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National AIDS Control Programme: A Critique

Condom-centric ways of controlling the spread of HIV/AIDS, coupled with targeted interventions among high-risk groups, have been advocated with near-religious fundamentalist zeal for prevention. But what is urgently needed is a fundamental shift to an alternative approach, one that reduces risk-exposure and builds an enabling ethos for strongly reinforcing and expanding the predominant base of low-risk behaviour/lifestyle patterns through community-based strategies.

Perspectives

National AIDS Control Programme: A Critique

Condom-centric ways of controlling the spread of HIV/AIDS, coupled with targeted interventions among high-risk groups, have been advocated with near-religious fundamentalist zeal for prevention. But what is urgently needed is a fundamental shift to an alternative approach, one that reduces risk-exposure and builds an enabling ethos for strongly reinforcing and expanding the predominant base of low-risk behaviour/lifestyle patterns through community-based strategies.

RAMI CHHABRA

T
he human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS), which is a condition in humans wherein the immune system begins to fail, leading to opportunistic infections that can be lifethreatening. Infection with HIV can occur by the transfer of blood, semen, vaginal fluid, Cowper’s fluid or breast milk, the major routes of transmission being unprotected sexual intercourse, infected blood transfusion, and transfer from an infected mother to her baby. However, with suitable precautions, prevention is quite feasible. Safe sexual behaviour and hygienic medical practices, particularly safe blood transfusion, are two basic requirements.

In this article, we focus our attention on the technical and ethical bankruptcy of strategies involving targeted interventions among high-risk groups (TIHRG). We examine the role of the National Aids Control Organisation (NACO) since its inception and trace the evolution and growth of targeted interventions among high-risk groups with heavy external resource inputs. TIHRG strategies are currently being centre-staged in Phase III of the National AIDS Control Programme (NACP-III) with World Bank (WB) and development partner support for a $ 2.2 billion package (more than half of which is allocated to targeted intervention strategies) for which India is committing nearly $ 1 billion of its own resources to receive $ 250 million IDA-credit, plus donor packets from the UK’s Department for International Development (DFID) of $ 80 million, the Gates Foundation (GF)

  • $ 317 million, and the Clinton Foundation – $ 25 million. Earlier slated for WB board approval in October 2006, this is now postponed to January 2007, because insufficient donor commitments have left a “financing gap” of $ 805 million.1An examination of NACP Phase I and II reveals the following:
  • International funding biases in setting up NACO/NACP in the vertical thrust mode;
  • How little NACO’s past record justifies the gigantic expansion of its programmes;
  • Expansion and up-scaling despite poor performance, lack of accountability and evidence of failure;
  • Unreliability of NACO data; and,
  • –Negative social consequences of TIHRGs.

    The International Response

    Although an international priority since HIV’s identification, the international community-led response to HIV/AIDS has not delivered results. Universal blood safety and good medical practices have not been guaranteed beyond first world countries, while a heavily condom-centric, sexual transmission prevention bias has befuddled sexual issues. The escalation of HIV/AIDS to a global pandemic in less than three decades – 65 million infected, 25 million dead, 40 million living with HIV2 – underlines the failure of received wisdom. Sub-Saharan Africa, the earliest site of internationally directed interventions and the epicentre of the pandemic, is a tragic testimony.

    Originally steered by World Health Organisation (WHO), HIV/AIDS is the only disease with a dedicated UN agency: the joint UN programme of HIV/ AIDS (UNAIDS). Since 2000, the coordinated might of nine UN agencies plus the WB are tackling HIV/AIDS prevention/ management. Global budgets – far exceeding any other disease – have been pledged. Funds for low/middle income countries are up 30-fold – from $ 300 million in 1996 to $ 8.9-10 billion in 2006-07, but are still considered inadequate.3 Mounting gaps – $ 6-8 billion projected over 2006-07, and growing in the future have been identified for meeting “actual needs”.4

    Few dispute the need for urgent action. But notwithstanding strategic road maps, hammered out at glittering global conferences, concerns mount on how to deal with the pandemic. World Bank/UN agencies, actively partnered by Northern governments and foundations, including the GF, bring homogenised, “laissez-faire” sensibilities to high-risk sexual behaviour, with a bias towards technology-based fixes. Condom provision, social marketing, and focused promotion to different segments, particularly high-risk populations, are the centrepieces of the AIDS response (2006-08).5 But condom surveys estimate condom use in only 9 per cent of acts of sexual intercourse with non-marital/noncohabitating partners in 2005,6 a decline since 2003,7 which is a pitiable outcome of two decades of condom promotion to prevent HIV/AIDS. But the global juggernaut for condoms is relentless.

    Condom-centric ways of preventing sexually transmitted diseases (STDs) coupled with TIHRG have been advocated with near – religious fundamentalist zeal in HIV/AIDS prevention. “Costeffectiveness” and the claim that this is the “only available preventive method” are strategic arguments. Ironically, international agencies solicit ever-greater national contributions to implement their defined perspective.

