India is pushing people back into sex trade by dismantling its successful AIDS programme

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India’s HIV prevention and treatment programme has been set back by 20 years, putting the health of lakhs at risk.
It had been three years since Sonu went back to the “hot spot” – a street corner in Lajpat Nagar, where he waited for clients. It was his office. Now, “spoilt” by a steady government job, he is out of his depth, as he smiles nervously at cars passing by.

Sonu, an Outreach Worker with National AIDS Control Organisation, has not been paid his salary since last September, making the rehabilitated, transgender sex worker go back to doing the only other thing he knows. “I had to earn a living… So, here I am, back to selling my body,” he said, sitting at the office of Delhi Network of Positive People in Neb Sarai in south Delhi.

Sonu’s story mirrors the general theme of exploitation suffered by the sexual minorities in India. Teased as a child for being effeminate, abused as a teenager by an elder cousin brother, he dropped out of school and ran away from home when he was 11.

He went to Lajpat Nagar where his friends, transgender commercial sex workers, lived. This was in 2008, a time that’s now seen as the golden years of India’s HIV programme. As part of the Targeted Intervention activities, the programme hired volunteers from the vulnerable communities. This was a brilliant start that helped the government reach maximum high risk communities – MSMs (men who have sex with men), IDUs (injecting drug users) and sex workers.

Sonu too joined as an Outreach Worker and over the next few years went on to become a peer educator and then a counsellor. It was in 2012 that trouble began. Initially the salaries were a few weeks late, then they were given in instalments every three months. By September 2014 the money stopping entirely.

“Slowly, but surely, India’s AIDS programme is collapsing,” said Vikas Ahuja, an HIV activist and president of Delhi Network of Positive People. Ahuja is currently putting together a Public Interest Litigation to take the Indian government to court for violation of the constitutional Right to Life (Article 21) and Right to Equality (article 14) after repeated “stock-outs” of free drugs and testing kits given by the government to people living with HIV in India.

Simply put, for the past three years, drugs and testing kits have been running out. Health budgets have been slashed. Salaries have not come on time. In a similar vein, the Maharashtra State AIDS Control Society, in a disastrous decision, has decided to suspend core health interventions and curtail staff for nine months from July 2015.

The amazing success story

Individuals like Sonu were the true success stories of India’s HIV/AIDS campaign, the largest HIV prevention and treatment programme in the world. As part of the outreach strategy, the programme allows commercial sex workers to quit and join the Targeted Intervention programmes – allowing them a clean slate. This and the fact that the government allowed access to stigma-free, comprehensive health services made it one of the world’s best HIV intervention programmes.

Three landmark cases – where India’s vocal, well-organised HIV activists took the Indian government to court – formed the basis of what went on to become one of the world’s best government-run HIV programmes.

In 1998, Sahara House, a non-governmental organisation, moved the Supreme Court stating that it was unconstitutional to deny treatment in government hospitals to people living with HIV. The next year, Sankalp Rehabilitation trust approached Lawyers Collective to file a case demanding that the government formulate guidelines for non-discriminatory treatment of people living with HIV.

While these two cases, commonly known as “Sankalp/Sahara verdict”, were underway, the Voluntary Health Association of India filed another petition in 2003 on the issue of access to antiretrovirals as part of government’s programme.

At the time VHAI went to courts, the Indian government had already become a signatory to a resolution adopted in a special session of the United Nations General Assembly in June 2001. The signatories had to commit financial resources to the cause, and India had signed up (and failed) to “intensify national, regional and international efforts” to combat AIDS by 2003.

As lawyer Leena Menghaney explained, “NACO was the first public health programme to create linkages between rights, HIV and public health with the assistance of Targeted Interventions. This paid off by bringing down the rates of HIV transmission in high burden states as it had a direct impact on improving perceptions about the benefits of HIV testing and uptake of prevention services by most-at-risk populations.”

Faced with this build-up, the government of India announced a liberal policy, free of moral judgement, promising free-of-cost HIV treatment. The implementation began on April 1, 2004, and covered over 1 lakh people living with HIV. It was available in select hospitals in six high-prevalence states – Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu, Manipur and Nagaland – besides Delhi.

Setting an example for others

By 2005, the World Health Organization estimated that India had 50 lakh HIV-affected people, out of which 5 lakh needed access to antiretrovirals immediately. UNAIDS estimated this number to be 7.85 lakh. By November 2006, a grand total of 32,000 people were on treatment, according to the Human Rights Law Network.

By January 2008, the government added second line antiretroviral therapy as a pilot project in Maharashtra and Tamil Nadu.

As of March 2014, India had 425 antiretroviral therapy centres and 870 link antiretroviral therapy centres, providing care to 7.68 lakh people with HIV. Additionally, 54 centres provided second line antiretroviral therapy as well.

