Halving the number of infected persons is a statistical trick. the prevalence may not have come down; the new and old estimates cannot be compared.
Mihir Srivastava reports:
Data from endemic, high prevalence states has been extrapolated to states like UP and Bihar to arrive at the figure
THE NEWS that India does not have the world's biggest HIV-positive caseload, and is less affected than South Africa and Nigeria, has produced its share of sighs of relief, but experts and activists are questioning the easy conclusions being drawn from the new data. While launching the third phase of the National AIDS Control Programme on July 6, 2007, the Minister for Health and Family Welfare, Dr Anbumani Ramadoss announced a dramatic fall in the estimated HIV+ population in India: 2 million to 3.1 million people infected with a prevalence level of about 0.36 percent, against the previous estimate of 5.7 million cases with a prevalence rate of 0.9 percent.
The new statistical methodology adopted this time to estimate HIV+ prevalence in India is said to have made all the difference. The new estimate is based on the National Family Health Survey (NFHS), which is a countrywide household survey covering about 2,00,000 people aged between 15 and 54, and was conducted through face-to-face interviews across India between December 2005 and August 2006. Also, the data from sentinel surveillance (prenatal clinics, sexually transmitted infection clinics and public hospitals) has been expanded to 1,122 sites from the earlier 703.
Ramadoss tried to score a point by saying: "We have always been faulted for underestimating the seriousness of the epidemic. That was a disturbing allegation as we were, and continue to be, very committed to containing and reversing the HIV AIDS epidemic." He, however, warned that the two sets of figures cannot be compared to show that there has been a steep decline. "These figures are not comparable. By using the same methodology for the past years that we used this year, there is only a marginal reduction in the prevalence," he clarified.
The implication is clear. There is no significant downfall in the HIV+ population. It is just a new estimate using a new method that is dubbed to be more reliable. "We should look at these figures with a pinch of salt," says Ashok K. Rau of the Freedom Foundation, a self-help group working with HIV+ people. "Different sets of people will arrive at different figures using the same data. It all depends on how it is treated statistically, on what assumptions are made. It is no surprise that the same data can be used to arrive at a higher figure than the last time. I will call it no more than another guesstimate."
Ashok Alexzander , the director of Bill and Melinda Gates Foundation's HIV/AIDS prevention initiative in India, Avahan, agrees that the fresh estimate indicates no trend. "The change in figure does not at all show a fall in the number of HIV+ cases. It's a new estimate with NFHS data, which is supposed to be more reliable. But it gives a clearer picture with southern states showing alarming figures with some hot spots in the northern states."
YOUR GUESS MY GUESS THEIR GUESS
TOTAL AFFECTED 5.7 million (Old estimate) 2.47 million (New estimate)
PREVALENCE RATE 0.9 % (Old estimate) 0.3 % (New estimate)
FUNDING IMPACT
The two figures are not comparable as different methodologies have been followed to arrive at them. The government is still to provide details of the new methodology used this time. For this reason the figures do not represent a decline, they are merely a new estimate that the government claims to be more reliable
NGOs are skeptical about the new estimate. They want more information on the new methodology adopted and demand aggregate data that has always being kept under wraps. They are apprehensive that this sudden fall in estimated numbers of HIV+ people will adversely affect the funding of AIDS mitigation efforts.
Anand Grover of the Lawyers' Collective says there might have been an over estimation of HIV+ population in India in the past, but questions the labelling of the new exercise as a more reliable estimate. "They say the earlier estimates were not so reliable, this one is more reliable. But nobody tells what was wrong with the earlier methodology. What changes have been made to arrive at this new figure? The primary data is never shared with NGOs, it is with agencies like NACO, UNAIDS or Bill and Melinda Gates Foundation," he says.
Rau points to the fact that data collected from endemic, high prevalence states has been extrapolated to other states to arrive at the figure. "It does not take into account states like UP and Bihar, which have huge populations and not much is known about them," he says.
