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Not long ago, AIDS was termed the scourge of the century and India was not
left out of its grasp. Not any more. Today, people are more educated about the disease, constant medical research is ongoing and AIDS is no longer viewed with fear and suspicion. The credit for this fight against AIDS in this country must go to international organisations such as the Bill and Melinda Gates Foundation, which has committed $200 million over five years to launch its HIV/AIDS prevention efforts.
Though there are no up-to-date and exact figures, official Indian government data mentions that the overall HIV prevalence in adults is 0.9 to 1.4 percent, with 4.6 million people infected. The disease has affected parts of the southern states of Tamil Nadu, Karnataka and Andhra Pradesh. In certain districts of Karnataka, for example, five to six percent of the adult male population are affected while in Maharashtra’s Pune and Mumbai, the rate of infection is around four percent.
The high rate of infection moved the Bill and Melinda Gates Foundation to increase its efforts to stem the disease. Global health is the primary thrust of the Gates Foundation and it has made HIV/AIDS its main objective, says Ashok Alexander, Director of the India AIDS Initiative of the Foundation. “By global health we specifically mean addressing inequities in global health. Around 90 percent of the world’s healthcare spending goes to only 10 percent of the world’s population and a country like ours gets very little of the benefits of advances in global health.” These inequities in real terms mean that even today children in this country are dying of measles while adults are stricken down by diarrhoea, tuberculosis – a cure of which was found a century or so ago — or malaria. Now of course there is AIDS. The Foundation is moving ahead to correct these inequities by providing solutions through vaccines, for example.
Within the ambit of global health, HIV/AIDS in India is a larger goal for the Foundation. Says Mr Alexander, “If you look at the new cases of HIV/AIDS, a large number are occurring in India, Russia and China, though in varying degrees. The Foundation decided that we must get involved in India in such a way that we can make a major contribution to stemming the growth of HIV/AIDS in the country.”
The Foundation started work on April 1, 2003, soon after the Microsoft-founder Bill Gates visit to India in November 2002. During his visit, Bill Gates announced that his Foundation would make a $100 million dollar contribution. “By the time we started,” said Ashok Alexander, “we had done our groundwork and we had more reasons to increase the allocation to $200 million.” So the budget that the Foundation is working with is $200 million over a period of five years.
The programme of the India AIDS initiative of the Bill & Melinda Gates Foundation, aptly named ‘Avahan’ (meaning “the call” in Sanskrit) comprises well-designed strategies, much like a well-planned war game, only this time it is war of a different kind. A professional chess player for sometime in his life, Ashok Alexander has his pieces in the right places. “Our approach,” he says, “is largely focused on prevention as opposed to care and treatment.” Perturbed over the epidemic growing so rapidly, the Foundation has consciously taken the decision to work on prevention. That does not mean that it has its spotlight only on that field of activity. Far from it in fact, it has direct “links with people who work on care and treatment”. Working hand in hand with the prevention programme, there are other equally important facets in the war on AIDS: communication, advocacy, research, measurement of impact and capacity-building. Alexander says, “We have a whole lot of supporting programmes, which form part of a very large architecture. The Gates Foundation has gone somewhere from being a pure grant-making organization to an implementing organisation.”
The Foundation, therefore, has what it refers to as primary partners. These could be NGOs in their own right or sometimes not NGOs at all. Explaining the concept of the Foundation’s system of functioning, Alexander said, “These partners are people or organizations who have the wherewithal – either the skills or the infrastructure – to implement the programme on this vast scale.” Each of the partners take up different parts of the programme: while some work on the prevention portion, others work on advocacy and the related subjects. The Foundation grants money to the primary partners and entrusts them to complete their bit of work. If those partners feel the need to sub-grant their work to someone else, they do it. As for the Foundation, says Alexander, “We work very closely with those partners to make sure that things are going right: they are in the right place and delivering the right quality of services.”
The thrust areas of the Foundation are six states on the National Highway system. These states, says Alexander, have selected themselves since they are in conformity with the WHO standards of the epidemic. That means that the disease is attracting one percent of the adult population. The states are Karnataka, Tamil Nadu, Maharashtra, Andhra Pradesh, Manipur and Nagaland. However, since the National Highway system goes to more states and a lot of the transmission of the epidemic happens on the trucking routes, “the Foundation has interventions along the way”.
Keeping track of a programme on such a large magnitude must be a big job and the Foundation with its small staff – barely a dozen – has its hands full. But they have their work cut out for them. Says Alexander, “We are choosing very large, sometimes international NGOs to run a big programme in a state. It could be someone for the entire highway system in the state. So we can’t really supervise them but we can make sure that the basic strategies are being followed.” It would be more proper to say that what the Foundation does is “more monitoring as opposed to supervision”. In the systematic method followed, targets are fixed and everyone concerned tries to keep to the schedules. “Our overall goal,” emphasizes Alexander, “is the reduction in the spread of HIV/AIDS in the high-risk population by 2008. That is a fairly near-term goal. That goal is broken down into sub-goals and targets.”
The Foundation has understood that a lot of HIV/AIDS is driven by Sexually Transmitted Infections (STIs) in our country and if that could be controlled, half the battle would be won That is, perhaps, why the Foundation has specific targets of the reduction of syphilis, gonorrhea, and the related diseases. “What we are trying to bring,” states Alexander, “is the precise level of goal-setting, goal clarity, and measurement” so that it can find out the result of the programme. Alexander is quick to point out that this has not always been the case with public health programmes worldwide. The impact of any such programme is almost always measured in two ways. “Ultimately,” says Alexander, “it has to be measured biologically…we can say that the HIV virus prevalence has to come down from X to Y. That usually takes five to seven years.”
Before that, however, the measures that have to be adopted are behavioural, which can be seen from the first year itself. The Foundation has found that behavioural changes have been witnessed after the first intervention and the results are there for all to see like the use of condoms going up from 40 percent to 70 percent. The other behavioural changes, which come from advocacy is the marked decrease among potential victims in the choice of irregular sex partners. If the percentage goes down from 80 to 50 percent, that will be an indication enough that the programme is successful. These standards are from the WHO’s definitions and according to the Foundation Director, “these are guideposts to say that we are on the right track”.
The Foundation’s “real work” started with the announcement of the first set of grants in mid-October of 2003. Though it is too early to gauge the results, Alexander is optimistic that once the final set of grants are announced in May this year, there would certainly be a significant change in the horrifying scenario for “one year down the line, we would be in full implementation of the programme,” he says.
No programme of this magnitude can succeed without the help of the authorities and more so in India. So, one of the first tasks of the Foundation was to contact the public health authorities. Emphasises Alexander, “This is truly a public-private partnership. It is impossible for any single party to bring on something as large or as ambitious as this programme.” That is why in each of the six states, the Foundation has been in direct touch from the Chief Minister’s office down to the district level health officer. “Everyone comes into play: the judiciary, the police…The Government brings that big reach, the infrastructure.” In addition, the central government is involved through the National AIDS Control Organisation (NACO). “We constantly seek their inputs and guidance,” says Alexander.
Despite the hard work, Alexander is cautious about the future. “When you are tackling a virus like the HIV virus, it is difficult to see immediate results except in the long run,” says he. “Personally, I would like to say that we haven’t done enough. It is such a gigantic epidemic and we wish we could have done things faster. You can’t go too fast because you can crash.” But the Foundation has reasons to cheer. As Alexander confessed, “We have a whole lot of variables and according to the variables, people tell us that we have got off the ground remarkably fast.”
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