By any standards, this was an impressive achievement, particularly since it was achieved in a short span of seven years.

“India is the only country that designed its own strategy based on evidence and was able to achieve a 57% reduction in incidence (new cases),” said K Sujata Rao, former NACO secretary. “Ironically, Africa is adopting India’s strategy of focusing on prevention. It is saddening that instead of being proud of our achievements, the government is bent on undoing the gains. A lot of thought, research and experimentation has gone into this for over two decades before we were able to see gains. If all that is given up and we go back to the beginning then all one can feel is intense sadness. It is difficult to build a momentum once lost.”

Rao ended the interview bitterly stating that “going back to abstinence as the way forward can be nothing but simply foolish,” pointing to the current government’s policy of preaching abstinence and loyalty as a counter to AIDS.

Turning back the clock

While the scale up was momentous, the collapse of the programme was equally monumental. According to the WHO’s first global monitoring report “Tracking Universal health Coverage”, as of 2013, India, despite running one of the largest HIV programmes, had a coverage rate of only 36% – meaning the government provides treatment to just about a third of the patients in need.

“In the last 15 years, we – the activist community – has fought for these very things,” said Ahuja. “It is like being stuck in a time warp. We are again starting from scratch, again saying it is unconstitutional to not give us drugs. We should have been working on scaling up the programme to include Tuberculosis and Hepatitis right now. Instead, we have gone back 20 years. Keeping patients on treatment isn’t the only job the government has. Prevention is just as important as treatment. This government doesn’t want to deal with Injecting Drug Users and Men who have Sex with Men or be seen distributing condoms.”

At this juncture, after coming all this way, for history to repeat itself would be a heartbreaking catastrophe.

According to an investigation by the Delhi Network of Positive People, as of April 10, 2015, several antiretroviral therapy centres across Delhi were shockingly out of various lifesaving drugs and testing kits.

Ambedkar Hospital – HIV and dried blood spot test kits unavailable.

AIIMS Hospital – HIV, DBS and STI 6 test kits unavailable.

Safdarjung Hospital – HIV and DBS test kits unavailable.

Lok Nayak Jai Prakash Narayan Hospital – DBS test kits unavailable.

Lala Ram Sarup Hospital – HIV test kits unavailable.

Ram Manohar Lohia Hospital – CD4 test kits unavailable.

Losing out in the last mile

Throughout the past year, the health ministry has consistently underplayed India’s HIV crisis. The two health ministers – Dr Harsh Vardhan and JP Nadda – both made identical statements insisting that the budget cuts will not impact any of the ministry’s flagship programmes.

However, in a drastic measure, the Maharashtra State AIDS Control Society has decided to suspend core health interventions and curtail staff from July 2015 to March 2016.

“I am not surprised as it is in line with what the ministry did in the case of malaria,” said Rao. “The success of reducing cases from 75 million to 2 million led to the disbandment of the malaria workers that resulted in the comeback of malaria and other vector borne diseases. Likewise, when leprosy got eliminated the ministry disbanded the leprosy set up and diverted it for HIV/AIDS resulting in the re-emergence of leprosy. TB successes in the early years led to complacency and a tripling of MDR TB.”

Rao added: “Today, they are doing the same with HIV and will possibly do the same with polio tomorrow. The ministry simply seems to lack the stamina to go the last mile and gives up half-way which is very dangerous in the case of infectious diseases as they always bounce back in a worse form that is more expensive to treat and control.”

In a circular issued on June 11, Khushalsinh Pardeshi, the project director of the Maharashtra State AIDS Control Society has instructed all non-governmental organisations involved in with the government-run HIV AIDS programme to “suspend some of the activities from July 2015 till March 2016”. Maharashtra, incidentally, is one of India’s six high prevalence states – the others are Andhra Pradesh, Manipur, Nagaland, Karnataka and Tamil Nadu.

As of July, the Health Ministry had released over Rs 250 crore to state governments. “We are not certain the state governments give this the same priority that we do,” said a senior official with the NACO. “We send in the money, but it does not get released from the state treasury on time. There is very little we can do about this sitting in Nirman Bhawan.”

Meanwhile, in another corner of Delhi, Sonu has just finished his day job at Bal Vikas Dhara, an NGO that runs Targeted Intervention programmes in Baradarpur. The next few hours will again be spent nervously on the streets of Lajpat Nagar, soliciting.

“The trouble is, I am not used to standing on street corners anymore. I rented a room but one of my clients is now threatening to cut me with a blade if I take any more customers. He knows the place and I cannot put the lives of my clients at risk.”

As an afterthought, he added, “I am shocked the government can do this to us – so many of us.”

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