IRHAP

Background

The HIV epidemic in India is heterogeneous, with diverse modes of infection, particularly in southern and northeastern states, namely, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Nagaland and Manipur. There is increasing evidence to suggest that India’s epidemic is being driven by sex worker client interactions, except in the North East where injecting drug use is clearly the major mode of spread infection (although there too sexual transmission is increasing). There is evidence of increasing drug use in some other regions too.

The Indian epidemic continues to be concentrated in populations with high risk behaviour characterized by unprotected sex, anal sex and injecting drug use with shared injecting equipment. Several hig hrisk groups have high HIV prevalence, and sexual networks are wide and interlinked. However, these groups are not isolated communities but often mixed up with other subpopulations. 57% of the total HIV infections are in rural areas.

In the general population, women and young people are becoming increasingly vulnerable to the infection. According to 2005 sentinel surveillance findings, 38.4% of those living with HIV are women. In many states, more and more monogamous women are getting infected by their husbands. The male to female ratio of infected persons indicates an increasing feminisation of the epidemic. As in many other countries, unequal power relations and the low status of women, as expressed by limited access to human, financial, and economic assets, weakens the ability of women to protect themselves and negotiate safer sex, thereby increasing their vulnerability.

Similarly, HIV and AIDS disproportionately affect young people. Young people comprise almost 50 percent of the new HIV infections, and nearly 32 per cent of reported AIDS cases till 31 August 2006 were in the 15 to 29 years age group 1 . Their risks vary with culture, age, sex and individual circumstances. It is increasingly apparent that the key to turning back the pandemic is to enable young people to protect themselves against its transmission

However, the low rate of multiple partners and concurrent sexual relationships in the wider community seems so far to have, protected the wider population with 99% percent of the adult Indian population being HIV negative. To reduce the overall level of the epidemic, it will be important to saturate the coverage of the HRGs as well as expand the coverage of the bridge populations and populations at varying levels of risk.

NACP – III envisages expanding the coverage of high risk groups (HRGs) to 80% during the programme period.

Goal of NACP III

The goal of NACP III is to reverse the epidemic in India over the next 5 years through integration of prevention and treatment programmes. This will be achieved through:

1. Prevention of new infections in high risk groups and vulnerable populations through:

a) Saturation of coverage of high risk groups with Targeted Interventions (TIs)

b) Scaled up interventions among other vulnerable populations

2. Increasing the proportion of persons living with HIV/AIDS receiving care and treatment

3. Strengthening the infrastructure, systems and human resources in prevention and treatment programmes at the district, state and national levels

4. Establishing nation wide strategic planning, programme management, monitoring and evaluation system.

The vision of NACP III for vulnerable populations is to scale up interventions among these groups, with the presumption that increased awareness, skills building, changes in attitude and behaviour, and predominantly social change through communication, community mobilisation and advocacy, will result in the adoption and maintenance of sustaining safe behaviours and reduction of risk.

Programme Priorities and Thrust areas

NACPIII places the highest priority on preventive efforts while, at the same time, seeking to integrate prevention with care, support and treatment.

Subpopulations that have the highest risk of exposure to HIV will receive the highest priority for intervention. These include sex worker, men who have sex with men and injecting drug users. Other groups which are highly vulnerable to HIV infection are long distance truckers, migrants (including refugees), prisoners and street children.

The HRG 1 in the rural areas (based on district mapping ) will be addressed through the IRHAP Link Worker Scheme. These groups are:

• · Sex worker (FSWs) and clients of the sex worker
• · Men who have sex with men (MSM)
• · Injecting drug users (IDUs)

· The following bridge populations will also be addressed:

• · Truck drivers/cleaners and
• · Migrant worker

· Vulnerable young people may belong to the above groups and could also be partners/spouses of migrants, mobile populations and IDUs. Young girls/women in women headed Households, persons infected and affected by HIV, particularly in the context of stigma and discrimination and their linkage to care , support and treatment may also be vulnerable. These subpopulations too will also be addressed by the IRHAP (Link Worker Scheme).

Objectives of the IRHAP (Link Worker Scheme)

The Scheme will generate a cadre of trained local personnel as Link Workers and volunteers to work with HRGs and vulnerable young people and women in A and B Districts of India (Number of A and B Districts in each State) towards the following:

1. Create an enabling environment for PLHAs and their families by reducing stigma and discrimination through work with existing community structures/groups, e.g. Village Health Committees, SHG, PRI, etc.

2. Reach out to HRGs and vulnerable young people (men and women) in rural areas with information, knowledge and skills on STI/HIV prevention and risk reduction.

3. Establish inter linkages between gender, sexuality and HIV and bring into focus factors that enhance vulnerability of young people and women, both in HRGs and the general population.

4. Promote increased and consistent use of condoms to protect against STIs and unwanted pregnancy.

5. Generate awareness and enhance utilisation of prevention, care and support programmes and services (especially STI, ICTC, PPTCT, ART, DOT and other health services).

6. Facilitate the delivery of youth friendly health and counselling services through existing public health services/service delivery points.

7. Facilitate the reintegration of HRGs into the community and work with families against trafficking of women and children.