There is still a paucity of reliable data on high-risk groups like sex workers and drug addicts using syringes. Says Vivek Diwan, lawyer and activist on HIV/AIDS issues, "There is little information on what is happening to vulnerable groups. This is crucial. It is important to provide these vulnerable groups with counselling. The level of literacy is shocking in these groups." Agrees Alexzander, "We are carrying out studies on high-risk groups that would provide vital information to design our mitigation response."
THE CHIEF of the National AIDS Control Organisation (NACO), Sujatha Rao, said the figure "has come down" and not merely been "re-estimated to be less", despite her minister Ramadoss saying that the two estimates were not comparable. "Even as the general prevalence is reported to have come down, the trends of HIV infection continue to remain the same. It's more in rural areas and amongst women," Rao said in a speech. Peter Ghys, in-charge of epidemic and impact monitoring at UNAIDS, seconded Sujatha Rao's claim. "We are today a lot more confident that what is being presented to you is closer to the true prevalence as it exists in the population," Ghys said.
There are concerns that the revised estimate increases chances of large pharmaceutical firms securing patents for essential AIDS drugs. "If more than one percent of population was HIV+ an epidemic would have been declared. This was very much on the cards with 0.9 percent of the population estimated to be HIV+. If the figure wasn't revised downwards it would have hampered the granting of patents on AIDS drugs," said a senior functionary in the Ministry of Health and Family Welfare.
NGOs say the new estimate will adversely affect the funding of Aids mitigation projects. "The reduced numbers will definitely mean reduced funding for AIDS-related projects that till now have been a major money spinner for NGOs," says Grover. "More numbers means more money," agrees Chandran. Alexander, however, doesn't see a decline ahead in support from international donor agencies. "I do not think so because the numbers are still very high. In fact, there is a greater need for funding in India. In per capita terms, India is getting less than countries like China and Cambodia," he said. Meanwhile, HIV+ patients remain, at best, confused.
Monday, July 16, 2007
Monday, July 9, 2007
HEALTH MINISTER LAUNCHES THIRD PHASE OF NACP
Friday, July 06, 2007
Ministry of Health and Family Welfare
HEALTH MINISTER LAUNCHES THIRD PHASE OF NACP
18:15 IST
Minister for Health & Family Welfare, Dr. Anbumani Ramadoss launched the third Phase of the National AIDS Control Programme (NACP), here today. *Speaking on the occasion, he said that there are an estimated 2 million to 3.1 million people infected with HIV/AIDS with a prevalence level of about 0.36%. He was optimistic of the country’s ability to win the battle against AIDS.
*
Smt. Panabaka Lakshmi, Minister of State for Health & Family Welfare, Shri Naresh Dayal, Secretary, H&FW, Ms. K. Sujatha Rao, AS&DG (NACO) and Representatives of the UN Group, World Bank, DFID, GFATM, USAID and Private Foundations also attended the function.
The following is the text of the Minister’s speech:
“I am indeed very happy to be here today with you all to launch the Third Phase of the National AIDS Control Programme. Today is a momentous day for all of us present here as it brings us to the end of one critical phase in the evolution of our battle against HIV AIDS. The strategies and approaches outlined in the NACP III indicate the maturity of the epidemic and the vast improvement in our knowledge of this disease which continues to challenge our ability to find a cure. I am also happy to note that the NACP III is founded on the important principle of equality and inclusion, demonstrated by giving primary focus to prevention and behaviour change among the high risk groups through a process of empowerment.
There is one other reason to be happy today. Many of you know how we have always been found fault with for underestimating the seriousness of the epidemic. That was a disturbing allegation as we were and continue to be very committed to containing and reversing the HIV AIDS epidemic. Today we have with us a far more reliable estimate of the burden of HIV disease in India. These estimates are based mainly on two important sources of data. First, we continue to have the data from our sentinel surveillance, now expanded to 1122 sites from the earlier 703 sentinel sites. This year we have the additional inputs from the National Family Health Survey, which is a country wide community based household survey.
