AIDS Response at Crossroads: World AIDS Day 2013

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This year’s World AIDS Day will not just be a string of events the world community observes every year on December 1st, reiterating our resolve to combat the pandemic. This year, it will occur at a defining moment in the global response when all stakeholders are standing at crossroads, looking to where we should head.

There is celebration, sometimes excessive, about the successes achieved since 2001 when the rules of engagement with HIV/AIDS changed from appeasement to aggressive combat, denial to ownership, and condemnation to meaningful participation by communities infected and affected by the epidemic. The resource base for AIDS programmes moved to billions, and affordable generic medicines have been made available, saving the lives of 10 million people. New infections have made an appreciable decline of 33% in the Ground Zero of the epidemic, sub-Saharan Africa. Most important, there has been an aggressive breakthrough in reducing the number of children born with HIV, and the target of zero new infections among children by 2015 appears feasible.

Encouraged by this impressive progress, world leaders have started talking about an AIDS-free society as an achievable goal in a finite time frame. Secretary-General United Nations has spoken on more than one occasion about the emergence of an AIDS-free world. The UN Joint Programme on AIDS (UNAIDS) has adopted the achievement of three zeroes as a global strategy. A new Commission established jointly by UNAIDS and Lancet has ‘what will it take to end AIDS’ as one of its three overarching objectives.

An outsider who is not familiar with the history of the epidemic can be led to believe that success is on hand and an AIDS-free world is just round the corner. This is the pitfall in crying victory too early when there are many challenges lying ahead, including sustainable financing and political support for AIDS programmes. While new infections are on decline in Africa and Asia-Pacific, they are still on rise in Eastern Europe, Middle East and Northern Africa. Another 5 million more people are in need of treatment, and this number will increase further with the new WHO guidelines on treatment. The biggest obstacle is however the adverse legal environment surrounding the people living with HIV and key affected populations. Progress on decriminalising these behaviours has been extremely slow and in some countries negative.

Resource availability for AIDS programmes has been impressive until now, but it is uncertain whether countries will commit matching domestic resources to cover the gap left by withdrawal of donors from AIDS financing. Evidence shows that external financing has funded prevention programmes focussing on vulnerable key populations. These communities are apprehensive about whether countries would continue with this prioritisation once the external funds are withdrawn. And for political leaders at country level, AIDS is no more a challenge. By providing treatment services to infected populations and preventing them from dying, they feel they have won the battle.

The added challenge on this World AIDS Day is the ongoing global dialogue on defining the post-2015 development agenda for the next 15 years. In the next year, world leaders will be actively negotiating various components of a new development regime where priority will be accorded to issues like environment and sustainable development. There is overall concern whether health and HIV will get the right priority in the post-2015 agenda. As this will evolve through an intergovernmental process in the UN General Assembly, much depends on what priority country leadership, especially non-health actors, will accord to AIDS and whether emergence of an AIDS-free society would be considered by them as an achievable goal.

On this World AIDS Day, we need to be vigilant and work closely with country leadership and UNAIDS to ensure that AIDS is not dropped just at a time when the battle is half won.

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The author of this post, J.V.R. Prasada Rao, is UN Secretary-General’s Special Envoy for AIDS in Asia and the Pacific and serves as chair on the board of India HIV/AIDS Alliance.

World Hepatitis Day 2013: Making Hepatitis C a Priority

Sixteen million people inject drugs worldwide. Three million live with HIV, and two-thirds of them live with Hepatitis C. (Photo by Francis Joseph for India HIV/AIDS Alliance)

Sixteen million people inject drugs worldwide. Three million live with HIV, and two-thirds of them live with Hepatitis C. (Photo by Francis Joseph for India HIV/AIDS Alliance)

A dear friend of mine was struggling as a single mother, working two jobs and balancing drug use. To make things simpler, she quit the jobs and started working from home. Unfortunately, her drug use turned out to be more problematic than anticipated. Her situation was further complicated when she was diagnosed as positive for Hepatitis C, a viral disease that leads to the inflammation of the liver and related complications.

With no medical insurance, she faced a financial challenge to cover the six-month long treatment. At first, she got contributions from family and friends and then a loan, and lastly she sold her jewellery. She recovered only to be hit with the virus again. This time her condition deteriorated so quickly that she was not able to make it through a second round of treatment. Only half of those who are treated actually recover. My friend’s is just one of the many stories of people struggling with Hepatitis C.

Hepatitis C represents a huge public health problem in India and globally. According to the World Health Organization about 150 million people are chronically infected with the Hepatitis C virus, and more than 350,000 people die every year from Hepatitis C-related liver diseases. The Hepatitis C virus is more infectious than HIV. An estimated 10–12 million people in India are infected with Hepatitis C, including 50 percent of people who inject drugs (PWID) nationally and 90 percent of PWID in the northeast. Left untreated, Hepatitis C can lead to liver cirrhosis, liver cancer or liver failure.

Hepatitis C is especially of concern for those co-infected with HIV, as several studies have shown that HIV-Hepatitis C co-infection leads to increased rates of disease progression. PWID are especially vulnerable to infection by both HIV and Hepatitis C; co-infection rates are as high as 93% among PWID in Manipur. However, unlike first- and now second-line HIV treatment, which is available to people living with HIV who need it in India, Hepatitis C treatment is not available in government hospitals largely due to its high cost, and health programmes for PWID typically do not screen patients for Hepatitis C due to the unavailability of treatment. Consequently, this results in high morbidity and mortality among PWID.