    New evidence comes from Thailand, a best practices icon in the HIV/AIDS literature, where there is national promulgation of a “100 per cent Condom Use in

    Economic and Political Weekly January 13, 2007 Brothels Strategy”.8 Past HIV prevalence decline, partly as a result of high mortality from the disease, partly from fear-propelled reduction of entrenched commercial sex patronage and multiple partner sex behaviour patterns, alongside condom use increase,9 has reduced Thailand’s adult HIV prevalence rate. However, a second wave of HIV infection is hitting Thailand, particularly among monogamous partners of philandering men and men-having-sexwith-men (MSM) and minors.10

    The UNDP’s report on Thailand (2004) warns that the HIV epidemic is getting worse. Indeed, it acknowledges sinister new developments: increased demand for and supply of commercial/casual sex; a 50 per cent increase in “sex-service” establishments over 1998-2003;11 high “staff-turnover” in “sex-establishments”; a significant number of new HIV infections in the sex trade;12 more young people drawn into the sex trade as workers/clients; rising experimentation with sex, drugs and alcohol amongst young Thais, including schoolgoers;13 increasing numbers of “sex workers”, particularly “indirect sex-work”, operating in diverse, more-difficult-toregulate settings, now accounting for a sizeable portion of the sex-industry; and authorities expressing an inability to monitor condom compliance in vastly increased direct/indirect “sex-serviceestablishments”.14

    A ‘Best Practices’ Icon?

    Soon after the first HIV infection was detected in Chennai in 1986, a modest HIV/AIDS control effort was launched by an AIDS cell in the union health ministry under WHO guidance, with a $ 10 million budget, financed from external sources.15 In 1992 this AIDS cell was significantly expanded. A $ 84 million IDA credit was sanctioned for AIDS prevention (NACP-I), conditional to setting-up the quasiautonomous NACO and accepting a strategy-package16that included a blood safety component and surveillance activities, and active media communication.

    A seemingly innocuous communitybased health research study (backed by WHO) for ascertaining the incidence of HIV/AIDS/STDs in Kolkata’s “red-light” Sonagachi area17 (HIV prevalence was

    0.53 per cent in 1991)18 graduated during Phase I to the first TIHRG with NACO, Norwegian NORAD and UK’s DFID (then ODA)19 collaboration to implement methodologies adopted and extensively funded in Africa. The strategy was predicated upon non-interference in the illicit “sex-trade” and bringing about “behavioural change” through condom promotion, early STD identification and treatment through trained, paid “peer outreach sex workers” working within the “sex workers” community,without disturbing the “trade”.20 This small project’s key importance is gauged from its multiple financiers and provision of extensive “technical expertise”– 200-250 international experts over the early 1990s, besides VIP visits, with local political bigwigs and union home and health ministers attending inaugurations/seminars to provide legitimacy.21

    The Sonagachi project was rapidly scaled up to the West Bengal Sexual Health Project (WBSHP), with DFID providing £ 3.9 million during 1995-9822 for 254 sites involving nearly 30,000 high-risk persons. Its goal: avert half-a-million STDs, including 860 HIV cases.23 But despite mega funding with meagre targets, WBSHP’s final evaluation report expressed its concern over rising HIV prevalence rates and admitted an inability to assess STD/HIV outcomes, for this would have required a large-scale study involving control groups, raising ethical considerations, and so on.24 Yet Sonagachi acquired an iconic status in HIV/AIDS circles.

    The reality of Sonagachi is worth dwelling upon. Thus, what about HIV prevention in Sonagachi – the TI prototype/best practices icon – whose initiators and outreach workers are now experts for the replication of TIHRG? Strangely, NACO has no independent studies on HIV infection control and the cost-effectiveness of the Sonagachi project (RTI communication with the author). Neither are there such studies on Kamathipura, India’s biggest brothel area where TIHRG projects commenced from the early 1990s. NACO’s reports on Sonagachi consistently project low HIV infection rates (6-10 per cent), long belied by studies conducted by others, including the Indian Council of Medical Research.25In 2002, the West Bengal SACS shared studies by the All India Institute of Hygiene and Public Health showing Kolkata “sex-workers” having an over 20 per cent incidence of HIV-infection.26

