by Rajan Gupta, June 2001

HIV/AIDS is simultaneously a medical and a societal problem as well as an indicator of developmental failures. The transmission rate of HIV per sexual intercourse with an infected person is small, yet the global spread has been explosive. The reason for the fast spread is the long, essentially asymptomatic, period between infection and development of AIDS and subsequently death. During this asymptomatic time most people are not aware of their HIV status and can, therefore, continue to transmit HIV to other individuals if their behaviors include risky sex or IV drug use. Since almost all people have sex often, especially during the most productive ages 15 to 49, the virus has found an easy transmission mechanism and created an explosive pandemic. Effective intervention has required a strong national response, and in the western world has relied on a literate population with access to health care. Nation states, especially developing nations, with inadequate basic services like universal primary education and health care, have to think of HIV as a national emergency.

Poverty, addictions, childhood abuse, gender bias, lack of health care and education, cultural norms, taboos, values, discrimination and stigma have all conspired to produce conditions under which risky sex and/or drug use thrives. The degree to which each condition is present and contributing to the spread of HIV varies within a country and between countries. Nevertheless, to fix this global problem will require confronting and dealing with all these issues simultaneously. In developing strategies for prevention, it is not obvious to me that different risks or risk groups should be assigned different emphasis or whether one should think in terms of "Universal Precautions". I briefly debate this issue below and recommend the latter.

I believe our rules for fighting the virus should be simple and universal, much like the virus's mode of transmission. Only the simplest policy applied universally and addressing the core issues has the maximum chance of being adopted and being successful. I have divided the population into three categories, pre-risk, at-risk, and post-risk, and specify action items in each category. While such categorization may seem simplistic, each of the five recommendations will be a departure from current policies (at least in India), and implementing them will demonstrate political will. The down side of such a universal approach is that some risk groups may not get adequate attention. The key distinction here is that while I recommend a Universal national policy, NGOs should be free to, and encouraged to, work with whatever risk groups they feel they are most effective with or motivated to work with.

Policy makers in developing countries that are strapped for resources will challenge the need to regard the spread of HIV as a national emergency. They like to believe that the destruction being witnessed in Sub-Saharan Africa will not reoccur in their country. The point I wish to make is that HIV per se should not be considered as the cause for invoking a national emergency but the lack of basic infrastructure -- education, primary health care, and the political will to focus on these. HIV has simply exposed the vulnerabilities and inadequacies, and any country that fails in providing these, or is politically and economically unstable, will most likely not succeed in controlling the spread of HIV/AIDS. Successful intervention against HIV/AIDS, as outlined in the five recommendations made below, requires a major enhancement of these basic services. The second point I would like to make is that the problem of HIV/AIDS in countries like India is already so large that external agencies, organizations and countries, no matter how well meaning and how generous, can only be the catalysts of change. The monetary and human resources will have to come, predominately, from within; to generate which requires social and political will and commitment.

The three categories and the action items in each category are stated next. Using India as an example, I then provide some justifications for the recommendations.

1. A comprehensive health curriculum taught in all schools to address three related issues that I call the triangle of trouble -- childhood abuse, addictions, and risky sex. The goal with respect to risky sex and HIV/AIDS should be to motivate delay in the start of sexual activity, avoid high risk sexual contacts, and minimize the number of different sexual partners. The students should understand reproductive health and modern methods of contraception and disease prevention. In this context education using audio-visual media will be very effective and has a very high probability of successful assimilation even in village communities.

1. A massive awareness campaign using all forms of media. The minimum should be
   1. A 15 second advertisement on all TV stations every 30 minutes
   2. All newspapers should carry a short awareness message on the front page every day.
2. Availability of condoms as well as access to counseling on reproductive health and addictions should be free, easy, convenient and unrestricted.

1. Free, anonymous, reliable HIV testing at all hospitals and blood banks.
2. Free anti-retroviral treatment for all with opportunistic infections indicative of AIDS, and for HIV+ pregnant women.

The corruption and carelessness with respect to sterilization and blood products has to stop. Unfortunately, it seems that this will only happen when the medical community itself feels threatened, when an aware public demands accountability, and when corruption as a social behavior is no longer accepted. The universal awareness campaign advocated in point (2) should address these issues.

The most captive audience is adolescent boys and girls in schools. At this age they are also the most impressionable, their behaviors can be modified, and emotional issues that lead to risky behavior addressed. The education (awareness) has to comprehensive and address three related issues that I call the triangle of trouble -- childhood abuse, addictions, and risky sex. Most teachers in schools do not feel comfortable or qualified to discuss issues of childhood abuse, sex, and sexually transmitted diseases. Many teachers have preconceived notions of what is appropriate and what is not appropriate to discuss in class, and often have their own biased views. As a result few schools have sustained awareness programs.

