Social Sciences

Targeted HIV Intervention in India: Should We Re-examine?

India has one of the highest numbers of HIV-infected people in the world. Total number of People Living with HIV/AIDS (PLHIVs) in the country is about 2.47 million. According to the National AIDS Control Organization (NACO)-2006, adult HIV prevalence in India is estimated to be 0.36%. HIV prevalence is higher among adult men (0.43%) than adult women (0.29%). HIV/AIDS programs and services are coordinated through the ‘State AIDS Control Societies (SACS)’ under the direction of NACO. SACS constitute of the Integrated Counseling and Testing Centers and a wide network of non-governmental organizations where PLHIVs receive free services such as pre-post test counseling, antiretroviral therapy (ART) counseling and ART, lab tests, treatment for opportunistic infections (OIs) and sexually transmitted infections (STIs), nutritional counseling, psychosocial counseling, counseling for positive living, condoms, etc.

Figure of people reaching towards AIDS red ribbons, dangling above them on strings, just out of reach

Image via GoI Monitor; links to source.


Despite such large number of PLHIVs, NACO claims that India has concentrated epidemic. Indicating that the HIV prevalence is <1% and that the disease affects certain population groups rather than the “general population”. This explanation is used to justify the implementation of the targeted intervention strategy for HIV/AIDS prevention and control. Certain population segments such as ‘men who have sex with men’ (MSM), female sex workers, and the injecting drug users are identified and targeted as “high risk groups” (HRGs). Interestingly, every year we see new population groups being added to this list on NACO’s website (http://www.nacoonline.org/National_AIDS_Control_Program/Programme_Priorities_and_Thrust_Areas/). As of today, clients of sex workers, long distance truck drivers, single male migrant workers, spouses of migrant workers, prisoners, street children, etc., are part of this list and are referred to as the “bridge population”. It is argued that such profiling and segmentation is necessary to focus and enhance the effectiveness of intervention. On the contrary, evaluation of second phase of the ‘National AIDS Control Program’ (NACP) highlighted severe limitations of such targeted approach. This strategy was found to have limited success in HIV prevention due to inadequate focus on male clients, rigidity in service delivery, few options for treatment of STIs for women, and limited evaluation of effectiveness. Scientists in the past have documented that targeted approach for an already stigmatized disease reiterates the stigma and hampers care seeking among the “general population”. Despite having the knowledge that HIV transmission in India is largely through sexual route (80%), not only heterosexual but also homosexual and bisexual and that ~8-70% adults engage in paid or unprotected sex, NACO chose to deny the fact that almost every Indian is at risk of acquiring HIV, STIs, physical or emotional trauma by engaging in unprotected sex.

Reproductive and sexual health programs in the country in the past have highlighted deficiencies of targeted approach. Health programs, specifically those pertaining to reproductive and sexual health, in India have traditionally targeted women. Consequently, men were neglected and they sparingly sought healthcare for reproductive and sexual health. In mid-1990’s a need was felt to involve men as equal partners in reproductive and sexual health. Despite substantial proportion of men being infected and affected by various reproductive and sexual health problems <40% benefit from existing health programs. Though women have been targeted all along, yet very few (approx. 10-60%) benefit due to stigma around sex and due to the subservient position of women in our society. Through targeted interventions HRGs are being aggressively reached-out but those (male and female) belonging to the general population are among the underserved/un-served. Though gender stratified data on utilization of HIV/AIDS healthcare services are sparse and deficient, a report of NACO documented that fewer women (<40%) accessed pre-test counseling and compared to men more women (approx. 65%) attended STI clinics.

A recent study in Delhi examined gender disparities in utilization of HIV/AIDS services by PLHIVs and found that since most of the services were dispensed at the sites of targeted interventions the utilization was optimum among MSM and minimal among male and female PLHIVs.

Tripura Medical College & Dr. B.R. Ambedkar Memorial Teaching Hospital (Tripura, Agartala, India) interns imparting health education to rural people

Tripura Medical College & Dr. B.R. Ambedkar Memorial Teaching Hospital (Tripura, Agartala, India) interns imparting
health education to rural people.
By Anna Frodesiak (Image license: Creative Commons BY-SA-3.0 http://creativecommons.org/licenses/by-sa/3.0/).

