3/16/2006

happened to be part of planning India's National AIDS Plan - here is a dig at it, for friends...

Going the last mile:

The National AIDS Control programme (NACP). ‘Control’ is a word that represents the early stages of the national aids programme. Today’s AIDS programme could well be called the ‘National AIDS Response Programme’ – a phrase that, in many ways, would truly capture the spectrum of activities the govt is aiming to do over the coming years – spanning across aids prevention and care.

While NACO (National AIDS Control Organisation, for the uninitiated) has moved ahead of its acronym, the programme itself has seen 2 phases – NACP1 and NACP2, abbreviations that the jargon friendly AIDS community has come to recognize as the well critiqued yet very giant, important and well intentioned steps towards responding to the epidemic. NACP 3, is at its planning stage, to be embarked upon towards the end of this year.

Most of the AIDS fraternity has been part of the planning process for the first time. Their participation was a key element of the planning process both at the state and central levels, either through direct consultative meetings or through electronic and other feedback mechanisms. This process is led by a high level planning team of 6 (needs to be checked) professionals with specific areas of expertise and experience. In many ways, the NACP 3 plan document will represent the hopes and aspirations of real HIV practitioners and those living with/directly affected by the virus.

However, the twist in the tale will come in its implementation. Many are waiting to see if the NACP 3 document lays out the details of how the plan will walk the last mile to reach every citizen’s backyard in the most appropriate, efficient and sustained manner. The question many are asking is, therefore, this – is the NACP3 document one that merely enumerates the intentions of the govt, or one that is also a blueprint with the nuts and bolts for action.

The voluminous NACP3 document will soon be readily available. But before it becomes a well thumbed, sufficiently book marked ‘rough guide to HIV programme implementation’ for the coming 5 years – here is an attempt to give you a peek at some salient features, however subjective the list maybe (and the order is not particularly significant either):
• The document makes the welcome break from tradition by arguing a strong case for synergizing HIV prevention and care. However, the non-negotiables for implementing this synergy and maximizing it, could be fleshed out a lot more.
• The document displays the ‘coming out’ of the national AIDS programme. There is, some say, the requisite amount of emphasis for prevention and care programming for sexual minorities, MSMs in particular.
• Nacp 3 goes bold, taking the bull by the horn – condom programming is center stage. A detailed process of making the rubber available, accessible and stigma free, is one of the most heartening pieces of the document.
• The NACP3 plan document aspires to be gen-next-friendly. Yes, youth friendly is the term hitherto used! While the document hopes to do a Rang De Basanti on young people, especially young girls who are most vulnerable to the virus, the document fights shy of addressing the dogmas of the land, the gatekeepers of morality, the deaf ear on the changing times – some practitioners have argued.
• The document does make every attempt to mainstream gender across sections. However, the inevitable has happened – issues around gender have been diluted in the garb of making it cross cutting. This, some say, is worrying. If the un-empowered woman is the weakest link in the epidemic, surely a more robust action plan is needed to take this aspect of the epidemic beyond the jargon into the perilous realm of real action.
• NACP 3 is trying an Everest climb with HIV related stigma. And why not? HIV related stigma is still at unhealthy high levels in most parts of the world, as much as it is in India. Every HIV practitioner has battled with stigma in trying to change behavior and sustaining it, in trying to address issues of sexuality within and outside marriage, in getting communities to accept voluntary testing, in helping pregnant HIV positive mothers avert risks to their unborn child, and any number of other aspects of the epidemic. NACP 3 is finally trying to make a clear, unambiguous, strategic plan to reduce stigma and discrimination. The indicators of success and change are difficult to arrive at, for a quantity as ephemeral, intangible and sometimes private, as stigma. But we ought to salute NACP3 for giving itself a fighting chance. This document is almost doing a Bush on India – war against stigma! Almost!
• Communication strategies are a very core element of the NACP3 document. At various points of the planning stage, the communication strategy seemed to come dangerously closely to becoming an advertising strategy for toothpaste – but sanity prevailed. HIV communication – the mother of all communication challenges (pardon the unfortunate gender reference) – goes way beyond the linearity of selling the idea of mutual fund investment plans or washing powder. A celebrity in a petal strewn bath tub surrounded with several other cleavage flaunting celebrities maybe able to sell body soap but may not be able to make a young man take that crucial, unsure step towards the chemists to buy a pack of condoms, far less tear open the pack in the heat of passion and use it right. Having said that, one communication plan for a country as diverse as India can only be strived for to paralyzing effect. The NACP3 document realizes the need for local communication plans based on a bouquet of options and guiding principles that have been learnt over the past 2 decades.
• NACP3 will give shape to a much needed Anti Retroviral Therapy (ART) programme as well as the PMTCT programme. The document lays out the required steps in great detail, to be implemented at the national, state and district levels. However, access is a two way street. The experience till now shows that merely rolling out the ART programme may not be sufficient to attract people to go for testing and treatment. The impediments in this process is the same as those in the area of STD treatment, for example, which has been easily and cheaply available through out the country for a long time now. Some of this dilemma may be sorted out at the state and district level plans that are in the process of being finalized.
• Capacity building is a phrase that has become synonymous with the HIV response world wide. The HIV response is human capacity intensive. People make the difference between a good response and an average response. Human capacity complements products such as condoms and medicines, in order to change quality of life. HIV prevention and care processes are therefore about making changes in the way people live their lives in the presence of the HIV epidemic. The NACP3 document attempts to lay out a detailed plan of capacity building across levels. However, the weakest link in the implementation of the plan can be the quality of capacity building. The plan document can still incorporate minimum standards of quality control for this very critical component of the HIV response.
• One of the key aims of the 3rd phase of the national aids response will be increased coverage, through more ‘targeted interventions, and NGO led activities. Reaching out to key populations such as MSM, SW and IDUs is the focus, considering India is experiencing a concentrated epidemic and there seems to be a window of opportunity to arrest the spread of the virus in the general population. However, most implementers feel that one of the key impediments in doing this will be the structural and managerial processes adopted at the level of the State AIDS control Societies. The plan document does recommend changes in the way that the SACS function and deliver. However, it has been recommended that SACS sets up a feedback mechanism to be used by NGOs in order to facilitate their implementation plans.
• Mainstreaming the HIV response into all govt sectors, whether it is the railways or agriculture, has been a valid demand by both NACO, as well as those that fathom the urgency of the HIV situation in India. Mainstreaming is a very complex concept that requires a buy-in from different sectors, over a sustained period of time. The NACP3 document does attempt to highlight the areas in which mainstreaming is required and the potential gains from doing so. The document however, leaves the ‘last mile’ details to future planning.
• Mobility and related vulnerabilities to HIV has featured in the NACP3 document. Even though truck drivers have for long been the recipients of condoms, song cassettes with HIV prevention messages and STI treatment facilities around highway dhabas, the larger community that is on the move has usually been ignored. The NACP3 document also needs to include human rights and related issues with regard to human trafficking and HIV vulnerabilities in this document – an area of work that will eventually help us win or lose the HIV battle in India.

The list above is a personal pick, based on discussions with a variety of stakeholders in the HIV practice community. It can be added to. Having said that, the only peril that NACP3 may eventually face is the trap of ‘doing business as usual’. We have to remember that the virus is winning. Programme planners and implementers need to get closer to the finish line, within the enabling framework of human rights, making the HIV response adequately contemporary, innovative and results based. We owe this to our people. NACP3 plan document is a space to watch out for.

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