Editor’s Note: Health Affairs’deputy editor Parmeeth Atwal spoke recently with Ashok Alexander, director of Avahan, the Bill & Melinda Gates Foundation’s HIV prevention initiative in India. Health Affairs devoted its current July/August issue to “Global Health Financing” with support from the Gates Foundation.

The Numbers

Atwal: The World Health Organization (WHO) and Indian health officials have disagreed in recent years over how many total HIV cases India has. Recent evidence on the prevalence front gives cause for optimism. What are the numbers really telling us about the state of India’s HIV/AIDS epidemic?

Alexander: I think a needless debate goes on in India about absolute numbers that we’ve considered largely irrelevant because the issue really is epidemic trends–where are new infections coming from–to really understand what is driving the epidemic and therefore to inform programming. So not enough of that goes on, and we get caught up in a debate of absolute numbers.

Now in terms of prevalence levels, I think the best news that is coming out of the epidemic is possibly from Tamil Nadu [state], and the message there is that if you manage prevention, prevention works if it’s done at quality and done on a sustained basis.

I think there is worrying news elsewhere in India. If you look at prevalence in high-risk groups where the epidemic is concentrated, that prevalence continues to be high. It’s worrying that those numbers are high in some places after years of intervention, as in Mumbai, as in Hyderabad, which are urban centers with a lot of intervention going on. If there’s any good news, it’s that a big spillover into the general population has not happened yet, and so we take all of those messages and say there’s some good news but not enough of it, and there’s room for extreme vigilance and continued focus on prevention.

Atwal: One of the interesting things about the Indian epidemic is that 70 percent of the prevalence seems to be concentrated in the southern states. What do you think accounts for this distribution?

Alexander: The higher prevalence usually comes in the parts of the country which are economically and socially more advanced. That’s happened in Africa — if you stretch it a bit, it happened in the U.S., in the West and on the East Coast first. A lot of the reasons amount simply to the fact that these richer areas have a better, if you will, recipe for HIV transmission. A lot of migrant labor coming in; a lot of people out of town, sex work and so forth. And so you take the northern states like UP [Uttar Pradesh]. Typically they are the sources of migrant labor. Places like Mumbai are the destination for the same labor who live in large urban slums there. So epidemiologically it takes longer for them to take that virus back and give it to the wife, etc.


Atwal: Another feature of the Indian HIV/AIDS epidemic is that it’s really composed of several regional sub-epidemics — each with its own unique characteristics complicating implementation of prevention strategies. How do you compensate for that in a country as large as India?

Alexander: There are things that you cannot standardize, because local conditions are so very different, but there’s a lot that can be standardized. In our program, for example, we have something called the “common minimum program,” which are standard operating procedures for everything that can be standardized. An example of that is, How do you manage clinical services for STIs [sexually transmitted infections]? You can standardize that, roll it out, and scale it up. Also, how you do effective condom distribution or effective social marketing of condoms?

In terms of the regional epidemics, you can choose a converse strategy there, which is to say if you understand where the transmission dynamics are particularly high, you can focus disproportionate effort there and have systemwide impact. So, for example, we believe, in coastal Andhra Pradesh in a cluster of four districts, or four or five so-called delta districts, we’ve put disproportionate effort there. Or in the corridor between north Karnataka and south Maharashtra, because of the furious migration that happens between these districts. So even though it looks as though, yes, these are very different, you can still find the nodes on the network.

Now the part of your question which asked what components really work? At one level, all the components are known — condoms and effective BCC [behavior change communication]. But we’ve learned two things here. We rapidly scaled up our program in a way that’s not been done. We reached a presence in about 550 towns in the first two years of our program. So we learnt that prevention can be scaled up, an assertion that hadn’t really been proven, and we learnt that applying business practices, ironically, to public health problems works very well. The second thing we learnt is about community mobilization. The vulnerable communities — sex workers and so on — who are the beneficiaries of our program are also the ones who drive the programs. So they conduct many parts of it and govern the program. That contributes to scale-up, sustainable quality, and many remarkable things we could not have known before we started.

Atwal: Are these lessons learned being applied and implemented by government?

Alexander: You know, the good thing about the national program in India is that it was a very transparent and open process where they invited input. And therefore, I would say that the program that the government has today, the plan at least starting in April this year, is very different from past designs in that it’s highly focused on prevention with high-risk groups and community mobilization. I would go so far as to say India has one of the most balanced and holistic national programs. Now one the biggest challenge is to implement it at scale and with quality. That remains to be done.