    But Sonagachi has succeeded remarkably in organising large national/international public assemblies in assertion of “sex-worker” identity, “sex-workers’ cooperatives”, trade unionisation and demand for legalisation of “sex-work”, recognition as legitimate occupation with workers’ entitlements, pensions, self-regulatory boards, and so on. Leaders of selfstyled “sex-networks” access top political leaders – as they did to protest proposed Immoral Traffic (Prevention) Act (ITPA) amendments penalising “clients”/brothelrunning as affecting their “right-to-livelihood”. The Parliament Standing Committee taking note of this demand could well help legitimate if not legalise sex as work.27 But has such “empowerment” reduced the incidence of sexually transmitted infections? Ignoring HIV infection rate controversies and accepting high condom use claims, the high rates of STDs and abortions still highlight continuing HIV vulnerability. Sonagachi’s own surveys reveal a considerable influx into “sex work”. A recent survey indicated that among the new recruits, a majority are in their teens or twenties; onethird to half engage in group-sex; 87 per cent got pregnant; 41 per cent underwent abortion, 17 per cent three times or more; 50 per cent underwent STD treatment during the previous year;28 14 per cent never used condoms; while “always use” condoms indicated 90 per cent of time.29

    NACP Phase I

    Sanctioned for five years, the $ 103 million NACP Phase I (including $ 27 million from the union government) extended to seven years. Sizeable unspent funds were frantically spent in the twoyear extension period, as NACO allowed the states to sanction NGOs up to Rs 10 lakh for maintenance and contingency expenses.30 Rupees 75 crore was spent on communication campaigns in one year, with one state spending on this account as much as the amount spent by all the other states.31 Such frenzied media-friendly campaign funding furnished “evidence” of NACO’s efficient gearing-up, making way for higher allocation of funds for Phase II! Interestingly, NACP Phase I had no ongoing audit and evaluation.32 An evaluation was done only after Phase II had begun (experts/activists were agitated about this, amongst other matters). The Planning Commission recorded strictures on the way the NACP had spent its funds and was critical of its funding patterns.33 Reviews by the Comptroller and Auditor General’s office were undertaken and highlighted considerable problems.

    Notwithstanding all this, the WB singled out the NACP Phase I as the only one amongst Bank-financed endemic disease control and health system projects in India

    Economic and Political Weekly January 13, 2007

    to receive a highly satisfactory rating.34 It dangled $ 191 million IDA credit, linked with $ 100 million bilateral/multilateral grants, which together with the union government’s and states’ contributions would be quite a bonanza for NACP Phase II.35

    NACP Phase II

    Phase II (1999-2004) committed India to a dramatic “paradigm shift” as insisted on by the WB and allied donors. This was to involve setting-up of decentralised stateand municipal-level AIDS control societies (SACS/MACS), as also registered societies functioning outside government control, assigning a pivotal position to NGOs in implementation and a focus on nonjudgmental “high impact prevention interventions targeting populations engaging in high-risk-behaviours”. The DFID earmarked Rs 104 crore for sexual health projects in four states, besides West Bengal, which was subsequently increased to Rs 783 crore and geographically expanded to include West Bengal and Madhya Pradesh.36 The targeted intervention (TI) component’s crucial importance was underlined in the overall assessment of India’s capacity to respond to HIV/AIDS, which would be measured by the percentage of states/ municipalities in which SACs are functioning, and the actual record of effectively managing TIs.37 The experience of targeted interventions of high-risk groups in Sonagachi and Thailand were specifically cited to technically justify the selection of the TI strategy.38

    Women-activists who condemned “verticalisation” and the conceptually flawed TI strategy, as “anti-law, antiwomen, and anti-poor” demanded an independent evaluation of Phase I and a reexamination of Phase II prior to its launch.39 The union government had by then already agreed to funding outside established government procedures and a strategic state response predicated on tolerance of prostitution (de facto including women being forced into prostitution), not rehabilitation/reintegration policies for “commercial sex workers”. Despite the then prime minister A B Vajpayee’s assurances to a women’s delegation that demanded immediate re-examination and rectification, NACP Phase II went ahead.40 Opposition to the programme was sidetracked by bureaucrats in the prime minister’s office and the union health ministry (many of these bureaucrats subsequently moved on to prestigious international and national assignments). TIHRGs have now acquired such a Midas touch that nobody speaks of the Emperor’s new clothes.

    Virtually conceding Phase I lapses, NACO declared for Phase II: “For the first time monitoring/evaluation (is) made (an) integral part of project strategy”.41 An independent national monitoring and evaluation agency was to be selected within the first year of the project and mid-term and end-term evaluations were mandated. Yet, as admitted under a right-to-information (RTI) complaint, neither mid-term nor endterm evaluations (due 2004 when the project period concluded) took place.42 NACP Phase II was extended till end-March 2006, enabling expenditure of unspent amounts and Phase III planning. An end-line behaviour impact study was expected in October/November 2006, but the status of the mandatory independent evaluation remains unknown. Moreover, NACO’s sponsored research, at huge cost to the public exchequer, has been unavailable in the public domain. For long the NACO website was stuck on PR material, the data section was on “maintenance” mode; it is now operational, with a few reports posted after RTI activists pursued the matter. The NACP III draft, which has been claimed to be conducted in “participatory, inclusive” mode, was secured by this writer under the RTI Act, but is still unavailable in the public domain, as are the ‘End-line Impact Study and Evaluation’.

