Read Part 1 here: TN’s HIV numbers may be falling, but here’s why the state should not grow complacent.PART 2.In the previous part, we saw how Tamil Nadu has a lot to cheer about when it comes to the fight against HIV/AIDS, and yet why this is not a time for complacency, as there are challenges, like the emergence of new at-risk groups. One of these groups are the young adults..“Out of nearly 30 to 40 new HIV case detections in the district in a month, nearly 15 newly infected people join our network,” says M Somesh, Founder Director of the Coimbatore Network for Positive People. He agrees that among newly detected cases, a large number of individuals come from outside the High Risk Groups (HRG). “A noticeable number of them are unmarried youths,” he adds..Awareness levels about HIV spread have not seen a corresponding rise among the youth. According to a UNAIDS report, in the year 2006, 25.67% of young adults were found to be aware of the risk of HIV, while in 2016, this number had increased very marginally to 26.16%..In comparison, HIV awareness and testing reach is very high among HRGs. At the Salem Government Medical College Hospital, for instance, Integrated Counselling and Testing Centres (ICTC) employees reveal that, from January this year, not a single case was detected among persons from HRGs. The Attur ICTC centre averages 30 new detections a month and, again, the number of cases from the general population outweighs those from HRGs. In Dharmapuri district, new infections are high among the bridge population (migrant workers), from whom HIV spreads among the general population in villages and in small towns, says Raja Mahendiran, President of the Dharmapuri District HIV Positive Welfare Society. Similarly, P Kousalya, Founder of the Positive Women Network in Chennai, says that new members joining the network come from diverse backgrounds. They include married, separated, and divorced individuals, and students. Among occupational groups, night shift workers including ITES sector employees number high among the new detections, she adds..There are also some region and district specific variations in this epidemic profile, with Dharmapuri showing a higher prevalence of HIV infections among the migrating labour force, while workers in micro and small industries clusters in Salem, Namakkal, Erode, Coimbatore and Tirupur are vulnerable. In these settings, sexual contact between employers or supervisors and female workers could be transactional in nature, in that they are motivated by the implicit assumption that sex will be exchanged for material benefits, including continued engagement in work. The correlation between the risk of HIV spread and widespread practices of bigamy, polygamy and polyandry practiced in districts like Salem, Dharmapuri and Krishnagiri is yet to be analysed. According to a staff member at Salem GH’s ICTC, a significant number of newly diagnosed persons are married but in a relationship with persons other than their spouse, or people who have separated from their spouses and are living with a new partner. Unmarried persons engaging in premarital sex also numbered among those newly diagnosed. Most of the newly diagnosed persons had been infected for quite long periods, but were unaware of their infection, say counsellors at the ICTC..The urban/rural profile of new HIV infections among the general population is equally distributed among rural and urban areas, with Chennai showing markedly lower rates of new detections..Engaging the common man.Tackling HIV/AIDS at a general population level is a delicate issue for programme implementers because of the culturally shaped mindset that still stigmatises HIV and AIDS, leading to strong denial behaviour. HIV and AIDS are still seen as “a disease affecting sexually deviant individuals”. This limits accurate data collection as many infected persons avoid testing because of the possible stigma..Yet, the stakes are high, as high risk behaviour among members of the general population can have a greater potential to spread the virus among a larger population, says Dr Lukas Babu, Founder Director of the Rural Integrated Development Organisation in Dharmapuri District. He says that persons exhibiting high risk behaviour in rural and small town settings often come from what are considered to be the higher rungs of societal hierarchy. They are, hence, a hidden and elusive group, whom it is difficult to influence through peer group interventions..Collector Rohini in intimate conversation with a community lunnch hosted to mark World AIDS Day 2017 December..The stigma associated with HIV, some activists say, actually works to deny women gender justice. Kousalya, for instance, points out that women bear the brunt of unsafe sexual behaviour. Women from outside HRGs, who seldom display high risk behaviour, are increasingly among the newly infected, says Kousalya. Kousalya argues that making disclosure of HIV status mandatory at the time of marriage will help protect women from being infected. However, as a result of the continuing stigma attached to HIV, the new HIV/AIDS Bill 2017 provides that no persons shall be compelled to disclose their HIV status except with their informed consent, and if required by a court order..Programmes aimed at reducing infections among the general population are not as intense and sustained as the engagement with high risk groups. But the danger posed by hidden virus carriers among the general public is enormous as such cases are detected late and come to light only during ante-natal tests, mandatory tests before surgeries or other treatments. Living with the virus for long without knowledge of being infected means that such persons could spread the virus to many others through circuits of persons engaging in high risk behaviour. A virus-supressed HIV positive person (a person on ART) is less likely of, if not totally incapacitated from, transmitting the infection. India’s success in reversing the HIV/AIDS epidemic is largely attributed to its evidence-based programmes implementing the strategy of targeted Intervention among high risk groups. As part of collecting this evidence, India carried out the world’s largest Integrated Biological Behaviour Surveillance as part of the NCAP 4. However, when it comes to the