PANOS London: 15 October 1996.
C.Y. Gopinath

She has taught her five-year-old son to feed his infant sister for neighbours have refused to baby-sit the children ever since they learnt that both parents are carriers of HIV, the virus which causes AIDS.

Anusuya's husband, a weaver who acquired the infection through unsafe sex outside marriage, has only a few months left to live. Anusuya faces homelessness, poverty, disease, and the fear that even her relatives will finally abandon her.

Parvati, 28 and HIV positive, is mother of three HIV-positive children. When her in-laws discovered that her husband, a police constable, was HIV-positive, they blamed her for it and threw her out on the streets to fend for herself.

After he died of AIDS two years ago, Parvati applied for and got a job as a clerk at the police department under a special scheme. Now that she has begun earning again, her in-laws have welcomed her back, though they realise that it is only a matter of ti me before she gets AIDS.

More and more cases like these are surfacing all over Maharashtra, a state which has almost half of all cases of AIDS in India and where the number of new HIV infections continues to rise rapidly. The state capital, Mumbai (formerly Bombay), has the high est reported HIV prevalence among all cities in India.

There were an estimated 30,000 people with HIV in July this year in Maharashtra, a dramatic increase from earlier figures. The epidemic is beginning to affect entire families, with virus usually being passed from an HIV-positive man to his wife, and then to their newly-born children.

Studies from the city's maternity wards indicate a steady rise in the number of HIV-positive women attending ante-natal clinics, with 2.8 percent testing positive compared to a national average of 1.6 percent. Most of them come from poor and struggling communities, thrown suddenly in the shadow of a disease they had always considered remote.

In high-risk groups such as commercial sex workers, HIV prevalence is estimated at between 70 and 80 percent.

The continued rise of HIV has led the state government to acknowledge that its AIDS strategies have not worked and have been based on incomplete research.

''There has been no provision for research, situation analyses and KAB (knowledge, attitude and be haviour) studies in any of our budgets till now,'' says Dr. Jagtap of the state government's Department of Health Services (DHS). ''As a result, strategies have not been based on a detailed understanding of how the disease is spreading in the state.''

But if the Maharashtra government's response to AIDS has been poor, it is at least acknowledged as having reacted more quickly than other Indian state governments, and far more quickly than the national government, whose initiatives, critics argue, have been sluggish and half-hearted.

It is becoming generally accepted that India's AIDS control programme -- beset by cumbersome bureaucracy, lack of political will, mismanagement and nepotism -- has had little impact on the epidemic.

The United Nations AIDS Programme (UNAIDS) estimates th at India will have between five and eight million people with HIV by the year 2000 -- the highest in the world.

The National AIDS Control Organisation (NACO), which is designed to coordinate the response to the epidemic in the country, is considered by many experts to be impotent and lacking authority, staffed by civil servants with no real perspective on AIDS.

Central to criticisms of the Indian government has been its administration of an 85 million dollar-loan from the World Bank. Four years after it was granted, only 35 million dollars have been spent.

However, Maharashtra may be on the verge of an unprecedented shift in its approach to tackling AIDS -- a move that could be followed by other states. The impetus comes from an open-eyed 200-page study by AAMRAE, an NGO working in rural Maharashtra.

The document -- commissioned by the DHS and the United Nations Children's Fund (UNICEF) on the suggestion of Maharashtra's Chief Minister -- is still undergoing revisions, but is unequivocal in two important recommendations.

The document urges that the state should move away from an AIDS control strategy based on medical and clinical intervention to one that aims to change behaviour by understanding and confronting the underlying social conditions that are driving the epidemic. And, it argues, information and education campaigns must be complemented by more targeted interventions and by efforts to improve care for people with AIDS.

Support for this approach is already building up.

''The AIDS field in Maharashtra and India has been hijacked by medical people, who have been treating it as just another disease,'' says Dr Subhash Hira, director of the Maharashtra government's AIDS Research and Control (ARCON).

''The reason we have fail ed to control AIDS is that we have ignored the social and behavioural issues that fuel the epidemic.''

But the fact that AAMRAE's ground-breaking study was preceded by Maharashtra's first-ever strategic plan to tackle the AIDS epidemic has led to fears that AAMRAE's recommendations may be sidelined. The state's plan -- formulated in January this year, nea rly five years after the fight against AIDS began here -- was drawn up by the DHS, ARCON, UNICEF and Seva Dham, an NGO.

Based on it, the World Bank sanctioned Rupees 210 million (6.3 million dollars) to the state, to be spent before December 1997.

There have been criticisms of the plan, particularly that the views of people living with HIV/AIDS were not sought. There also are reservations about its lack of emphasis on confronting tuberculosis, the most common AIDS-associated infection in India.

However, Dr Hira sees no clash between the strategic plan and AAMRAE's recommendations. ''I see AAMRAE's report as a very important addition to the plan -- one that will vastly increase our chances of success,'' he says.

If he is right, AIDS workers in Maharashtra, who have become increasingly demoralised at the lack of governmental commitment to combat the AIDS epidemic may now see credible action. But for people such as Anusuya and Parvati, the renewed government response may be a case of too little, too late. (END/PANOS/CYG/DDS/96)

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