Experts from India and round the world were consulted and after a lot of hard work and outstanding support from the WHO, UNAIDS, CDC and other partners, we have been able to arrive at robust figure that all our experts feel is as correct an estimate as we can get. The results show that there are an estimated 2 million to 3.1 million people infected with HIV/AIDS with a prevalence level of about 0.36%. While the prevalence appears to be less than the previous estimate of 0.9%, these figures are not comparable. By using the same methodology for the past years that we used this year, there is only a marginal reduction in the prevalence. Moreover, in terms of human lives affected, the numbers are still large and worrying. There is no doubt in my mind that we cannot let down our vigil but continue to work hard to ensure that the HIV/AIDS are under total control.
If I am sounding optimistic of our ability to win this battle, it is because the programme has achieved its aim of keeping the HIV sero-prevalence below 5% in the high prevalence states and below 3% in the moderate prevalence states and below 1-2 % in the other states. A case in point is Tamil Nadu which has shown a consistent decline in HIV prevalence in the last 5 years. The surveillance reports of 2006 reinforce the fact that expected outcomes of NACP were broadly accomplished.
Major policy initiatives were launched in NACP II. Initiatives such as the National AIDS Prevention and Control Policy, National Blood Policy, provision of Antiretroviral Therapy (ART), strategy for Greater Involvement of People with HIV/AIDS (GIPA) were initiated during the NACP II. Programmatically, we achieved good results. 1033 Targeted Interventions were implemented through NGOs among high risk groups and bridge populations. Facilities providing voluntary counseling and testing (VCT) and prevention of parent to child transmission services (PPTCT) were remodeled as ‘Integrated Counseling and Testing Centres’ (ICTC).
NACP II saw a massive scale up of counselling and testing services and today more than 10 million people have been counseled and tested in more than 4000 ICTCs spread throughout the country. The NACP III now envisages expansion of testing sites to 5000 and establishing another 10,000 through a system of franchising by forging partnerships with the private sector. Such expansion is necessary to achieve 42 million tests by the end of NACP-III. Launching the provider initiated testing and counseling for patients referred from clinics treating tuberculosis, STD or pregnant women in high risk areas will also help us identify persons infected by this virus. These measures will not only strengthen the prevention and control of HIV/AIDS but also be beneficial to the health outcomes of people living with HIV/AIDS.
Blood safety was a major area of focus in NACP II and modernization of blood banks and installation of blood component separation centres were taken up. Through these efforts, we have brought down the transmission of HIV infection through contaminated blood to less than 2%. But we have a long way to go in this area. We have yet to satisfactorily address the critical issues of volume, access and quality of blood. There is a lot of private blood collection and also a shortage of blood. This year, we will be initiating action to establish 4 centers of excellence in the four metros that will have a capacity to collect and process one lakh units of blood annually.
To address the various issues related to blood collection, storage, distribution and supply, we are working on a regulatory framework to establish a Blood Transfusion Authority on the lines of the FDA. I am confident that in the next couple of years, we will be able to have a world class system of blood collection and distribution. This will help bringing down blood transmissible diseases such as HIV and Hepatitis B etc.
Condoms, as you know, is the only prophylaxis we have with us to check transmission of sexually transmitted infection. Its promotion is essential in India as it has multiple uses – it can avert an unwanted pregnancies as well as stop the spread of sexually transmitted diseases. Though some work was done to promote the use of condoms, it is inadequate. I am pleased to learn that under NACP III, condom availability and use will be significantly scaled up. I am happy to learn that the Gates Foundation is providing us funding support to establish a professional group to help us expand the market for condoms. Promoting condom use is important. Thailand is now facing the possibility of a resurgence of the HIV epidemic because they gave up prevention and condom promotion and focused only on treatment. So also China. Non-emphasis on condoms is resulting in the gradual increase of HIV due to unsafe sex. This is the same story in Nagaland where we neglected the promotion of the condom and are today facing the spread of HIV on account of unsafe heterosexual behaviour.