    But available from the Comptroller and Auditor General’s office is the CAG report on NACO’s and SACs’ performance in Phase II. Reviewing the programme in its penultimate year, the CAG categorically concludes: “(I)t had achieved limited success mainly due to failure in generating sufficient awareness among the masses and the slow pace of the implementation of the various components…various activities under the programme could not be conducted efficiently for want of infrastructure facilities, drugs, equipment, trained manpower, etc…Targeted Interventions… [had] not been conducted efficiently”.43 CAG picks many holes, both in implementation and financial handling.

    Likewise, in 2005-06 the Public Accounts Committee (PAC) examined NACO/SACS performance. In summing up, the PAC report states: “Analysis of the performance of various components of NACP – both Phases I and II revealed that the programme had achieved limited success due to various reasons such as failure in generating sufficient awareness among the masses; under-utilisation of funds; non-reconciliation of accounts; absence of adequate infrastructure facilities; lack of adequate drugs quantity of drugs and trained manpower; non-completion of mapping exercise for identification of Target Groups; ineffective Targeted Interventions programme; failure of NACO to procure and distribute enough condoms; inadequate number of STD clinics, modernised blood banks and voluntary counselling and testing centres in every district of the country, etc, and non-assessment of the impact of various components of the programme due to failure of the National AIDS Committee to meet after 2001.”44 The PAC recommended an immediate independent evaluation to identify bottlenecks/constraints and suggest measures for effective implementation.

    Targeted Interventions

    TIHRG was evaluated in 2003 through a study conducted in over 17 states, according to which the efficacy of implementation, on average, was a poor 37.8 per cent.45 The DFID – a principal donor cum technical advisor – was scathing. Its 2003 evaluation of targeted interventions in five states termed the technical strategy “largely inappropriate to the epidemiology of HIV/AIDS in India”;46 deplored the remarkable sameness of TIs across five states, the poor quality of research and STD treatment, the lack of attention to social vulnerabilities to HIV/AIDS, and the irrelevance of “predetermined formats guaranteeing…‘standardised’ interventions”.47 DFID’s evaluation categorically stated that NACO did not have the information to measure the overall progress and impact of the TI component as NACO’s sentinel surveillance system does not provide for it.48 The DFID report assessed the cost effectiveness of the HIV/AIDS programme as a whole and of TIs as low; further, the effectiveness of TIs in preventing HIV transmission was also assessed as low.49 Financial accountability issues were raised. There was “considerable unease” with one state; “possible corruption in the allocation of funds by states to NGOs” was “a greater or lesser problem varying from state to state”. All this raised an “important accountability and transparency issue that warrants more attention from DFID”.50 But inexplicably thereafter (2004), GF green signalled $ 200 million support for HIV/AIDS prevention, meant exclusively

    Economic and Political Weekly January 13, 2007 for TIHRG in six high-prevalence states, reducing the WB and the DFID to smaller players.

    Overall, the linkage of TIHRGs to reduction in the incidence of HIV is fallacious. Curiously, while the evaluation by DFID describes 300 DFID funded TIs accounting for 80 per cent of the TIs implemented in India in 2003,51 the NACP Phase III Draft, reviewing Phase II “achievements”, lists over 1,000 TIs implemented, 700 covering 6,60,000 “core high-risk persons”.52 If one accepts the authenticity of these figures, then obviously the majority TIHRGs are post-2003, and hence their linkage with a reduction in the incidence of HIV is fallacious.

    It is curious that despite the adverse findings of the CAG and the PAC, DFID dissatisfaction, and the failure to schedule mid-term and end-term evaluations, the WB is now proactively processing a $ 2.2 billion loan for NACP Phase III that will “significantly scale-up” India’s HIV/AIDS response, saturating it with targeted interventions. Despite the poor implementation evidence, as marshalled, the WB certifies that “India has developed valuable experience” with TIs, which are projected as generating a “high-impact” with a “multiplier effect”, and therefore the need for “greater synergy with (the) financing of other Development Partners”.53

    Agenda-driven HIV Numbers

    NACO’s HIV estimation processes are as cavalier as its implementation/monitoring/ evaluation record; projections are clearly agenda-driven. Correspondingly, NACO estimates have zoomed: The end-1994 estimate was 1.75 million HIV-infected, which grew to 4 million prior to the WB appraisal mission, although Sentinel Surveillance (SS) published data (1994-98) failed to substantiate the increase and 1998-99 SS data indicated a decreasing trend. 54 Challenged, the NACO estimated 3.5 million persons as HIV infected (mid-1998). Subsequently, an expert group estimated the number by suggesting a range between