Male PLHIVs were 20% less likely to use pre-test counseling, 30% less likely to seek treatment for any STI, and 24% less likely to avail free condoms compared to MSM PLHIVs. At the same time, female PLHIVs were 16% less likely to utilize pre-test counseling and 6% less likely to avail free condoms than MSM PLHIVs. Contrarily, male PLHIVs were 3 times more likely to get treated for any opportunistic infections than MSM PLHIVs. This finding clearly indicates preference of PLHIVs to avail services from non-stigmatized facilities. OI treatment is available in tertiary healthcare facilities (big hospitals like AIIMS or SJH) where sections/wards are not classified by HIV or STI status. Concurrently, it is a disturbing finding since it indicates failure of primary and preventive HIV care which should minimize the occurrence of OIs.  Undoubtedly, targeted intervention impaired optimum and equal utilization of HIV/AIDS healthcare services across genders.

NACO boasts of financial sufficiency for fighting HIV/AIDS in the country. Close to $45 million, exclusive healthcare workers, facilities, policy makers, etc., are at NACO’s disposal. Would it be worthwhile for NACO to evaluate or re-examine their existing strategies and approaches so that everyone can equally benefit from available programs and services?  Third phase of NACP continues to concentrate on targeted intervention but at the same time aims at universal access to HIV care and reduction of gender-specific health disparities. To contain the spread of the virus and to ensure good health it is important that healthcare is available to all, irrespective of their gender identity and presumed indulgence in risk behaviors.

About the author

esaroha

Esaroha is Doctor of Public Health with research interests in caste, gender, and racial disparities in healthcare.

8 Comments

  • Why can’t we just make sure that people are provided proper sexual education at a young age ? That will make it a lot easier for everyone involved.

    • Karsh, thanks for your comment. I wanna be a little sarcastic, plz. dont mind…Come on we [policy makers] dont want to do the obvious, else we will be out of business, duh! On a serious note, I know of one org, TARSHI who has been pursuing the sex edu agenda for almost a decade now, but in vain 🙁 U can visit them on the web.

      • I don’t mind the sarcasm at all 😀 . But on a more serious note, I don’t think that the policy makers really care about sex-ed, or lack of it in educational institutions. They care more about their vote banks. The real problem is that the general populace is scared of sex-ed, and does not want it in the curriculum.

        Pardon my French, but fuck abstinence education.

  • Of late ‘targeted intervention’ has been hailed and promoted as a ‘smarter’ way of optimizing limited resources and there is a good deal of pop-science on this topic. Some TED talks on this topic are:

    http://www.ted.com/talks/nicholas_christakis_the_hidden_influence_of_social_networks.html (Nicholas Christakis on using social network data to choose targets for intervention)

    http://www.ted.com/talks/esther_duflo_social_experiments_to_fight_poverty.html (In a sense, this turns targeted intervention on its head, by first using randomized trials to choose interventions for later universalization)

    This article is a sobering reminder of how algorithmically targeting interventions is not only often infeasible but often downright risky in cases like HIV in India where commonsense ‘broadcast’ methods maybe the way to go.

  • Arivind, thanks for sending the links, I will check those out soon! In the meantime I would like to say if targeted interventions was the way to go then why did the list of ‘at risk population’ expanded instead of shrinking? You must have heard a few months ago, MoHFW had clearly announced that they dont want donor funds (especially DFID) coz they (MOHFW, NACO, etc.) are sufficiently funded. NACO’s budget & health budget in the 12th plan reflects the same. Thanks again for sharing all the information 🙂

  • Hey Arvind! I watched both the videos. thanks again for sending across these interesting talks! Esther’s talks about bednets but not about beds! Udaipur’s full immunization was 77.1% in 2008 (DLHS) & she said 1%??? Sadly, foreign aid is contaminated with its own politics 🙁 All those big bucks r not that big as they sound 🙁 Nicholas’s explanation of epidemic is pretty sound. But I think that HIV is just one consequence of our neglected sexual health agenda. In the past population explosion worried everyone but STI/STDs were conveniently ignored. All the problems indicate that a holistic/horizontal approach rather than a vertical/disease specific intervention is a solution. Especially in a country where despite <1% GDP going to health, the Health Ministry assures that they can fix it all with the money they got. My argument might not be very strong/convincing but having had close interactions with those who can provide [policy makers] & those who are in dire need, I feel that it needs to change….

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