With young men and women bearing the brunt of the disease burden, it is essential that we educate our youth on healthy lifestyles. While good work was done under NACP II in training 2 teachers and 2 students in all the 1.4 lakh high schools we need to do more. We are therefore, currently working on coming up with a health education package that will focus on healthy lifestyle which will say no to unsafe sexual behaviour, no to tobacco, no to alcohol and no to drugs. We hope to harness the abundant energies of youth, as has been done in Tamil Nadu, in combating HIV/AIDS.
While, prevention will continue to be the mainstay of the NACP III, strategy and focus on saturating coverage of an estimated 4 million high risk groups, continued attention will also be on providing care, support and treatment to the infected. The ART programme which was launched in 2004 brought hope and expectation in lives of thousands of people living with HIV/AIDS. The ART programme has been rapidly scaled up. Today about 80,000 patients are accessing free treatment in 127 centers. This year another 36 centers are going to be established. Efforts are being made to identify centers closer to the community level to make it easier for patients to get their refill of drugs and save them time and money spent on coming all the way to the ART center. Such decentralization of drug distribution will greatly enhance adherence, reduce loss to follow up and alleviate the economic hardship of the PLHA’s. I do hope these centers attached to the ART centers will come up soon.
India was a global leader in coming out with the treatment protocols for children. Since the launch of the Pediatric AIDS Initiative on 30th November, we have more than 6000 children on treatment and 12,000 diagnosed.
I would also like to reiterate that HIV/AIDS is not just a public health problem. It is a disease that is the result of deeply rooted socio-economic conditions and cultural beliefs, practices, attitudes and vulnerabilities. The virus spread in India mainly through the heterosexual route. Sexual behaviours and choices are an intensely private matter and difficult to change. At one level we have easy access to information though internet, rapidly changing values and attitudes as depicted in modern cinema and the TV, greater mobility etc. and greater impoverishment and unmatched aspirations at another level are factors that contribute to enhancing risk and increasing vulnerability to this infection. We cannot, therefore, let our guard down. _We need to understand the significance of the presence of the virus in some 20 to 30 lakh people in the country against the backdrop that we also have a very high population of young and sexually active persons.
_
Of utmost importance is fighting stigma and discrimination. Even as we are celebrating our successes, we need to also feel a sense of shame that we as a society continue to lack compassion and stigmatize those who have the misfortune of being affected by this disease. Be it the incident of little children in Kerala being denied admission or the one in Meerut being denied medical care, it is indeed unfortunate. I would like on this occasion to appeal to all my fellow colleagues in the medical profession to live upto their oath of treating all those who suffer disease and sickness on equal grounds. I appeal to all faith based organizations and civil society organizations to come forward and help us to fight irrational attitudes of stigma against PLHAs.
I would like to thank all the media, the donor partners, the PLHA networks and the NGO’s for all the support that they have been giving us in our fight against HIV /AIDS. We value their support and understanding that they have extended to us. I do hope that this partnership will continue and the NACP III will be implemented successfully”.
Ministry of Health and Family Welfare
HEALTH MINISTER LAUNCHES THIRD PHASE OF NACP
18:15 IST
Minister for Health & Family Welfare, Dr. Anbumani Ramadoss launched the third Phase of the National AIDS Control Programme (NACP), here today. *Speaking on the occasion, he said that there are an estimated 2 million to 3.1 million people infected with HIV/AIDS with a prevalence level of about 0.36%. He was optimistic of the country’s ability to win the battle against AIDS.
*
Smt. Panabaka Lakshmi, Minister of State for Health & Family Welfare, Shri Naresh Dayal, Secretary, H&FW, Ms. K. Sujatha Rao, AS&DG (NACO) and Representatives of the UN Group, World Bank, DFID, GFATM, USAID and Private Foundations also attended the function.
