The National AIDS Control Organisation (NACO) under the Health Ministry has just announced the latest set of HIV estimates for 2017 for India. The estimation process has been refined further by following the latest Spectrum modelling and using data from two successive rounds of National Family Health Surveys (NFHS) to present the most accurate data sets for prevalence, incidence and mortality due to HIV/AIDS.

For the first time, sub-national data at the State level has been made available on all indicators in a fairly accurate form.

All this is good news. At a time when governments world over hold HIV and other epidemiological related information close to their chest and do not share it even with national civil society organisations, NACO has consistently been adopting an open and transparent process not just for announcing the HIV estimates but even for analysis, modelling and projection into the future. This healthy trend was started in early 2000 and it goes to the credit of former Prime Minister AB Vajpayee to be the first to openly announce the national HIV estimates for India.

Not a happy picture

Coming to the results of the survey, they have been particularly chastening. For the last 15 years, India has been reporting a progressive decline in incidence rates which indicate the new HIV infections which get added year after year. For the first time, NACO has announced that the new infections in 2017 have not fallen — in fact they have increased from 86,000 in 2015 to a little more than 87,000 in 2017.

The prevalence levels, which show the total number of HIV infections in the country, have also marginally increased to 21.40 lakh. The mortality rates, which show the number of people who died of AIDS, have of course shown a significant and consistent fall, thanks to the highly successful treatment programmes implemented by NACO covering around 1.1 million people.

The sudden increase in the incidence rates has not come as a surprise to many. The trend of slowing down of the rate of decrease started since 2012 when the national response to AIDS started slowing down. The 2017 report shows that the new infections have fallen by only 27 per cent from 2010 to 2017 averaging a low 4 per cent per year decrease.

Fund crunch

First came the fund crunch, the programme not getting full funding based on cost estimates for prevention. Then came the administrative changes governing the AIDS control programme and, most importantly, the disengagement of civil society partners in the implementation of prevention programmes. Funds have not reached agencies implementing prevention programmes and many of the targeted interventions (TIs) have closed down, leaving the beneficiaries without any prevention services.

Despite strong evidence presented by successive expert committees on the need to bolster prevention efforts by increasing TI coverage among vulnerable populations, prevention continued to suffer due to inadequate funding and bottlenecks in fund flow.

This has resulted in new infections virtually plateauing in the last five years and it was only a matter of time when new infection rates would have jumped again. And it has proved to be true.

India cannot take comfort from the fact that it is a global phenomenon that HIV incidence has virtually plateaued not just in many high burden countries but in the developed world too. Much of it is because governments have declared victory much earlier when mortality rates started falling because of higher levels of ART coverage. External donors and UN bodies have also played their part by branding treatment as prevention and not laying adequate emphasis on primary prevention to ‘close the leaking tap’.

Primary prevention

India has the best evidence to show that primary prevention works, especially when it is focussed on vulnerable populations who stand a higher risk of getting infected by HIV. It would have been natural to keep the pedal pressed on prevention and provide full funding support to prevention interventions. But these very programmes suffered funding crunch and lost effectiveness in reducing new infection rates.

The national AIDS control programme faces the twin challenge of lack of visibility and sub-optimal funding.

An alternative approach is to bring convergence with national TB control programme which is an equally large and important national programme. An expert committee appointed by the Health Ministry recommended specific measures to bring convergence between HIV and TB programmes which are awaiting implementation. The strong commitment from the Prime Minister for elimination of TB by 2025 is a great opportunity which should be utilised to bring in a resurgence in response to control both these dominating epidemics in India.

Health systems

It is a common argument of public health experts that all interventions, including control of major diseases, should be delivered through the health systems. Ideally this should be the case. But with a weak health system in major parts of the country and with new responsibilities like Ayushman Bharat getting added to it, the health system in India is not in a position to achieve time-bound results in disease elimination.

Leprosy Elimination, which was achieved nationally in 2006, has also suffered a setback after the programme was merged with the general health system. Evidence shows that the annual case detection rate and prevalence rate for leprosy have plateaued in the last ten years with States like Chhattisgarh and Odisha maintaining higher rates of prevalence than the national average.

The strong remarks of the Supreme Court about neglect of leprosy elimination after merger with health systems point to the need for a rethink on this approach.

Elimination of major diseases like AIDS and TB will be possible only through a governance model which adopts a focussed approach with greater involvement of community-based organisations and the private sector. It is time the Centre adopts this approach to bring the incidence levels of HIV and TB significantly below the present levels in the next two to three years. Else, ending of AIDS by 2030 may become a receding target.

The writer is a former Secretary, Ministry of Health and Family Welfare, Government of India.

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