Thirty years back a World Summit of Ministers of Health on programmes for AIDS prevention decided on observing December 1 as the World AIDS day. Since then, specific themes are chosen every year to drive home the messages of prevention, treatment and fighting stigma and discrimination associated with AIDS. This year the theme is ‘know your status’ which signifies universal testing followed by treatment of those who are tested positive.

In the last 30 years, no other disease control programme has attracted such global attention as AIDS.

Several other firsts were a UN General Assembly Special Session (UNGASS) on AIDS in 2000, a Security Council resolution treating AIDS as a security issue, and a special Global Fund to finance AIDS programme along with TB and Malaria disbursing about $20 billion for AIDS programmes alone. But the real game changer was the strong involvement of civil society, especially of marginalised communities like sex workers, transgender population, gay men, people who use drugs and people living with HIV/AIDS. The cumulative effect was a greatly reduced mortality due to AIDS related illnesses, from a high of 1.5 million in 2000 to 9,40,000 in 2017.

The incidence of HIV, the new infections occurring every year, has also registered an impressive decrease from 0.49 per thousand adults in 2000 to 0.33 in 2010.

But instead of keeping the pedal pressed on reduction of new infections, the global programme lost direction around that time. When both prevention of new infections and saving lives of infected people should be twin priorities, the emphasis has decisively shifted to treatment. An entire spectrum of anti- retroviral drugs came into the market and donors started investing in treatment programmes focussed on generalised epidemic countries in sub-Saharan Africa. UNAIDS has kept 90-90-90 as their top priority focussing on testing, treatment and viral suppression as the three nineties.

Somewhere in this process, the agenda of reduction of new infections among key populations who were bearing the brunt of the epidemic was relegated to low priority in national programmes. To make matters worse, the legal environment surrounding these populations has turned increasingly hostile, despite clear evidence from the Global Commission on HIV and Law that improving the legal environment alone could save up to one million new infections every year. Same sex relations, transgender identity and sex work have all come under increasing pressure of criminalisation driving these populations underground.

Prevention programmes have lost their effectiveness for the same reason why they were initially successful. Access to affordable prevention devices like condoms, needles and syringes greatly suffered in the last six to seven years. Funds for prevention programmes have dried up and the meagre amounts earmarked never reached the implementers. Several civil society organisations who did admirable work earlier have simply folded up for want of adequate financial support. Programme management for prevention has been the biggest casualty as interventions were left in the hands of inexperienced programme managers.

Worrying signs

The results are there to show. The rate of decrease of new infections started slowing down since 2011 and has virtually plateaued in the last three to four years. The cumulative decrease of new infections from 2010 to 2017 was just 18 per cent, a little more than 2 per cent per year. Global HIV incidence still stands at an unacceptably high 1.8 million as revealed by UNAIDS in its latest estimate. Short of a miracle, nothing can reach us to the global fast track targets of reduction of new infections by 85 per cent by 2020. And the goal of ending AIDS by 2030 appears that much farther away.

Instead of slogans and messages, what is needed now is hard core programming for prevention, principally focussing on populations vulnerable to HIV. We should not forget that an entire new generation has been borne without any prevention messages on responsible sexual behaviour and harm reduction. Awareness levels need to once again reach new heights which were earlier achieved in the first 10 years of the new millennium.

Instead of pitting prevention against treatment, global managers need to advocate equitable allocation of resources for preventing new infections and for keeping people alive, healthy and empowered. AIDS programmes around the world need to be brought on track. That will be a true World AIDS Day message.

The writer is a former Union health secretary

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