To address this concern, our Government of the Netherlands-supported Hridaya programme disseminates information on Hepatitis C prevention through outreach and counselling sessions at drop-in centers (DICs) in 36 sites in four states: Bihar, Jammu, Haryana and Uttarakhand. The programme also identifies clients and refers them for testing. Those found to be Hepatitis C-positive are further educated on self-care and positive prevention. The programme’s outreach team works with spouses and families of PWID, explaining Hepatitis C risk and prevention in the context of injecting drug use.

To address the growing problem of HIV-Hepatitis C co-infection among women who inject drugs, our Elton John AIDS Foundation-funded Chanura Kol project has initiated Hepatitis C interventions. Women enrolled in the project are educated about transmission risks, prevention strategies, and the importance of testing.

With both programmes, Alliance India is working to ensure that Hepatitis C prevention education and treatment literacy become a priority for PWID and a core part of this country’s efforts to improve the lives and health of PWID.

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The author of this post, Simon W. Beddoe, is Advocacy Officer: Drug Use & Harm Reduction.

With funding from European Commission, the Asia Action on Harm Reduction programme supports advocacy to increase access by people who inject drugs (PWID) in India to comprehensive harm reduction services and reduce stigma, discrimination and abuse towards this vulnerable population. The three-year programme in the beginning will primarily engage with PWID and local partners in Bihar, Haryana, Uttarakhand, Delhi and Manipur and  gradually extend its reach across India.

The Best of Times, the Worst of Times: Do WHO’s New ARV Guidelines Serve the Needs of Key Populations?

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One of the highlights of the recently concluded 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur, Malaysia, was the launch by World Health Organization (WHO) of new Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.

Announced on 30 June 2013 at a satellite session, the new guidelines, if implemented at scale, could help avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025. At their core is the idea that earlier initiation of anti-retroviral (ARV) drugs will help people living with HIV (PLHIV) live longer and healthier lives.

The new guidelines recommend initiation of anti-retroviral treatment (ART) in all adults who have a CD4 count of 500 cells/mm3 or less, and priority should be given to individuals who have CD4 counts less of 350 cells/mm3 or less. Additionally the new guidelines also recommend that ART should be initiated immediately for PLHIV coinfected with TB or Hepatitis B and for those in serodiscordant couples. It also calls for Initiation of ART in all children infected with HIV below five years of age, regardless of WHO clinical state.

Soon after the launch, one of the conference participants, a self-identified MSM living with HIV, aptly described the new recommendations to me: ‘It was the best of times, it was the worst of times.’ One of the guiding principles behind the new recommendations is ‘promoting human rights and health equity,’ and for the first time WHO clinical ARV guidelines acknowledge the distinct challenges faced by key populations affected by the epidemic—men who have sex with men, transgenders, people who inject drugs, and female sex workers.

This is great progress for many reasons. The failure of the global HIV response to adequately acknowledge and address the barriers that prevent key populations from accessing treatment and related clinical services continues to be a gap of significant proportions. Structural, legal, institutional, and social forces keep key populations from entering into the continuum of care. For example, Alliance India conducted operations research in 2012 to assess the quality of HIV-related services for MSM and transgender populations in India. The research identified specific issues such as lack of confidentiality, lack of privacy, overall unfriendly environment at the service centre, and insensitivity amongst health-care providers at this country’s ART centres.

In fact, a recently published article in the New India Express describes how India’s transgenders continue to face serious barriers to accessing HIV treatment and other health services. Rather than face discrimination and stigmatizing attitudes, too many are avoiding clinics and not getting the care they need.  One transgender describes her experience, ‘When we go to big hospitals, the nurses send us away. They refuse to examine us because they feel disgusted to make physical contact with us.’

In India and elsewhere, key populations are routinely denied their right to health. They are refused treatment and other services and have little or no access to care and support. Like it or not, these are still the worst of times for too many key populations. Though these guidelines do offer hope and optimism, we need to reimagine how key populations access health services and ensure that governments and donors like the Global Fund and PEPFAR include expanded access for key populations as an essential component of their supported treatment programming. If we take the lives of key populations seriously, the promise of the WHO’s new ARV guidelines might just guide the way to a better future.

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The author of this post, Yadavendra Singh, is Senior Programme Officer: Capacity Building for Alliance India’s Pehchan Programme.

With support from the Global FundPehchan builds the capacity of 200 community-based organisations (CBOs) for men who have sex with men (MSM), transgenders and hijras in 17 states in India to be more effective partners in the government’s HIV prevention programme. By supporting the development of strong CBOs, Pehchan will address some of the capacity gaps that have often prevented CBOs from receiving government funding for much-needed HIV programming. Named Pehchan which in Hindi means ‘identity’, ‘recognition’ or ‘acknowledgement,’ this programme is implemented by India HIV/AIDS Alliance in consortium with Humsafar TrustPNRO,  SAATHII, Sangama, and SIAAP and will reach 453,750 MSM, transgenders and hijras by 2015. It is the Global Fund’s largest single-country grant to date focused on the HIV response for vulnerable sexual minorities.