    2.4 million and 3.7 million. NACO arbitrarily picked the higher-end, coming close to the WB’s estimate of 4 million at the start of NACP Phase II.55 The WB’s estimates and projections when NACP Phase II was on the anvil were altogether startling in terms of its loose assumptions and statistical incoherence, e g, 1.3 million new-infections estimated per year; approximately 1 per cent of the Indian sexually-active female population assumed to be in “sex-work”, 4.2 million new HIV cases in India during 1999-2004 without the WB project; 3.7 million new HIV cases with the same project 50 per cent successful; lacking successful intervention, the WB then projected 37 million plus HIV-infected personsby 2005!56All this perhaps led the Independent Commission on Health in India to note at the start of Phase II that “Flawed estimates at the outset could result in scams of enormous public expenditures vindicated through notional reduction of ‘infections averted’ from levels not scaled in the first place! Fudged figures as in the family planning ‘sterilisation and births averted’ claims could lie ahead.”57 Notably, such disregarded critiques are proving prescient in the context of the current claims of a decline!

    The shrill hype on exploding numbers has since muted. An expert group is resolving the differences between NACO’s estimate of 5.2 million and UNAIDS’ estimate of 5.7 million HIV-infected in 2005; the WB’s estimate of 37 million in 2005 has been thrashed. But it should be noted that the current requirement is to demonstrate that the HIV explosion has been stemmed with the successful implementation of the TI strategy of NACP Phase II. Pertinently, a study highlighting a one-third decline in HIV-incidence in south India got world media-hyped on March 31, 2006, on the day NACP Phase II closed.58 The findings – widely quoted to substantiate Phase II achievements – come from research spearheaded by a former task force leader during the time when Phase II was being formulated. NACO’s sentinel surveillance eventually tabulated 1.3 million new HIV infections over 1999-2004.59 Now the most recent data indicates that the increase in HIV infectedpersonsisat a snail’s pace; the total number of persons infected is 5.10 million in 2003, 5.13 million in 2004 and 5.21 million in 2005.60

    It is another matter that a plateau may actually have been reached in the numbers infected. This would vindicate the theory of leading Indian epidemiologists who have argued that the HIV/AIDS infection, like all other communicable diseases, would initially spread quickly, saturating the susceptible, then peak and decline. They postulated that the declining trend would continue after the “susceptible” population had been exhausted, unless and until fresh entrants to the “promiscuitypool” grew by an order exceeding those leaving through death or reversal of promiscuous behaviour. The key is the extent of promiscuity and its effective self-restraint.61

    This thinking suggests a paradigm shift involving the reduction of risk-exposure, not harm reduction during exposure, requiring a fundamental strategic shift from targeted interventions among high-risk groups to community-based strategies. This will entail deferring to people’s innate wisdom to arrive at appropriate solutions, together with programmatic inputs concentrated on instituting primary preventive interventions against causative factors identified by the people so that exposure to the risks or behaviour in question is tackledtogether with effective, appropriate information and counselling, including secondary preventive measures like condoms.62

    Epidemiological theories apart, NACO’s SS tracking needs further scrutiny. The spread of SS sites over the years from 55 in 1994 to 384 in 2002 and 703 in 2005 mocks scientific longitudinal tracking, rendering the shifting scene non-comparable. Epidemiologists point out that SS was set up to provide trends, not magnitudes; sites do not have an additive value, nor are they representative of the population. Further, trends can be gauged from a fixed number of sites over the years.63 Queries to NACO (under the RTI Act) reveal that in a tracking of 170 constant sites during 1998-2005 showed an increasing trend in 18 STD sites, a decreasing one in nine STD sites, an increasing trend in 20 ANC sites, and a decreasing one in 14 ANC sites, while in the remainder there is no clear trend (with sharp fluctuations from year to year).64 Both, NACO’s HIV estimates and claims regarding a decline lack a scientific basis. Similarly, estimates of numbers exposed to high risks of being infected with HIV lack scientific rigour.

    NACP Phase III baseline estimates for TIHRG provide a fascinating re-run of HIV numbers being inflated. Participatory mapping of high-risk-persons was a key Phase II output indicator. Each state spent Rs 5-15 lakh for each “mapping” exercise.65 The expert group on high-risk estimates received mapping data from all the states (except Tamil Nadu and Tripura). The data pinpoints 5,23,000 women who have been forced into prostitution in the country.66 Highlighting the limitations in mapping, the expert group has dismissed this figure as a “crude estimate”. With several adjustments/assumptions, a range estimate is arrived at: 8,31,677-12,50,115.67

    Economic and Political Weekly January 13, 2007

    NACP III has settled for the higher end of the range. Déjà vu?

    Even more loose estimation procedures and arbitrary assumptions underlie the calculation of the number of MSM. The figure from the mappings of 0.01 per cent of adult males zooms to 5 per cent of twothirds of adult males considered sexually active. Extrapolating from small studies,

    2.3 million MSM are put in the multipartner category – half selected for Phase III target.68On the basis of unverified assumptions, 3 million “vulnerable” truckers are added; so are 9 million “vulnerable” migrants as “bridge” populations.