general population, large data gaps exist that must be closed to formulate effective behaviour change communication and programmes, say experts..Particularly with regard to adolescents and young adults, limited sample sizes reduce the available evidence to inform programming. Due to these gaps, adolescents and young people are often missing from national HIV strategic plans, beyond Prevention of Mother-to-Child Transmission (PMTCT) interventions. This is also true in the case of women, says Kousalya..Though testing for HIV cannot be mandated, NACO, in its NSP 2017-2024, has adopted the global 90-90-90 strategy to fight high prevalence. According to this strategy, it is aimed to ensure that 90% of persons living with HIV (PLWH) should know their HIV status, 90% of diagnosed PLWH should be on ART and 90% of PLWH on ART should be virally suppressed by the year 2020. By 2030 AIDS should be eradicated as an epidemic. However, the question of the extent to which this goal is translated into action on the ground needs to be posed in the light of the current saturated TI focus of officials and the system orientation..Fund shortage.One of the key difficulties for TN to craft an AIDS prevention and control programme for the general population is the population’s huge size and diversity, cutting across multiple socio-economic, cultural, occupational, demographic, and educational strata. For such a scale, the costs of awareness campaigns and prevention programmes will pose a great challenge. .However, a growing fund crunch stands as a massive obstacle in the way of any broad-based efforts by TN. Before 2012, efforts to tackle the HIV epidemic in India relied heavily on international funding. In 2012, India committed to financing 90% of its HIV and AIDS programmes. In recent years, India’s domestic funding for its HIV response has decreased significantly, falling by 22% (948 million USD) between 2014/15 and 2015/16. Consequently, it has been a tightrope walk for TANSACS, with the organisation struggling to clear salary bills for staff members of NGO partners over the last few months, officials say. According to information obtained through an RTI, the total expenditure of TANSACS has been dwindling to drastically low levels, from Rs 159.36 lakh in 2013-14 to Rs 33.16 lakh in 2014-15, Rs 90.38 lakh in 2015-16, Rs 53.96 lakh in 2016-17 and Rs 20.13 in 2017-18..‘Enough being done’.Some doctors who are part of TANSACS’s HIV/AIDS control efforts, however, feel that the organisation’s efforts are sufficient to address the problem. Dr Sundaresan of the District AIDS Prevention Unit in Coimbatore, for instance, defends TANSACS’s on-going programme. “Through blood donation camps, awareness rallies, and special observances like the annual candle light programmes the general population is being reached. A mobile testing unit goes around in all districts to create awareness and to test the general public with informed consent,” he says..The numbers, he adds, speak in TANSACS’s favour. “The data showing new infections among the general public and a telling decline among persons from high risk groups testifies that more people among the general public are becoming aware and coming forward to get tested. And the high risk groups being a concentrated lot, the interventions have reached saturation and a majority of them are already tested.”.“As regards reaching the youth the red ribbon clubs in educational institutions are active enough to raise the level of awareness and are providing the motivation to shed stigma and to go in for voluntary tests. The mobile app Iyyam Thavir (Clear your doubts) is a one stop outlet for information about AIDS infection, treatment, care and support services,” he says..Glaring Gaps.However, the NACO’s National Strategic Plan (NSP) 2017 highlights significant points that validate doubts about such claims. The document points to several gaps that need to be filled: Identifying larger ‘at risk’ groups; designing, demonstrating and upscaling appropriate-prevention intervention strategies; linkage of this group to test and treat services; gaps in prevention focus; gaps in coverage and quality, especially at sub-district health facilities; reporting gaps, including those from private sectors and the National Health Mission; lack of adequate, appropriate and current data for planning; lack of coordination between different departments and NACO on youth programmes; and a lack of innovative activities under youth intervention..The last two years of NACP IV have seen a paucity of funds, coupled with changes in the mechanism for disbursement, thus affecting the scale and nature of information, education, communication (IEC) initiatives. Some of the challenges and gaps in IEC and communication are: adoption of newer technologies, in-depth analyses of ICTC data with special focus on the socio-demographic and self-reported risk behaviour information that counsellors collect, testing data analysis to produce preliminary results, and data quality assessments to ascertain to what degree “at risk” groups are under- or mis-reported as “belonging to an HRG”. State and District AIDS Control units will require adequate fund flows and programme modifications to address these issues in order to stay on course with the NSP..Course correction needed.NACO’s NSP recognizes data gaps in identifying people as at-risk, and conversely, inaccurately identifying walk-in HRGs as part of the general population. A more accurate system of epidemiological profiling is being aimed at by fine tuning surveillance and monitoring systems at the district and sub-district level and also to reach out to more persons with high risk behaviour who remain untested. Despite progress in this direction, around one quarter of people living with HIV in India (23%) are unaware of their status according to UNAIDS..Targeted interventions are implemented on the premise that prevention of HIV transmission among key groups (HRGs) will lower HIV spread among the general population. AIDS prevention in TN too is largely a TI exercise due to the state’s epidemiology being concentrated primarily on HRGs. But the emergence of new at-risk groups and persisting rates of infection in high prevalence districts point to a course correction that is urgently needed.