While school teachers are the best educators as they can weave the message into all their classes, there are two alternatives to school teachers for providing this information -- external speakers and counselors or electronically accessible material that is mostly audio-visual images for self-study. (Electronic media reduces very significantly the expense of printing books that have hundreds of color photographs and which have to be updated regularly). I have found very few schools that are comfortable with inviting external speakers regularly, and even in these schools the teachers and the management get "bored" after one or two visits because, to them, the material remains the same (they forget that each year there are new students in a given class and that repetition is necessary even with a given class). On the other hand material available on a CD-ROM or through the WEB, which the teachers can use to provide the information and lead a discussion (thereby maintaining some distance from it), can be very effective, especially if it is audio-visual and self explanatory

Another advantage of a mostly visual learning tool is overcoming language barriers. For example, many of the Indian languages do not have a clinical vocabulary for discussing sex, sexuality, and sexually transmitted diseases. Consequently, such discussions are considered vulgar and therefore shunned.

The goals of this curriculum should be to

1. Provide knowledge of the male and female reproductive system, reproductive health, and methods of contraception.
2. Provide awareness on issues of sex and sexuality, and on the understanding, identification, and prevention of the various sexually transmitted diseases.
3. Prevent/Delay start of experimentation with sex, alcohol, and drugs.
4. Understand and prevent childhood abuse that leads to low self-esteem, low self-confidence, and low self-efficacy.
5. Develop communication skills needed to form healthy relationships and for negotiating safe sex.

I believe that just like hospitals follow "Universal Precautions" so too HIV awareness should be universal rather than risk group specific. By this I mean that while individual NGOs may choose to work with specific groups they consider as high risk, the national policy and awareness campaign should be universal. National policy should be designed to ensure two action items. First, awareness of the disease and its methods of transmission, and second, promoting the use of condoms as a habit in the public at large. In fact, unless a couple desires a child, the message should emphasize the use of a condom both as a means of contraception and preventing sexually transmitted diseases. The first action item can be implemented by developing 5-10 very simple 15 second videos that are aired by all TV stations say every 30 minutes. In addition, every newspaper should carry a small awareness message on the front page every day. The second action item is to flood the system with condoms, i.e., make them available without restriction, very easy access, and free. The public will initially rebel and find ridiculous such universal attention, however, after a while the seriousness of the situation will sink in and lead to behavior changes.

I recommend this universal approach because of an obvious problem with targeting high-risk groups -- one has to identity them first. In many cases this is not easy or even possible. Most Indian cities do not have well defined "red-light" areas and even those that do like Delhi, Mumbai, and Calcutta have a significant fraction of the sex workers that are dispersed and do not identify themselves as such. Also, many sex workers are migrant or atypical in that they have sex for money only when they have an emergency that requires money in hand to solve. Similarly, most MSM (men having sex with men) and IV drug users prefer to remain anonymous. Another problem with dividing populations by risk category is that society is not static -- a low risk rural farmer can become a high risk urban slum dweller or a truck driver essentially overnight. Other issues that arise when one focuses on targeting high-risk groups are the resulting social isolation and stigmatization, and the lack of appreciation of the risk by those who do not belong to these groups and therefore do not consider themselves at risk. One must not loose focus of the fact that it is high risk behavior that leads to HIV infection and not belonging to a high risk group.

Another purpose of such a universal and sustained message is to impress the need for using sterilized instruments and clean blood supply upon the medical community. Emphasizing high-risk groups has led the medical community to believe that corruption and carelessness by them will not affect them or their families. Also, by marginalizing and stimatizing high risk groups, we remove their voice and ability to demand their rights. The medical community, which already feels special and above question because of the huge unmet demand for health care, do not fear legal action even when their behavior towards high risk behavior patients is criminal.

I do not wish to imply that high risk groups, once identified and known, should not be given special consideration. Experience in different countries and with different kinds of high risk groups shows that the best approach and strategy should be to develop peers as educators and intervention workers. It is important to recognize that these communities were marginalized, stigmatized, often without rights to implement behavior changes, and abused even before HIV. Attention from unsympathetic, forceful, critical, and moralizing intervention workers only helps push them underground. Developing, training, and funding peer groups is the most effective, and over the long haul, perhaps the only solution.

Access to condoms and familiarity with their use should be universal -- in fact, only by flooding the system with condoms will we start to impress upon the people the gravity of the problem. Condom distribution programs are, today, sporadic -- NGOs get condoms to distribute for a few months and then nothing for few months when the government (or their suppliers) supplies or budget runs out. Most sex workers are too poor to afford condoms (the cost is a significant fraction of their earnings, and often leads to a choice between food or condoms). Studies show that condoms must be used in over 90% of sex acts by sex workers and their clients to stop the spread. Thus, maintaining uninterrupted supply and flooding the system is essential. In short, I believe that to accelerate the development of safer sexual habits we must spread awareness by sustaining the message; make availability of condoms easy, free, and commonplace; and ride out the initial protest and ridicule against such an universal approach. Such a policy will not only reduce the spread of HIV/AIDS but of all sexually transmitted diseases including Hepatitis B and C, which today are more prevalent than HIV/AIDS in India. (Thailand has shown success in containing HIV and STD spread through a vigorous condom campaign).

