Sujatha Rao, director-general of the National AIDS Control Organisation, explains in an exclusive interview with Rashme Sehgal why it is important as part of the HIV/AIDS programme in India to promote life skills education amongst young people.
NACO receives a huge amount of funding, which has crossed $1billion from the Global Fund alone, apart from receiving funding from USAID, UNDP and the Bill and Melinda Gates Foundation
What work has NACO done to promote life skills education /sex education?
We have been working hard to empower young people in the age groups of 15-18. We want them to learn to cope with peer pressure in order to be able to deal with risk-prone behaviour. They must learn to say no to drugs, alcohol and unsafe drugs and they must be able to protect themselves from all forms of exploitation.
When we say “life skills” it means youngsters must be able to distinguish between what comprises a friendly and an unfriendly gesture. They must develop self-esteem, learn to value and respect relationships and focus on their studies. All life skills education is value-based. Much of this will have to be taught by teachers in schools and extended to colleges as well. The whole purpose of starting Red Ribbon Clubs for both adolescents and young persons is to have teachers impart value-based education to them.
Can you give us more details about the Population Council study regarding the risks that adolescents face?
The Population Council survey covering 40,000 youth showed that 8% of youth were prone to risky behaviour largely on account of peer pressure or because the atmosphere at home was not conducive for these young people.
I must here emphasise that 92% of the youth are not indulging in risky behaviour. It is difficult for us to categorise who these 8% are. They could belong to the rich and irresponsible sections of society or they could belong to the jobless, low income groups. They cannot be defined as a group and so cut across all sections of society.
We have started 6,000 red ribbon clubs in Maharashtra where we try and seek out young people who have vulnerabilities. It works child to child, peer to peer and we have teachers talking to them and interacting with them so that they can imbibe value-based skills.
How has NACO responded to the Parliamentary Panel's report on sex education?
The Parliamentary Committee did not say “no” to sex education. Rather, they expressed concern about the manner in which it was being implemented. Their concern revolved around the fact that they did not find it age appropriate. They have made some recommendations which we have no problem in accepting.
I personally feel we failed to correctly communicate what we were doing. It was a failure on our part. We are not in the area of promoting promiscuity, nor are we focusing on safe sex and condoms.
We have withdrawn our earlier module and have reworked it. This has been sent to different states for consultations. The different stakeholders, including teachers and policy makers, are in the process of finalising the module and incorporating what changes they want. Once this is done, I do not see any reason why the new modules should not be implemented.
There is a crying need for adolescent education across the country in order to prevent adolescents from being exploited. Our modules are not about reproductive organs or about how babies are born. They are much more than that. Ninety per cent of the thrust of our modules deals with ‘no’ to drugs, ‘no’ to unwanted relationships and ‘no’ to alcohol.
Can these programmes make any difference? Do you have any evidence to show both from within India and outside that these interventions have made a difference?
A similar debate to what is going on in India took place in the US in the 1980s. Even in the US, there were groups that had insisted there should be no education in life skills and the thrust should be on providing a good moral education.
Let me cite the example of Uganda where 13 years ago, the prevalence of HIV/AIDS was 32%, that is, one out of three Ugandans suffered from this infection.
The Ugandan government started a programme which went from school to school teaching life skills to adolescents between the ages of 13 and 16. In our country, the average age would extend up to 20 or so. HIV/AIDS in Uganda is now down to 6% of the population. These interventions definitely make a difference.
Teaching abstinence is not the answer. I keep stressing that my life skills modules will not make you promiscuous. If young people are not warned, they will end up losing their lives so it is unethical to withhold information. Young people today are getting access through the internet, TV, movies. If the government wants to withhold sex education, then it should look at all these different channels of information.
What is NACO doing to ensure that prisoners with HIV are given proper treatment?
According to information provided in a bail plea reported extensively in some Mumbai newspapers, as many as 32 HIV-positive prisoners died in the Yerawada jail between 2001 and 2006.
Between 2001 and 2006, we did not have much treatment. It was only in 2004 that the ART (antiretroviral therapy) was introduced, and that too in eight centres. The treatment has now been extended to 215 centres. We need to keep in mind that this is an asymptomatic infection and little can be done if the patients are brought too late because by that time the disease would have progressed. All we can hope to do is extend a patient’s life by two to three years. A second line of treatment – in case a patient has become drug resistant – is being rolled out from this year. Jails have been covered by this line of treatment and we have informed all the jail agencies that no patient must be allowed to miss out on his ART. The date of a court hearing can be changed, but this must not be allowed to happen with his treatment.
The Maharashtra government has told the Bombay High Court that prisoners "suspected of being HIV positive" should be segregated. Doesn’t this sound a little arbitrary as this would mean breaking confidentiality on their HIV status? It also suggests that prisoners are at risk of HIV transmission. Wouldn’t it be more appropriate for authorities to focus on education and in providing better prevention services?
I don’t believe that any state government would have come up with such a suggestion. Something like this would not help the programme at all. We have worked extensively with state governments and counselled them on how they should deal with HIV patients. Both Andhra Pradesh and Kerala have made inroads in this area of counselling.
We keep hearing complaints about doctors refusing treatment to positive people. How does NACO plan to tackle this?
These complaints are largely in the private sector. Public hospitals today are treating more than 2.5 lakh patients without them being segregated. Doctors in the private sector do not seem to have any problem in treating rich patients – you never hear about a rich patient being thrown out. This is really a class issue. I suspect that 20-30% of HIV infected patients belong to the richer strata of society. These people do not come to government hospitals for treatment. I am only making a guess estimate on the basis of the amount of drugs being sold in the country.
Two studies in the West have concluded that ART, when started at a CD4 count of 350, saves lives. NACO guidelines recommend only "considering" ART for positive people who are asymptomatic or have mild symptoms. Are you planning to reconsider this decision or to start studies on when ART should be started?
All patients who are asymptomatic with a CD4 count of less than 250 are initiated on ART. Asymptomatic patients with a CD4 count more than 250 are followed up with regular CD4 counts and clinical examinations. They are also counselled on the need for a healthy lifestyle, good nutrition and regular exercise, and advised to come to the hospital if they have symptoms suggesting an opportunistic infection. Patients with a CD4 count less than 350 are initiated on ART if they are in WHO stage 3 or 4 (based on their symptoms and the presence of any AIDS-defining illnesses).
We try to maintain patients on first-line drugs as long as possible. Second-line drugs are 10 times more expensive than first-line drugs and more toxic. There are no third-line drugs available in India.
How can you explain the fact that states with a high HIV prevalence have registered a drop while those with low prevalence, including Delhi, Bihar and West Bengal, have registered an increase?
We had put all our resources in the high prevalence states and so the epidemic has matured there. As you know, the epidemic has a peak and then it goes down. We are now trying to ensure that the epidemic does not become severe in the other states.
What is happening to the HIV/AIDS Bill?
It is still pending and we are hoping that it will be cleared soon.