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Meeting the AIDS Challenge

Challenge AIDS in Asia: The Challenge Ahead edited by Jai P Narain; Sage Publications, New Delhi, 2004; pp 395, Rs 295 (paperback). SUNEETHA KADIYALA HIV/AIDS is a global health and development challenge, an impact that will be felt for decades to come. HIV/ AIDS is different. It is a lentivirus and a retrovirus. These two features make it particularly significant for economies and societies. A lentivirus is very slow acting

Meeting the AIDS

Challenge

AIDS in Asia: The Challenge Ahead

edited by Jai P Narain; Sage Publications, New Delhi, 2004; pp 395, Rs 295 (paperback).

SUNEETHA KADIYALA

H
IV/AIDS is a global health and development challenge, an impact that will be felt for decades to come. HIV/ AIDS is different. It is a lentivirus and a retrovirus. These two features make it particularly significant for economies and societies. A lentivirus is very slow acting – people could be infected over a long period of time but may not experience any ill effects until the disease reaches a terminal stage. They may thus inadvertently infect many others. It is a retrovirus and as such has to convert its core genetic material (RNA) to DNA by inserting itself into a host’s cell, which then becomes a factory for many millions of new viral particles. In the case of HIV, slow “incubation”, a high reproduction rate of infection and predominantly sexual transmission mean that it affects active adults in large numbers. HIV/AIDS makes prime age adults, those who should be the most productive, caring and thrusting in their societies, sick and dependent and finally kills them. A large population is no protection from the effects of the virus – it is the population structure (the ratio of sexually active to those that are not) rather than size, that matters. There is no cure, although antiretrovirals radically slow down the disease progression. There is no vaccine – and the virus mutates rapidly and often. Stigma is everywhere. Prevention is the best route but we do not really know how to persuade people to change sexual behaviours.

With 70 per cent of those infected with HIV/AIDS living in sub-Saharan Africa, the region is already bearing the brunt of the epidemic. The latest projections for Asia point to a gloomy future. The time to act to avert the worst impacts of the epidemic in Asia is now. Whatever may be the impact of the much publicised, but slow moving anti-retroviral (ARV) rollout in Asia, there is an urgent need to take stock of experiences to date, distil lessons learnt to formulate future strategies to effectively address the multiple causes and consequences of the epidemic. In this context, the book under review, edited by Jai P Narain is timely.

Combating the Epidemic

This book, an undertaking by WHO, attempts to discuss the epidemiological aspects and responses mounted to combat the HIV/AIDS epidemic in the last two decades. This volume, organised into 23 chapters, mainly presents:

  • (a) Country reports on epidemiology of HIV/AIDS and specific national responses from many countries including India, China, Afghanistan, Thailand, Sri Lanka and Nepal. These case studies at first present HIV/AIDS statistics and the epidemiology of the disease from the biomedical and behavioural paradigms. Then the authors discuss the national responses such as the establishment of National AIDS Control Organisations, adopting strategies for blood safety, controlling sexually transmitted diseases, information and education campaigns, condom promotion and provision of ARVs in some countries.
  • (b) Care and treatment related thematic areas including the “3 by 5 initiative”; the challenges and opportunities in scaling-up access to treatment and improving access to ARVs in resource-limited settings; the current state of vaccine trials and difficulties foreseen in implementing them; and preventing and managing opportunistic infections including tuberculosis are discussed in detail. The authors then present strategies and guiding principles in tackling these issues, mainly from a WHO perspective.
  • (c) And finally, drawing heavily from the African literature, the volume also discusses socio-economic, cultural and multisectoral dimensions of the epidemic, including some lessons for Asia from Africa. Here the authors discuss the threat of HIV/AIDS to human security, the impact of HIV/AIDS on various population subgroups including the elderly widows, and the gaps in collective response to the epidemic.
  • Given the diversity of Asian economies and societies, attempting to capture the Asian experience is ambitious. The country case studies provide a useful catalogue of information to those trying to understand the scope of the epidemic and the national response. The topics related to care and treatment give a perspective of the overall complexity of issues surrounding the virus and the scientific and

    Economic and Political Weekly March 25, 2006 logistical challenges in scaling-up responses to the virus. This point is brought into sharp focus on chapters discussing vaccine development to fight a rapidly mutating but fast moving virus. Teokul (chapter 20) provides a wholistic analysis of socio-economic and cultural dimensions giving a flavour of added complexity in effective response. For example, how can ARV access and voluntary counselling and testing be scaled-up in the context of a disease that is characterised by stigma and discrimination? The authors present a comprehensive picture of the challenges in combating the proximal causes of HIV transmission.

