Why the battle against HIV/AIDS is far from over

Despite enormous progress, six Indian states have HIV prevalence that is more than double the national average

Fifteen years ago, there were global fears that the HIV/AIDS epidemic in India could spin out of control. Today, India ranks among countries with the lowest HIV prevalence. The control of HIV is one of India’s greatest public health achievements. Sadly, it has not received the recognition it deserves, because of the high levels of stigma that still surround this cruel disease.

In 2002, India’s National AIDS Control Organisation (NACO) estimated 4.8 million people living with HIV (revised to 2.7 million later), with 150,000 new infections each year. The prevalence of HIV among female sex workers was more than 25 times that in the general population. There were global fears that the epidemic would spiral out of control.

Today, new infections per year have come down to 88,000 as per NACO data. HIV prevalence in India has been declining steadily. At 0.22%, India’s HIV prevalence today is one of the lowest in the world, less than that in the US. In 2000, most countries committed to meeting four health-related targets by 2015 — reduce the under-five mortality rate, reduce the maternal mortality ratio, halt and begin to reverse the spread of HIV/AIDS, and that of malaria and other major diseases. India achieved only two — the target for HIV/ AIDS, and for malaria and other diseases.

From 2003-2013, I had the honour of leading the building of Avahan, the India HIV prevention programme sponsored by the Bill and Melinda Gates Foundation. Avahan worked with communities most at risk of contracting the HIV virus. There were female and male sex workers, transgenders, injecting drug users, and long-distance truck drivers. Female sex workers were our largest target group. Thousands of people most vulnerable to the HIV virus, mainly female sex workers, fought at the frontline of the war against HIV, driven by a huge sense of community. Avahan worked in Manipur, Nagaland, Maharashtra, Tamil Nadu, Andhra Pradesh and Karnataka.

Avahan expanded rapidly, and soon established itself as the world’s largest ever privately sponsored Hiv-prevention programme. The programme covered all but one of the 78 high prevalence districts. At its peak, Avahan delivered prevention services across 672 towns within 83 districts in six states. It reached out to more than 250,000 people from highest-at-risk communities and was distributing 13 million condoms a month. In 2013, Lancet credited Avahan with having averted over 600,000 HIV infections.

The fact that we could mount such a large campaign, so quickly, is not because of any great aptitude on our part. The smartest thing we did really was to ask the communities of sex workers to point the way to the solution. Sex workers across six states then went on to lead the effort of identifying and mapping every single member of their community by risk category. They used innovative ways to mark hot spots on street maps, create social networks to generate awareness, and prepare elaborate monitoring tools for beneficiary-level tracking. Groups of women sex workers shared data about inci- dence of violence with police and media, collaboratively combatting the issue. This was the second learning — that smart data use by front line health workers to achieve focus — was critical for effective response.

At Avahan, we always knew that we were playing a temporary role, and so we made every effort to work with and through government, and NACO. Once we had played our role, we successfully transitioned our programme to the government, and stepped back after 10 years. This was the third lesson: that it is necessary for any outside agency to work with and though government to achieve scale and sustainability. More important, that the transition of a massive privately sponsored programme to government was feasible.

Having come so far in the battle against HIV, it will be a fatal mistake to declare victory too soon. Several nations made the mistake of being complacent when Aids-related mortality decreased. Six Indian states have an HIV prevalence that is more than double the national average.

The situation in Mizoram, Manipur and Nagaland, driven primarily by injecting drug use, is worrying. We ignore the threat of HIV at our own peril, even as we celebrate what we have achieved.

For me, participating in the campaign against HIV in India was a life-changing experience. Coming from Mckinsey, where we would deliver smart solutions to clients’ issues, into a world where consumers knew far more than the supposed experts, was sobering. Working with communities of sex workers to find answers to problems in HIV prevention, I was humbled and inspired by their leadership, courage and selflessness.