JOIN USRecognising the social basis of the prevention of disease is critical to formulating policy for ensuring preventative care, treatment and cure. Indifference to the social dimension of public health can prove costly. In the case of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), this is evident from the dramatic rise in infection across the developed and developing world.
According to UNAIDS, globally, in 2015, 36.7 million people were living with HIV and 2.1 million of those people had become newly infected with HIV. National governments, international agencies and non-governmental organisations (NGOs) have relied on a variety of prevention strategies. Efforts increasingly include involvement of the ‘community’ – high risk groups and people living with HIV. Participatory approaches at all levels of programme planning, implementation and review has been the goal.
For instance, in India, much impetus has been provided by the National AIDS Control Organisation (NACO) as well as others such as the Bill and Melinda Gates Foundation to mobilise high risk groups such as women sex workers, and create community organisations through NGOs. According to NACO’s (National AIDS Control Organisation) State Fact Sheet, the adult HIV prevalence at the national level has steadily declined from an estimated level of 0.41% in 2001 through 0.35% in 2006 to 0.27% in 2011. This is indeed heartening assuming the data are reliable.
However, in order to avert any increase in the incidence of HIV, the national and state governments and other agencies must keep their feet on the pedal, particularly in high prevalence states such as Karnataka where the prevalence rate of 0.52% (2011) is much higher than the national rate. In my opinion, four key strategies are crucial for HIV prevention efforts in Karnataka.
First, there is an urgent need to closely examine the funding of prevention programmes by the government and other agencies. There is no doubt that significant work on HIV prevention – periodic testing, provision of rights to government aid such as ration card, interventions to address violence – is in progress in Karnataka. However, dwindling resources is affecting programme activities. “Unlike in the past, we do not have adequate money to organise review meetings of peer educators or outreach workers to assess the contacts they’ve made,” said a woman I met at a community organisation.
The effect of withdrawing resources and expecting community organisations to mobilise adequate resources to sustain activities over a short period can prove costly in the long term. It can, among other things, lead to reduced outreach efforts and limit the ability to contact new entrants into sex work that in turn can raise rates of HIV incidence.
Resources from the government and/or international agencies must flow continuously to ensure sustained prevention activities. Committing funds for specific interventions for a relatively short period of time – two or three years – overlooks two issues.
One, it obfuscates the need for long-term funding for key activities such as testing, outreach work and preventing, rather than addressing, violence. So identifying key activities that require continuous funding is crucial. Two, government and international agencies should consider a phased withdrawal of funding for other HIV prevention activities rather than abruptly ending programmes. A phased withdrawal will ensure that implementing agencies and community organisations are not starved for reso-urces and do not cease prevention activities.
Multi-agency consortium
Second, leadership for handling HIV prevention activities across multiple agencies – state, NGOs, and international bodies – is much needed. Currently, multi-agency implementation in the state is like lateral organising with no one at the helm to steer it. Creating a consortium and planning collaborative activities among the agencies can lead to more effective use of resources.
Third, the government and international agencies must consider addressing issues of risk and assessment of effectiveness of capacity building through rigorous research. A specific objective of the National AIDS Control Programme Phase III (2007-11) was to decentralise HIV prevention efforts to local levels, with increased attention to building the capacities of community organisations that would direct interventions and activities.
As my ongoing research shows, community organisations provide high risk groups with a vehicle for effective self-mobilisation to access prevention services; and serve as a space for sharing information about prevention and treatment. But constant capacity-building of members, as local leaders, is critical for creating an enabling environment that is free of suspicion or fear of violence and marginalisation.
Violence – in the private and public sphere – raises risks to HIV and needs deeper interrogation for developing prevention mec-hanisms. While agencies continue to organise training and workshops for building leadership and addressing violence, little rigorous research is available to understand the impact of these programmes.
Research can be useful for determining where to invest resources and how to shape additional programmes. But designing research, gathering data and undertaking systematic analysis needs trained, experienced researchers who know the local language and context. Such people should be given the space to conduct unbiased research.
Finally, political will and commitment is key for considering path-breaking shifts that will consolidate HIV prevention activities in the state. Denial of incidences of HIV by limiting resources for prevention interventions, failing to hold a specific agency or organisation as a leader responsible for prevention activities through the creation of a consortium, and making programmes unimportant by delaying release of funds can have an adverse effect on current declining trends of HIV incidence. Therefore, state accountability is central for continuing to arrest rates of infection.
(The writer is Associate Professor, Department of Sociology, Purdue University, West Lafayette, USA)