Governance of HIV/AIDS: Implications for Health Sector Response (original) (raw)

HIV/AIDS scenario: a different epidemic Globally, there were 35.30 million people living with HIV by 2012 with 2.10 million in India (1). Government of India estimates that about 2.40 million Indians are living with HIV (1.93-3.04 million) with an adult prevalence of 0.31% (2009) of whom 39% are female and 4.40% are children (2). India began preventive actions targeting to slow down the epidemic at an early stage; a possible explanation for the low prevalence of 0.30% in the adult population (3). During the Cairo International Conference on Population and Development (ICPD+5), all countries recognized the genuine opportunity to plan for the end of AIDS, and accordingly agreed on targets for action. These actions are to be insured through provision of access to information, education, and services necessary to develop life skills required to reduce vulnerability to HIV infection (4). The case of India: current situation and challenges ahead The primary drivers of HIV epidemic in India are commercial female sex work, unprotected sex between men who have sex with men, and injecting drug use. Based on program data, unprotected sex (87.40% heterosexual and 1.30% homosexual) is the major route of HIV transmission, followed by transmission from parent to child (5.40%) and use of infected blood and blood products (1%). While injecting drug use is the predominant route of transmission in North Eastern Indian states, it accounts for 1.60% of HIV infections (Figure 1). HIV epidemic in India is concentrated in nature and heterogeneous in its spread. While interventions have brought successful decline in HIV epidemic at most of the places, emerging pockets and risk groups with high vulnerability warrant focused attention under the program. Challenges remain in sustaining effective governance of health sector response using health systems approach in the existing scenario to fight against AIDS in India. In a large diversity setting in India, government effort would be difficult and ineffective in strategizing disease-specific safeguards for infection control and health waste management instead, the facilitation of health systems strengthening approach with defined responsibilities at the implementation levels is advocated. Health systems approach is needed in deciding safeguard policies instead of bureaucratic 'box-ticking' compliance that uses scarce time and disease-specific resources without adding value for intended beneficiaries. In case of HIV/AIDS, convergence strategies with National Rural Health Mission (NRHM) remains strategic as well as challenging using health systems as response. Strengthening health systemsparticularly HIV-related infrastructure, logistics system, and human resource capacities-is inbuilt to the national program of HIV/AIDS instead of being convergent with NRHM which accounts for health systems capacity and outcome in both rural and urban areas. How do these stresses, relationships, and changes in governments affect health systems' capacities to deliver treatment and care? How are legislative and policy reforms in area of local government, service delivery, and governance impacting the access of HIV/AIDS affected households and communities to health, education, transportation, agricultural extension, and other services? What governance factors do determine differences among countries and regions? What challenges does the availability of treatment create for distribution, access,