The following is the text of the Minister’s speech:
“I am indeed very happy to be here today with you all to launch the Third Phase of the National AIDS Control Programme. Today is a momentous day for all of us present here as it brings us to the end of one critical phase in the evolution of our battle against HIV AIDS. The strategies and approaches outlined in the NACP III indicate the maturity of the epidemic and the vast improvement in our knowledge of this disease which continues to challenge our ability to find a cure. I am also happy to note that the NACP III is founded on the important principle of equality and inclusion, demonstrated by giving primary focus to prevention and behaviour change among the high risk groups through a process of empowerment.
There is one other reason to be happy today. Many of you know how we have always been found fault with for underestimating the seriousness of the epidemic. That was a disturbing allegation as we were and continue to be very committed to containing and reversing the HIV AIDS epidemic. Today we have with us a far more reliable estimate of the burden of HIV disease in India. These estimates are based mainly on two important sources of data. First, we continue to have the data from our sentinel surveillance, now expanded to 1122 sites from the earlier 703 sentinel sites. This year we have the additional inputs from the National Family Health Survey, which is a country wide community based household survey.
Experts from India and round the world were consulted and after a lot of hard work and outstanding support from the WHO, UNAIDS, CDC and other partners, we have been able to arrive at robust figure that all our experts feel is as correct an estimate as we can get. The results show that there are an estimated 2 million to 3.1 million people infected with HIV/AIDS with a prevalence level of about 0.36%. While the prevalence appears to be less than the previous estimate of 0.9%, these figures are not comparable. By using the same methodology for the past years that we used this year, there is only a marginal reduction in the prevalence. Moreover, in terms of human lives affected, the numbers are still large and worrying. There is no doubt in my mind that we cannot let down our vigil but continue to work hard to ensure that the HIV/AIDS are under total control.
If I am sounding optimistic of our ability to win this battle, it is because the programme has achieved its aim of keeping the HIV sero-prevalence below 5% in the high prevalence states and below 3% in the moderate prevalence states and below 1-2 % in the other states. A case in point is Tamil Nadu which has shown a consistent decline in HIV prevalence in the last 5 years. The surveillance reports of 2006 reinforce the fact that expected outcomes of NACP were broadly accomplished.
Major policy initiatives were launched in NACP II. Initiatives such as the National AIDS Prevention and Control Policy, National Blood Policy, provision of Antiretroviral Therapy (ART), strategy for Greater Involvement of People with HIV/AIDS (GIPA) were initiated during the NACP II. Programmatically, we achieved good results. 1033 Targeted Interventions were implemented through NGOs among high risk groups and bridge populations. Facilities providing voluntary counseling and testing (VCT) and prevention of parent to child transmission services (PPTCT) were remodeled as ‘Integrated Counseling and Testing Centres’ (ICTC).
NACP II saw a massive scale up of counselling and testing services and today more than 10 million people have been counseled and tested in more than 4000 ICTCs spread throughout the country. The NACP III now envisages expansion of testing sites to 5000 and establishing another 10,000 through a system of franchising by forging partnerships with the private sector. Such expansion is necessary to achieve 42 million tests by the end of NACP-III. Launching the provider initiated testing and counseling for patients referred from clinics treating tuberculosis, STD or pregnant women in high risk areas will also help us identify persons infected by this virus. These measures will not only strengthen the prevention and control of HIV/AIDS but also be beneficial to the health outcomes of people living with HIV/AIDS.
Blood safety was a major area of focus in NACP II and modernization of blood banks and installation of blood component separation centres were taken up. Through these efforts, we have brought down the transmission of HIV infection through contaminated blood to less than 2%. But we have a long way to go in this area. We have yet to satisfactorily address the critical issues of volume, access and quality of blood. There is a lot of private blood collection and also a shortage of blood. This year, we will be initiating action to establish 4 centers of excellence in the four metros that will have a capacity to collect and process one lakh units of blood annually.
To address the various issues related to blood collection, storage, distribution and supply, we are working on a regulatory framework to establish a Blood Transfusion Authority on the lines of the FDA. I am confident that in the next couple of years, we will be able to have a world class system of blood collection and distribution. This will help bringing down blood transmissible diseases such as HIV and Hepatitis B etc.
