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Missing the wood for the trees

By Ramesh Venkataraman

Following the NFHS survey, the HIV numbers game has begun again. The point is that regardless of the actual number of people infected in India, there can be no complacency or drop in political and societal commitment towards HIV intervention and the rights of positive people

The news that India has less than the 5.7 million HIV-positive people estimated by UNAIDS in 2006 once again highlights the disastrous effects of the constant bickering about numbers beyond academic, government and research circles. The National Family Health Survey conducted in 2006 now suggests that India has around 2-3 million people living with HIV/AIDS. It has now become a 'numbers game', even though many epidemiologists and researchers do not agree on the methodology used, and, in India's case (as implied in a recent New York Times article), the surveillance mechanism used.

According to the Times, the methods used to calculate HIV/AIDS rates in countries are a "subject of debate, with some experts contending that the rates in many places may be exaggerated". Standard methods for calculating a country's HIV/AIDS prevalence include testing high-risk groups and pregnant women who come to health clinics. Some more recent studies, including the Indian survey, have taken blood samples in randomly chosen households in rural and urban areas. According to the Times, the survey's results suggest that India's HIV cases are contained within high-risk groups, including commercial sex workers, truck drivers, injection drug users and men who have sex with men.

According to the Times, the results mirror "exactly what some experts on AIDS surveillance techniques have been arguing for years". While the Government of India may be receiving a few pats on the back for apparently 'good' programming (that may have brought the numbers down), there's another danger here. As far as healthcare delivery by the Indian State is concerned, we already know that the system is unapproachable, unhealthy and discriminatory, with far more non-deliverables than deliverables. By implying that HIV is much more (read 'only') prevalent among high-risk groups, we are laying the ground for greater discrimination, less empowerment of women, and more ostracism and violence in cases where the community is misled about the causes and consequences of HIV/AIDS. This discrimination could mean that we will see more of what the New York Times piece stated as "an AIDS patient left on the street outside a hospital to die; five infected children expelled from school; and a woman beaten to death by her in-laws who feared she would infect the family".

The irony, rather the outrage, is that while everyone agrees that women face the brunt of AIDS, our budget allocations are still not nearly enough for this burgeoning 'sexually active' population. Our justice mechanisms still have no legislation for affected people in place; and within the healthcare system the poor, the affected and the vulnerable are still denied respect or help. Yet we say: "Actually we have fewer numbers." And, sooner or later, this will lead to even less commitment of money and expertise and less provision of treatment and universal access.

I suspect the numbers debate will now rage on, and will waste a lot of people's time and energy as they chase up the wrong street of statistics and 'who is right' and 'who is wrong'. Once again the clear message that there must be no complacency or drop in political and societal commitment towards HIV intervention and the rights of positive people will be lost in the din.

It's still early days in the development of an assessment methodology that will be found to be "beyond a doubt" by experts and organisations on the ground. Meanwhile, the speculation about numbers is being fuelled by the National Family Health Survey whose findings have not yet been made fully public.

It's also not surprising that a majority of such surveys are underwritten by American financing, through government or through American foundations known specifically for their focus on prevention (and now, abstinence). The Indian government and certain prominent American foundations have for long backed only targeted interventions with a 'prevention mostly' thrust (it now has an 'abstinence' push) that may or may not work in an active, moving population. This could mean more targeted interventions among the so-called high-risk groups, and less importance and fewer funds given for work with women, children, migrants and other minorities. Funds that are sought by everyone who wishes to use the sheer push of advocacy and urgency of the situation that higher numbers imply.

Clearly, if doubts are being cast on the growing constituency of positive people -- in our kind of 'mixed-up' vote bank-based democracy and lack of functioning health, human security and justice systems for such people -- then there is trouble brewing. If our engagement with affected (not just positive) people's issues does not increase we could face greater discrimination, this time on the prevention side, and our prevention schemes will have much less impact.

(Ramesh Venkataraman is Asia HIV and AIDS Coordinator, ActionAid International)

InfoChange News & Features, June 2007