Globally, today, each individual has no choice but to use condoms during all sexual encounters other than in a stable, one-to-one, long term relationship (for example a faithful marriage). In fact, in many societies most affected by, and vulnerable to, HIV/AIDS, wives have few rights or opportunities for negotiating protected sex even when they know their husbands are infected. Thus, only by sustaining a universal message that promotes the use of condoms for all sex do we stand a chance of reducing the rate of spread in the near future, i.e., without waiting for a social transformation to an enlightened and responsible citizenry first.

Historically, humans have modified behavior in response to threats or opportunities. Examples are: we started using door locks, solid walls, and guards to protect our families and belongings as small communities with close ties grew into large cities; extensive purification of water as pollution spread; seat belts in automobiles as roads became more crowded and automobile speeds increased. None of these behaviors carry stigma or are considered taboo and yet the change took decades. HIV is forcing a change in our sexual behavior, an aspect of our lives that is considered private and about which education or even discussion is still considered taboo in most societies. Such a change in behavior, leading to a life-saving habit, has very close parallels to the use of seat belts to counter the loss of life in road accidents due to the increase in the number of cars on the road, their speed, and the presence of drunken drivers (I find this analogy very effective when talking to school students in the US and the upper crust students in India who have access to cars). Unlike seat belts, one cannot mandate the use of condoms, consequently the awareness campaign has to be pervasive and persistent. Nations failing to imprint the need for using condoms to protect against STIs on their citizens will have to deal with an increasing fraction of population that is HIV infected.

Testing and treatment (including the associated counseling) are two integral components of care for the afflicted. Without adequate testing facilities people are reluctant to and do not feel empowered to get tested, and without access to treatment people have no incentive to get tested until they are so sick that they have to be hospitalized. This is the current pattern -- people are diagnosed in late stages of the infection when they have AIDS or are close to it. Since, to detect HIV requires a specific blood test and the treatment is complex (ARV medicines have many very toxic side effects and effective therapy requires that appropriate combination of drugs and dosages be determined by trial. Because of the toxic side effects compliance with the drug regimen has been hard for people even in the developed countries), medical infrastructure is necessary for both testing and treatment. India has a medical infrastructure, albeit inadequate (grossly so in rural India) and often inefficient and corrupt. Nevertheless, one has no choice but to engage the doctors and utilize the existing infrastructure for it is completely unreasonable to contemplate that one can or will create a new, better system to respond to HIV in time. The best one can hope for is to strengthen and enhance the present system. Given the scarcity of resources -- both money and committed people -- the question becomes how much resource for testing and how much for treatment?

There can be no credible response to the spread of HIV without reliable testing that is readily available. Furthermore, one has to hope that no more than 5% of those testing will turn out to be HIV+ otherwise the pandemic would already be out of control. Assuming that there are roughly 400 million people that are sexually active, India alone must have the capacity to test at least 20-50 million people per year, in addition to the tests being done by the blood banks.

The issue of whether HAART is administered properly and is the patient better off with or without HAART should be left to individual cases. Debate on this question really challenges the reality of whether there exists a health care system and not the toxicity of the drugs. My belief is that only by providing treatment will we engage and strengthened the medical system. Sure there will be misuse, an obvious symptom of an inadequate and corrupt system, but only by providing HAART and engaging the medical system will we turn HIV/AIDS into another life threatening terminal disease to which the community responds in time. (example: Brazil). However, the cost of HAART is prohibitive for most developing countries. Assuming a total medical cost of $1000.00 per patient per year (with roughly $400 for ARV medicines as promised by CIPLA, AUROBINDO, and other Indian pharmaceutical companies), the entire budget of the health ministry of India (Rs 13 billion) could provide for only 250,000 patients, a mere 6% of the estimated number of HIV+ people. Nevertheless, ignoring the issue or further delay will only make the situation worse.

In short, the global society has to start providing free (or very low cost) HAART to all HIV+ patients that display symptoms of the class of opportunistic infections typically indicative of AIDS. Waiting to develop the capacity for optimal medical facilities, and testing for CD4 cell count and viral loads for tens of millions of poor HIV+ people, will prove disastrous. International agencies, and developed countries can do a lot to share the burden, both financially and in volunteering caring committed people, nevertheless the war against HIV/AIDS will be won only when all nations assume responsibility and each considers it a national emergency.

To summarize, my final recommendations for testing and taking care of those already infected are (i) Every hospital should provide free and anonymous HIV testing, and (ii) HAART should be available free to every HIV+ patient (at the very least for those with serious opportunistic infections or those diagnosed with AIDS) and to prevent mother to child transmission. In a resource strapped developing nation implementing these recommendations is fundamentally an issue of setting priorities and generating the will to accept the cost for developing the necessary infrastructure. This investment should not be regarded as wasted money because the benefits are far more widespread and long lasting than just controlling HIV. Lessons from sub-Saharan Africa tell us that, today, all countries have no choice but to act strongly and decisively; procrastinating will only make the problem worse. I believe that the money is there, what are missing is the political will, committed people, and societies that take ownership for their welfare.

Rajan Gupta