Condoms, as you know, is the only prophylaxis we have with us to check transmission of sexually transmitted infection. Its promotion is essential in India as it has multiple uses – it can avert an unwanted pregnancies as well as stop the spread of sexually transmitted diseases. Though some work was done to promote the use of condoms, it is inadequate. I am pleased to learn that under NACP III, condom availability and use will be significantly scaled up. I am happy to learn that the Gates Foundation is providing us funding support to establish a professional group to help us expand the market for condoms. Promoting condom use is important. Thailand is now facing the possibility of a resurgence of the HIV epidemic because they gave up prevention and condom promotion and focused only on treatment. So also China. Non-emphasis on condoms is resulting in the gradual increase of HIV due to unsafe sex. This is the same story in Nagaland where we neglected the promotion of the condom and are today facing the spread of HIV on account of unsafe heterosexual behaviour.
With young men and women bearing the brunt of the disease burden, it is essential that we educate our youth on healthy lifestyles. While good work was done under NACP II in training 2 teachers and 2 students in all the 1.4 lakh high schools we need to do more. We are therefore, currently working on coming up with a health education package that will focus on healthy lifestyle which will say no to unsafe sexual behaviour, no to tobacco, no to alcohol and no to drugs. We hope to harness the abundant energies of youth, as has been done in Tamil Nadu, in combating HIV/AIDS.
While, prevention will continue to be the mainstay of the NACP III, strategy and focus on saturating coverage of an estimated 4 million high risk groups, continued attention will also be on providing care, support and treatment to the infected. The ART programme which was launched in 2004 brought hope and expectation in lives of thousands of people living with HIV/AIDS. The ART programme has been rapidly scaled up. Today about 80,000 patients are accessing free treatment in 127 centers. This year another 36 centers are going to be established. Efforts are being made to identify centers closer to the community level to make it easier for patients to get their refill of drugs and save them time and money spent on coming all the way to the ART center. Such decentralization of drug distribution will greatly enhance adherence, reduce loss to follow up and alleviate the economic hardship of the PLHA’s. I do hope these centers attached to the ART centers will come up soon.
India was a global leader in coming out with the treatment protocols for children. Since the launch of the Pediatric AIDS Initiative on 30th November, we have more than 6000 children on treatment and 12,000 diagnosed.
I would also like to reiterate that HIV/AIDS is not just a public health problem. It is a disease that is the result of deeply rooted socio-economic conditions and cultural beliefs, practices, attitudes and vulnerabilities. The virus spread in India mainly through the heterosexual route. Sexual behaviours and choices are an intensely private matter and difficult to change. At one level we have easy access to information though internet, rapidly changing values and attitudes as depicted in modern cinema and the TV, greater mobility etc. and greater impoverishment and unmatched aspirations at another level are factors that contribute to enhancing risk and increasing vulnerability to this infection. We cannot, therefore, let our guard down. _We need to understand the significance of the presence of the virus in some 20 to 30 lakh people in the country against the backdrop that we also have a very high population of young and sexually active persons.
_
Of utmost importance is fighting stigma and discrimination. Even as we are celebrating our successes, we need to also feel a sense of shame that we as a society continue to lack compassion and stigmatize those who have the misfortune of being affected by this disease. Be it the incident of little children in Kerala being denied admission or the one in Meerut being denied medical care, it is indeed unfortunate. I would like on this occasion to appeal to all my fellow colleagues in the medical profession to live upto their oath of treating all those who suffer disease and sickness on equal grounds. I appeal to all faith based organizations and civil society organizations to come forward and help us to fight irrational attitudes of stigma against PLHAs.
I would like to thank all the media, the donor partners, the PLHA networks and the NGO’s for all the support that they have been giving us in our fight against HIV /AIDS. We value their support and understanding that they have extended to us. I do hope that this partnership will continue and the NACP III will be implemented successfully”.
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