    NACP Phase III: Flawed Strategy

    Thus, a flawed and failed TIHRG strategy using wild guesstimates is NACP III’s centrepiece with an allocation of over half of the Rs 11,585 crore direct outlay.69 This is a mind-boggling operational blitz, with the condom as the “Superman”, which is a clear bonanza for the condom lobbies. A distribution target of 3.5 billion condoms a year is aimed at by 2010, two billion social marketed, half a billion commercially sold, and a billion distributed free through subsidies.70The basis for these optimistic targets is also not clear; nor is there a basis to assume consistent/correct usage on such a scale to justify a huge allocation of funds for public health.

    NACP III’s overall goal is halting and reversing the HIV/AIDS epidemic in India in the next five years by integrating programmes for prevention, care, support and treatment. But less than 17 per cent of the total allocation is for care/support/ treatment of the 5.2-5.7 million HIV infected, at least 10 per cent (5,20,0005,70,000) of whose immunity is seriously compromised. Treatment and care targets are cautiously sketched, obviously leaving as many out. For instance, free ARTs will reach only 3,00,000 persons by 2011. Indeed, the total allocation for care/ support/treatment is under three-fourths of the Rs 2,000 crore that has been earmarked for a single prevention commodity

    – condoms. Prevention consumes twothirds of the total allocation, but blood safety is allocated a mere 8.2 per cent and communication and social mobilisation a mere 8.8 per cent. The rest is mostly for TIHRGs (nearly Rs 3,000 crore), limited “services” (Rs 1,400 crore), condoms (Rs 2,000 crore), and for an “enabling environment” (Rs 50 crore) for this work, including advocacy for legal changes in the ITPA, IPC, etc, identified as “hampering” TIHRG implementation.71

    In NACP III, 2.3 million “core-transmitters” – 1.0 million “commercial-sexworkers”; 1.3 million MSM; 1,90,000 IDU

    – are to be rapidly mobilised and organised in groups for outreach within three years. Half of the TIHRGs will be implemented through new community-based organisations, but ironically these are of the newly created “communities” of the “core-transmitters”. Funding provisions are made for immediate payouts of onetime costs, fixed recurring costs irrespective of numbers, etc.72 Enormous public resources are to be utilised to create organisations around sexual identity/ practice and networking communities exclusively around high-risk behaviour, not for abandonment of harm-causinghabits but persuading persons engaged in sexual behaviour involving high-risk to go in for “harm-minimising protection”, i e, condoms, STD treatment, new needles and possibly, substitute drugs, and so on, the state becoming “proactive for creating safe spaces”73 for commercial sex work and other high-risk situations.

    NACP III is conspicuously silent on structural socio-economic vulnerabilities and the root causes of the continuing flow of sub-populations into situations involving high-risk behaviour. It offers nothing to address these vulnerabilities through creating viable, holistic alternatives for those presently entrapped. Hardly any resources are being dedicated to prevent, rescue, rehabilitate/reintegrate endangered persons and survivors of “sex work” to enable to overcome their endangering lifestyles that make them highly vulnerable to HIV/AIDS. The perspective, targets and budget allocation are preoccupied with getting high-risk groups to use condoms, besides addressing “certain vulnerabilities particular to the commercial-sex-trade”74 and other high-risk situations, while the

    5.2 million persons living with HIV/AIDS

    – are not approached with the same zeal and efficiency.

    The NACP Phase III, which will spend $2.2 billion, besides cornering considerable human resources and public energies, is being launched on a deficient set-up, strongly censured by the country’s public audit systems for its performance and supervision. This set-up, which needs dismantling, is to be fortified and up-scaled, contradicting the national rural health mission’s preference for integrated programmes. The vertical NACO empire of SACS, MACS and funded NGOs, created by external fiat, will now further extend to the district and sub-district level units. Earlier externally-promoted vertical programmes, e g, family planning, pulse polio, etc have demonstrated, “convergences” notwithstanding, an erosive effect on the primary health care infrastructure and delivery-systems (the primary health centres) that desperately need consolidation and substantive capability improvement to cater to basic community health needs and critical medicines, including ART. In other words, functioning integrated public health systems are needed, not vertical programmes with a supra-status for one disease, or else, HIV/AIDS treatment/care itself will be the casualty, alongside other critical health requirements.

    NACP III’s major component, TIHRG – force-fed to India by external agencies with very poor implementation results so far – is being taken to an unprecedented operational scale. This is not only unjustified by past experience at the national level, but untried at this scale anywhere in the world. The very scale of this operation carries serious repercussions, not addressed by India’s political leaders/policy. State and societal legitimisation of “commercial sex work” will overturn existing societal values of sexual restraint/responsibility that have acted as the principal bulwark against the rapid transmission of HIV/AIDS so far and which need to be at the core of HIV/ AIDS prevention efforts.

