CLASS in the Media

An AIDS-free Future

Dr Catherine Lo’s book is the winning entry of 2017 Global Health Section Book Prize.

Written by
Dr Lo Yuk-ping Catherine Research Fellow, Department of Asian and International Studies;
Dr Kirit Premjibhai Solanki Professor of Surgery, member of Parliament in India

The road map must include higher budgetary allocation to public health-care and increasing AIDS awareness

In July 2000, the United Nations Security Council (UNSC) adopted Resolution 1308, calling for “urgent and exceptional actions” to mitigate the threats posed by HIV/AIDS. These exceptional actions referred to the need to provide exclusive responses and resources to mitigate the threat posed by HIV/AIDS. As the first disease to be the subject of a UNSC resolution, the exceptional status of HIV/AIDS has brought about unprecedented levels of international funding allocated primarily in developing countries where responses to the disease have historically been scarce or non-existent.

Sword of funding cuts

With financial assistance from international institutions and bilateral governments, HIV/AIDS responses intensified in many developing countries. While the exceptional approach to HIV/AIDS was warranted in the earlier stages of responses at the national level, it has become increasingly ineffective over time. This is visible through duplicated/parallel health systems and unsustainable funding. The overdependence on international assistance, coupled with the overwhelming policy preference towards HIV/AIDS, has resulted in the marginalisation of other pressing health threats such as malnutrition, and maternal and child health-care.

Most importantly, there has been a stagnating and even declining trend of HIV/AIDS international financial assistance in recent years. Data show that most European donor governments have reduced their HIV/AIDS financial commitments since 2012. Moreover, in light of the continuous economic boom in countries such as India and China, international funding agencies now argue that these countries should be donors instead of recipients of international HIV/AIDS-specific grants and loans. Without renewed and increased commitment from international donors and recipient governments, the sustainability of future national HIV/AIDS programmes is in doubt.

Integration into health systems

In response to the changing global health agenda, most of these countries are prioritising the integration of HIV/ AIDS programmes into existing health related systems. This shift implies that international funding organisations now exert a tremendous influence on the priority of health issues in the developing world. In this, India is by no means unique. An integration of HIV/AIDS interventions and primary health-care systems has taken place in India from 2010 onwards. For instance, six components of the National AIDS Control Programme (NACP)-III merged with the National Rural Health Mission (NRHM) in 2010. These included Integrated Counselling and Testing Centresers (ICTC); prevention of parent-to-child transmission (PPTCT); blood safety; sexually transmitted infections (STI) services; condom programming; together with antiretroviral treatment (ART). The continued integration of HIV/ AIDS responses under the umbrella health system is ongoing in the NACP-IV; where all the service delivery units except the targeted interventions (TIs) have been set up within the health-care system.

At the 2016 high-level meeting at the UN General Assembly, India pledged to follow targets to fast track the pace of progress towards ending HIV/AIDS as a public health threat in the next five years, and ending the epidemic by 2030. To fulfil the commitment, the Government of India is now playing a larger role in funding its HIV/AIDS programmes — this is evident from the fact that two-thirds of the budget for the NACP-IV is provided by the Government of India and comes from the domestic budget. Indian HIV/ AIDS programmes have progressively become less dependent on foreign assistance considering that over 85% of the budgets in the first and second phases of the NACPs and 75% in the third phase were supported by international and bilateral funding mechanisms. Ongoing improvement in the funding levels shows an increased policy commitment and fiscal capacity to address HIV/AIDS locally. But in order to ensure the sustainability of the HIV/AIDS interventions, continuous integration of HIV/AIDS programmes into a larger health system is required. However, health-care has never been a priority in India per se. Despite rapid economic development over the past two decades, public expenditure on health-care in India as a proportion of GDP is among the world’s lowest. Health expenditure in India was merely 1.3% in 2015-16, while countries such as Norway, Canada, and Japan allocated over 9% of GDP to health. India’s health-care expenditure is also comparatively less than other BRICS countries. The highest expenditure is by Brazil composing of 4.7% of its GDP. India’s overall health budget has declined by 13%, i.e. from 35,780 crore in 2014-15 to 31,501 crore in 2015-16.

Awareness versus stigma

A UN report showed that “India has the third largest number of people living with HIV/AIDS in the world — 2.1 million at the end of 2013 — and accounts for about 4 out of 10 people living with HIV/AIDS in the region”. If the goal of ending HIV/AIDS in India by 2030 is to become reality, there not only has to be an increase in budgetary allocation to public health-care but also a more concentrated effort to increase AIDS awareness. Evidence suggests that many people suffering from HIV/ AIDS in Asia lack the awareness that they test positive for HIV/AIDS.

Throughout India, numerous nongovernmental and community-based organisations have joined hands to spread awareness of HIV/AIDS at the local, state and national levels. Such projects seek to target the HIV/AIDS vulnerable populations — homosexuals, sex workers, drug users, transgenders, prisoners, women and children. They focus on offering direct care to people suffering from HIV/AIDS, general awareness campaigns and the care of children orphaned due to HIV/AIDS-related scenarios. Various organisations are working on innovative projects to tackle the stigma and discrimination that hinders access to effective HIV/ AIDS prevention, treatment and care services amongst high-risk populations.

Despite the prevailing advocacy of HIV/ AIDS interventions in an integrative manner, there has been a consistent push to maintain the exceptional status of HIV/AIDS as a unique global health challenge. It is argued that certain levels of AIDS exceptionalism should be maintained when we perceive ending HIV/AIDS as a means to an end. If we can end HIV/AIDS, we can end other pressing developmental problems, where the costs of the disease and its care present a serious economic burden.

This is an updated version of an article originally published on The Hindu, on April 6, 2017. (