After a whirlwind tour of India last week, Prof. Richard Feachem, the executive director of the Global Fund Against AIDS, TB and Malaria (GFATM) appears watchfully optimistic about the way HIV/AIDS control programme in India has progressed since his visit last year.
Feachem was on a mission to revive ties with friends in the new government, especially with the recently elected Prime Minister of India, Dr. Manmohan Singh, who worked alongside Feachem at the Commission of Macroeconomics and Health (CMH) in Geneva. He hopes that his visit will bring in more intent and commitment in the existing governance and policy on HIV/AIDS.
Another important point on Prof. Feachem's agenda was to create consensus among the Big-Five donors (World Bank, USAID, the UK Department for International Development, The Bill and Melinda Gates Foundation, and The Global Fund). Prof Feachem hopes that his visit will help bridge some of the gaps.
Feachem says, "HIV/AIDS response is substantially funded through foreign assistance. Although the donor community is committed to maximise the impact of their money, processes needed to be harmonised, without creating any more bureaucracy or duplication in efforts. For this, India's Country Co-ordinating Mechanism (CCM) needs to have equal and active participation of donors committed to HIV/AIDS.
But he realises that every country is doing more than before. "Treatment and testing are still new arrivals in India. In many places agencies have begun from a zero base. Prevention is critical, but framework to access for testing and treatment is very low."
On a collective vision and strategy among donors, Feachem believes that there are no fundamental disagreements. But he finds that often donors' success remains restricted to a small community or region and this is where the opportunity to scale-up exist. "Scaling up is critical for India. Testing, treatment, prevention, awareness and advocacy need to go hand in hand. Who pays for what is immaterial, and The Fund is agnostic about it as far as the results are achieved.
"Synergy between donors in operational aspects (prevention-testing-treatment-advocacy) is vital,” he says. "Many agree that prevention in high-risk groups is insufficiently emphasised and resources may be frugal. The Gates Foundation is among the few donors, which is looking at prevention in a comprehensive manner. Prevention however needs many partners and only recently has the United National Fund for Population (UNFPA) joined in the CCM in India."
About the other GFATM projects, Feachem believes that the TB project is going well and the HIV/AIDS project from Round 2 (of US$100 million), which was slow to start, will gain momentum. A second grant on HIV/AIDS will strengthen areas that are weak in the current programme, he maintains. The malaria project proposal that was earlier rejected (in 2003) has now been accepted after revisions.
With the Confederation of Indian Industry (CII), GFATM proposes to forge links and raise resources from corporate India. "Business and economic implications can be severe and cannot be foretold as of now," warned Feachem. He has found encouragement in the fact that one of India's largest company's, Tata Steel had put forward a proposal for GFATM funds. However, the proposal was rejected due to undisclosed reasons.
He also reports signs of progress in the Indian government’s attitude towards the AIDS crisis. "The overall climate of engagement will increase with awareness. The shift in the political and social climate is slow but positive, but needs to be hastened so that we can keep a few paces ahead of the virus. The new government in India and its leadership is well informed and it sees the window of opportunity of addressing HIV/AIDS issues now. The leadership seems convinced that the longer we wait, the more expensive it will get to deal with it."
Prof. Feachem emphasises that leadership must therefore evolve at every level and every sphere and with wider participation. "Faith-based organisations are important, so are Bollywood actors, cricketers, civil society, politicians alike. No country has had a successful campaign unless the top leader is involved. Thailand, Uganda, Botswana, Mozambique and Senegal have countered HIV by motivated leadership at the top." He was happy that Bollywood finally made a serious attempt at making film of people living with HIV/AIDS, a film titled Phir Milenge (Till we meet again) with popular stars, but was disappointed that the film failed at the box office. "If more people would see such a film, greater awareness is created," he said.
Several things have assured Feachem that things are moving in the right direction. One, the evidence of an increasing degree of commitment by the new government to HIV control is particularly symbolised by the attendance of Mrs. Sonia Gandhi at the Bangkok AIDS conference. Two, Feachem has noticed that there is a growing debate in the public arena, especially in the media around AIDS and third, the first Bollywood production taking on the disease has been released.
Since his last visit here Feachem has seen more intent and more interaction among stakeholders, "but things are not just resolving," according to Feachem. "The awareness levels need to be stepped up further and state government and civil society must contribute in both cash and kind to take things happen. Clearly, the denial that HIV/AIDS won't affect India has gone, and there is more intent than before.”
But doubts about HIV numbers still persist in India and were raised again during Feachem's visit. Feachem does not believe that official estimates of about 5.1 million Indians infected with HIV are accurate, especially when compared to 5.4 million in South Africa, which keeps India in second place. India may have overtaken South Africa as the country with the largest number of HIV-infected people.
Says Feachem: "India is at the centre of the global AIDS epidemic and I would like to be wrong. If India is not in the first place today, then it will be in a few months from now. Do the maths." Feachem believes that the Indian epidemic is on an African trajectory. If efforts are not made now, the virus will continue to win, stresses Feachem. The Indian media however perceived Feachem as being alarmist.
In a press conference in Chennai, Tamil Nadu, the capital of the state with the highest numbers of HIV/AIDS cases, the Union health minister, Anbumani Ramadoss said there are no reasons to get alarmed over the number of AIDS patients, as only 0.5% of the population was affected, compared to double figures in some African countries or 3% in Thailand. However, in an implicit admission that India's HIV statistics may be unreliable, he said that his ministry has shortlisted Tata Consultancy Services, the McKinsey Group and the Indian Institute of Management, Bangalore to create a HIV surveillance system to improve reporting of cases.
The response to Prof. Feachem's visit among donors and bureaucrats in the government has been positive. "Prof. Feachem's visit shows that globally the world is watching how India responds to the growing HIV/AIDS crisis. But more effort needs to be made by the National AIDS Control Organization (NACO) and the Ministry to raise additional resources from both within the country and outside," says Ashok Alexander of The Gates Foundation in New Delhi.
Two weeks ago, the Ministry of Health and Family Welfare carried out a major shake up in NACO, after financial and management irregularity were found by a government investigative agency. A week into his job as NACO's chief, S.Y. Quraishi is circumspect and reserved about the developments in the past few days. Says Quraishi, “HIV infections and the percentage of people infected remain much lower in India than in South Africa. But this does not mean that we do not take the issue seriously. We know how serious the epidemic is and there is no time to waste on debates or red tape. That will be my agenda. Prof. Feachem’s visit has been a good eye opener on what the global perspective on India is, and this is important to us.”
Anandi Yuvaraj, Programme Coordinator with the New Delhi-based HIV/AIDS Alliance believed that the Feachem visit provides a fillip to the Indian programme's intent. Yuvaraj, who also represents India's civil society on the board of the GFATM said, "the realisation process of the gravity of the epidemic has been slow, but the intent now appears to be much more serious in the government than two years ago. Pressure and constant lobbying at the top is helping the cause."