    International “evidence-based” showcase examples already clearly “unravelling” and riddled with second-generation problems afford valuable hindsight. The Thai experience demonstrates a mechanistic approach that pragmatically overlooks social-costs which will prove dearer in the long run, while ironically, failing to dent the HIV/AIDS epidemic. Whatever Sonagachi’s other claims to fame, its HIV infection control profile lacks credibility. Legitimisation of the “sex industry” must not occur under the HIV/AIDS prevention mantle.

    Towards an Alternative Approach

    India needs an alternative approach, one that reduces risk-exposure and “builds an enabling ethos for strongly reinforcing and expanding the predominant base of low-risk behaviour/lifestyle patterns yet existing amongst Indian youth and adults”. As pointed out by the health experts advocating this: “The entire trajectory of

    Economic and Political Weekly January 13, 2007 solutions flows differently depending on the basic approach chosen”.75 The first step is rejection of NACP-III. Although it is not within the scope of this article to suggest ways of operationalising an alternative approach based on a risk exposurecutting paradigm, formulating and implementing such an approach must be India’s top priority. Here one can also draw on the Swedish approach, which views women being driven into prostitution as a form of “male violence” and men who buy sex as criminal offenders. The Swedish government does all it can to help women get out of prostitution. Such an approach can really be an integral part of the alternative we are suggesting.

    Harm minimisation efforts, as in TIHRGs, can only be justified if adopted as a small, carefully calibrated, “clinical” part of a an HIV/AIDS prevention programme essentially predicated upon reduction of risk exposure. With commercial sex and injection drug use identified as core transmission sources, harm minimisation can at best be a temporary measure to gain a foothold in order to wean away high-risk persons within a clearly defined time bound plan. A corpus fund dedicated to rescuing, rehabilitating and reintegrating the “vulnerable” is essential to a risk exposure cutting approach. Also, calibrated “harmminimisation” requires a different worldview to prevail, one that is predicated upon an “enabling ethos” that effectively curbs high risk situations and provides the legal and structural wherewithal to target and diminish the “demand” factors that fuel harm exposure, while the supply is stemmed and weaned away, out of the arena of high risk exposure.

    EPW

    Email: aalna@del3.vsnl.net.in

    Notes

    1 World Bank (2006), ‘Integrated Safeguards Datasheet’, Appraisal Stage Report No AC2430; prepared/updated November 2001, accessed from www.worldbank.org on December 3, 2006.

    2 UNAIDS (2006), Report on the Global AIDS

    Epidemic, May, p 4. 3 Ibid, p 24. 4 Ibid, p 249. 5 Ibid, p 226. 6 Ibid, p 287. 7 Ibid, p 287. 8 Lawrence Altman, ‘Former Model of Success

    – Thailand’s AID Effort Falters, UN Reports’, New York Times, July 9, 2004.

    9 United Nations Development Programme

    (2004): Thailand’s Response to HIV/AIDS:

    Progress and Challenges, pp 22-24.

    10 Ibid, p 45. 11 Ibid, p 52.

    12 Ibid, p 70.

    13 Ibid, pp 3, 45, 70.

    14 Ibid, p 54.

    15 NACO (1997-98): Country Scenario, p 4.

    16 D Banerjee, ‘AIDS Threat to India: A Response’,Health for the Millions, November-December 1996, p 26.

    17 Durbar Mahila Samanwaya Committee (1997):The ‘Fallen’ Learn to Rise: The Social Impact of STD/HIV Intervention Programme, p 6.

    18 Rami Chhabra (2002): ‘Sonagachi: An Ignored “Virus” ’, Health for the Millions, p 17; West Bengal Sexual Health Project, 1999; Society for Human Development and Social Action, STD/HIV Intervention Programme (2001): ‘Report of Fourth Follow-up Survey on Sonagachi’, May-June 2001 (mimeo).

    19 Durbar Mahila Samanwaya Committee (1997), op cit, p 9.

    20 West Bengal Sexual Health Project (1999):Developing an Effective Clinical Intervention Strategy among a Sex Workers Community: An Experience of STD/HIV InterventionProgramme (Sonagachi Project), pp 9-10.

    21 Rami Chhabra (2002), op cit, p 17.

    22 DFID (1997), ‘Interventions for Sexual Health Andhra Pradesh, Gujarat, Kerala, Orissa, India: Draft Project Memorandum’, New Delhi, August, p 4 (mimeo).

    23 IFH Sexual Health Consultancy – Final Report (1999), ‘West Bengal Sexual Health Project Evaluation’, September (mimeo), p 38.

    24 Ibid, p 39.

    25 Independent Commission on Health in India (December 2000): Presentation made by Members to Member (Health) Planning Commission of India (mimeo).