Atwal: Some of the initiatives that Indian policymakers have promoted as signs of progress on the prevention front are school programs intended to increase awareness and diminish stigma. Is the implementation of such programs reason for optimism?

Alexander: I’m not that optimistic because stigma remains the biggest barrier to prevention, and it’s widespread, and it’s deeply entrenched as a terrible fallout for programs. Most schools do not even have sex education in India, leave alone HIV transmission [programs]. Secondly, most of the youth don’t go to school, so how do you reach them? There are little pockets of good things happening, but not enough is being done to talk about sex, sexuality, HIV, in a very open way in Indian society. School programs are of course good things — but they alone will not go far enough or reach most people. They will not make enough difference on core issues like stigma.

Atwal: What can reach more people and counteract stigma?

Alexander: At the end of the day, stigma gets tackled when you talk about and understand an issue, and ultimately it has to be talked about within the home. Now how do you achieve that? I personally think that so-called society leaders will lead us. Some people have a disproportionate reach, whether it’s a Bollywood star, cricket player, or politician, or a business leader. Now HIV/AIDS is, unfortunately, not a popular cause — there are too many myths surrounding it. A few very noteworthy people have come forward, but most people want to move to the next issue, rather than HIV/AIDS. So we’re missing an opportunity here.

Atwal: That seems to be the difference in India, compared to the Western context, where HIV is more of a cause celebre. It seems that it’s reached a point where it’s not difficult in the U.S. to get public figures and others involved in creating awareness.

Alexander: I suppose so, but, you know, in the West, because prevalence levels are so very small, it’s a kind of like a boutique disease, and you always find somebody who has a personal reason to do it. Certainly in Africa stigma continues to be a big issue, so this is one of the biggest challenges we face.

Atwal: U.S. policymakers still struggle with striking the right balance between urban and rural areas in terms of allocation of prevention and treatment resources. Have Indian officials achieved the right distribution? Are rural areas, where many Indians continue to be concentrated, being left behind?

Alexander: Where should the focus be? The focus should be in the urban areas, because that’s where the concentration of populations is, and that’s where the prevalence levels are higher and the transmission is the greatest. Also, from a program management point of view, it’s impractical. Everything needs to be focused and more concentrated where you get the most impact. I don’t think there’s an imbalance. More effort is being spent in urban areas, and I personally think that is appropriate. Now when I say urban areas, I don’t mean Delhi, Mumbai, Kolkata. When you go down to a district in India, a district will typically have six or seven towns. The focus should be, and is, on those towns, though it doesn’t really get to the villages, which are thousands and scattered.


Atwal: One of the messages public health officials in the U.S. and India strive to disseminate to decrease fear and stigma is that life-sustaining treatment is available. Putting aside prevention for the moment, what are the challenges that exist in terms of Indians’ accessing efficacious treatment?

Alexander: Treatment continues to be very expensive for the poorer people in India, so if it’s the cost of about $100 dollars a month, that’s out of the question for many people. So we need to see treatment coming in almost universal and free, and the government had talked about doing that. But there are other challenges — we don’t have enough doctors trained in AIDS diagnosis and treatment. We don’t have pediatric formulations available readily. We don’t have enough CD4 machines, and we have very few viral load testing machines. So the whole infrastructure is still to be put into place. That presents a barrier, besides stigma, to treatment.

Looking Ahead

Atwal: What needs to happen down the road to continue managing the Indian HIV/AIDS epidemic and prevent it from going in the catastrophic direction that, say, the African epidemic has gone?

Alexander: I think the challenge is to keep the focus on prevention. Then there is the second challenge, which is to understand how to scale up prevention with quality rapidly, which is not an easy thing to do, given all the barriers and issues we spoke of earlier in this discussion. Then I would always say the stigma thing (I keep coming back to it) is today a huge, huge barrier. And I don’t mean stigma literally in the sense of turning away someone with HIV/AIDS. I am talking about the more subtle forms of stigma, which leads to indifference and apathy, which prevents enough resources being put or someone who’s in a position to make policy not really paying attention while he simply nods his head and agrees — that kind of thing. But scaling up prevention is the challenge that has to be done. The national program has set itself very ambitious goals; now how do you do it? It requires a different kind of thinking than exists today just in public health and the HIV/AIDS sector. I’m convinced that business thinking, and Indian business, can contribute a lot to this because that kind of thinking is very relevant. Scaling up is the business of business, right?

Atwal: Indeed. Thank you for taking the time to talk to me.