states with rising trends and vulnerabilities.”
Take another significant pointer. Sustained advocacy and prevention work with female sex workers and their clients appear to have worked, but accessing sex workers is becoming more difficult. Sex workers no longer have to work out of brothels, thanks to the cellphone and the Internet. The trade is also expanding across Asia’s fast-growing economies to include those who indulge in occasional commercial sex but don’t see themselves as “sex workers”.
“In Kolkata, India, a study among call girls showed that 60 per cent of them had professional identities, which helped them to conceal their links to the sex industry. Almost all of them are housewives and yet their invisibility is rather paradoxical because they belong to a well-structured network, which operates with great efficiency in most cities and towns of India,” noted Asian Economies in Rapid Transition: HIV Now and Through 2031, a UNAIDS report focusing on China, India, Indonesia, Malaysia, Thailand and Vietnam.
Evidence also shows that injecting drug users (IDUs) and men who have sex with men are increasingly vulnerable to HIV in many Indian states. This requires a rapid expansion of “harm-reduction” programmes. Worryingly, many states confronting the spread of HIV have relatively poor health infrastructure and
governance.
All this is happening at a time when the policy space is changing: AIDS is no longer the hot development issue; there is a Planning Commission proposal to bring about convergence between Naco — currently the nodal agency overseeing India’s response to HIV and AIDS — and the National Rural Health Mission (NRHM). The public health community has reacted nervously to this. Everyone agrees that HIV-related interventions need to be mainstreamed because it is a cross-cutting issue in many ways, but there are serious apprehensions about how this will play out, given the realities on the ground.
How will India finance the response to the new challenges? Who will pay and how much to reach out to those who have slipped through the cracks of society and who are politically insignificant?
“Unfortunately, in the scheme of things, marginalised populations vulnerable to HIV are not political priorities, even while they remain epidemiologically urgent. India’s response has recognised this tension, but as HIV services move towards increased integration, effective programming for groups like sex workers and men who have sex with men needs to be sustained. India has been guided by a world-class national strategy that reflects this understanding, and at this crucial juncture, we need to leverage the progress that this country has made addressing the epidemic,” says James Robertson, country director, India HIV/ AIDS Alliance, an NGO.
If HIV and AIDS prevention and treatment are moved from Naco into the public healthcare system without adequate preparation and sensitisation, will the hard-fought victories be reversed? On World AIDS Day, as we speak of an AIDS-free world, let us talk of the need for more empathy along with more resources.

The writer focuses on development issues in India and emerging economies.