    26 Lalit M Nath, ‘The Independent Commission on Development and Health in India’, HIV/ AIDS in India: Some Issues, p 27.

    27 Rajya Sabha (2006): Parliament Standing Committee on Human Resource Development’s 182nd Report on ‘The Immoral Traffic (Prevention) Amendment Bill, 2006’, November 2006, pp 15-17.

    28 Society for Human Development and Social Action, STD/HIV Intervention Programme (1998; 2001), ‘Reports of Third and Fourth Follow Up Surveys of Sonagachi’, April-June 1998; April-June 2001 (mimeo).

    29 Ibid.

    30 Voluntary Health Association of India, Independent Commission on Health in India (2001): ‘National Aids Control Programme: A Critique’ (mimeo), p 6.

    31 Ibid, p 6.

    32 Ibid.

    33 Noting on relevant files by Advisor, Health, Planning Commission, 1998-99.

    34 World Bank (1999): Project Appraisal Document on a Proposed Credit in the Amount of SDR140.82 Million to India for a Second National HIV/AIDS Control Project Report No18918-IN, May 13, p 9.

    35 Ministry of Health and Family Welfare (2001): ‘National Aids Control Project, Phase 2 (19992004)’, National Project Implementation Plan, May 1999 (mimeo), p 25.

    36 www.nacoonline.org/partnership.htm.

    37 World Bank (1999): op cit, pp 3, 17.

    38 Ibid, p 11.

    39 Memorandum handed to Prime Minister by 14 Member Women’s Delegation on December 8, 1999.

    40 Voluntary Health Association of India, Independent Commission on Health in India (2000): ‘National Aids Control Programme:

    A Critique’ (mimeo), p 5.

    41 NACO (1999-2000): Combating HIV/AIDS inIndia 1999-2000, p 94.

    42 NACO communication to Rami Chhabra in response to RTI Application, July 25, 2006.

    43 Union Government (2004): Report of the Comptroller and Auditor General of India for the Year Ended 2003, No 3 of 2004, pp v-vi.

    44 Lok Sabha (2005): Report of the Public Accounts Committee, 2005-2006, p 185.

    45 NACO (2003): TI Evaluation Report, p 6.

    46 DFID (2003): ‘DFID Evaluation of Targeted Intervention in Reduction of HIV Transmission in Five States in India’, September 2003, Second Draft (mimeo), p 9.

    47 Ibid, pp 5, 7.

    48 Ibid, p 15.

    49 Ibid, p 11.

    50 Ibid, p 18.

    51 Ibid, p 1.

    52 NACO (2006): National Aids Control Programme Phase III, 2006-2010 Draft, July 19, p 160.

    53 World Bank (2006): ‘National Aids Control Project III – Project Information Document (Appraisal Stage)’, Report No AB2461.

    54 Report of Independent Commission on Health in India (ICHI), ‘Consultation with Experts on HIV/AIDS Current Estimates: World Bank Project Estimates/Assumptions (2000)’ (mimeo), p 1.

    55 NACO (1999-2000): op cit, pp 5-6.

    56 Report of ICHI Consultation with Experts (2000): op cit, pp 5-6.

    57 Voluntary Health Association of India, Independent Commission on Health in India (2000): op cit, p 4.

    58 Rajesh Kumar et al (2006): ‘Trends in HIV I in Young Adults in South India from 2000 to 2004: A Prevalence Study’, www.thelancet.com.

    59 www.nacoonline.org/facts_overview.htm

    60 www.nacoonline.org/facts_hivestimates.htm

    61 N S Deodhar (1998): ‘Epidemiology of HIV Infection: A Critique’, Indian Journal of Community Medicine, Vol XXIII, No 4, October-December, pp 176-83.

    62 N S Deodhar (2000): ‘Review of National HIV/ AIDS Control Programme in India With a View to Make It Community-Oriented, More Effective and Sustainable’, unpublished paper for ICHI (mimeo). Also see N S Deodhar (2003): ‘Commonsense and the New Venereal Disease Called HIV/AIDS’, Health for the Millions, Vols 28-29, No 1, pp 21-25.

    63 Independent Commission on Health in India Consultation with Experts (2000): op cit, p 1.

    64 NACO (2006): Communication received under RTI.

    65 NACO (2006), Communication under RTI.

    66 NACO (December 2005): ‘Report of the Expert Group on Size Estimation of Population with High Risk Behaviour for NACP III Planning’, prepared by RCSHA, New Delhi (mimeo).

    67 Ibid.

    68 Ibid.

    69 NACO (2006), National Aids Control Programme Phase III, 2006-2010, July 19, p 180.

    70 Ibid, p 183.

    71 Ibid, p 120.

    72 Ibid, p 162.

    73 Ibid, p 25.

    74 Ibid, p 25.

    75 Independent Commission on Health in India (2001): ‘A Call for Rethinking: National Aids Prevention and Control Policy and Programme’ (mimeo).

    Economic and Political Weekly January 13, 2007

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