    Shortcomings

    However, the volume falls short on many aspects. The authors present the biomedical and behavioural aspects of causes and response to the diseases without much intellectual engagement. Often, the authors present statements without references to current research. For example, in chapter 3, while discussing risk factors contributing to HIV transmissions in Africa, Latif states, “most countries in the subregion have embarked on educating women on the use of female condoms and making these widely available” (p 61). Nielsen and Melgaard in chapter 2 on economic and security dimensions of HIV/AIDS in Asia conclude that HIV/AIDS does not impact environment. They state, “with the exception of environmental security, all these aspects [food, personal, health, etc] could be affected” (p 49). Yet, they present no analysis of the data that enabled them to reach such conclusions. On the contrary, research from Africa (conducted by University of the Witwatersrand and University of Colorado) shows that households affected by HIV/AIDS rely increasingly on natural resources to provide for their food needs. The book devotes four chapters to enhancing access to ARVs (chapters 6, 17, 18 and 19). The authors of these chapters for the most part merely catalogue the strategies for action by national governments and/or WHO. For example, Chaudhury in Chapter 18 on ‘Enhancing Access to ARV in Developing Countries’ presents a generic seven-step strategy. It would have been helpful if the authors of these chapters presented an analysis of what each of these steps means in the current socio-political economy of various countries, critique the experiences to date and what that means to rapidly scaling-up.

    These examples are just indicative of a wider problem of lack of analysis and critique of the current literature and experiences throughout the book.

    The authors for the most part merely endorse the status quo of response to the epidemic. Some serious and incisive questions need to be asked. Why have the much-acclaimed 100 per cent condom use strategy (Chapter 4) in Thailand and Sonagachi Sex Workers Projects in Kolkata (Chapter 1, p 34; Chapter 9, p 167) not been scaled-up to other areas and regions of Asia? What were the enabling factors that made these initiatives a success? What has limited their scaling-up? Can these experiences inform ARV roll-outs? Again, such lack of synthesis of experiences in an integrated manner from the above stated chapters is an illustration of the paucity of rigorous analysis throughout the book.

    A significant shortcoming of the book is lack of vision, failing to realise the expectations set by the sub-title of the book: The Challenge Ahead. The main conclusion of this book for a way forward, in addition to vaccine development, is to enhance political will and commitment, expanding information education and communication campaigns, promoting condom use and voluntary counselling and testing, scaling-up ARV therapy and controlling sexually transmitted diseases and opportunistic infections. All these are unarguably essential components of a successful strategy to prevent further spread of HIV. If these strategies are already in place and are working, as Shaukat and Panakadan contend in case of India, one would not expect to see the number of those living with HIV to increase by half a million a year in India. It would have been helpful if the authors examined the evidence of success of some of these programmes (for example, prevention campaigns) as a basis for evidenced based policy-making that is grossly lacking in responding to the causes and consequences of HIV/AIDS.

    A part of the failure of these abovementioned conventional strategies could be attributed to a failure to understand the significance of socio-economic, cultural and political influence on the spread of infectious diseases. As long as a large portion of the population is not in a position to defend their rights (for example, freedom from sexual abuse and abuse by the police, discrimination from doctors) and to restore their dignity (women able to control their sexuality) any individual action will be counterproductive at best and dangerous at worst. The main challenge ahead is to ensure that the responses to the epidemic are based on sound framework of ethics, human and legal rights. Devoid of this, simply more of the same is not enough.

    EPW

    Email: s.kadiyala@cgiar.org

    Economic and Political Weekly March 25, 2006

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