The attributable factors for such rapid spread of the epidemic across the country today is labour migration and mobility in search of employment from economically backward to more advanced regions, low literacy levels leading to low awareness among the potential high risk groups, gender disparity, Sexually Transmitted Infections and Reproductive Tract Infections both among men and women. The social stigma attached to sexually transmitted infections also hold good for HIV / AIDS, even in a much more serious manner. This, coupled with lack of awareness, results in reporting of full-blown AIDS cases in cities like Mumbai and Chennai causing severe strain on the hospital infrastructure.

There have been cases of refusal of AIDS patients in hospitals and nursing homes both in Government and private sectors. This has compounded the misery of the AIDS patients. More often it is mistaken to be a contagious disease and patients are isolated in the wards creating a scare among the general patients. In the workplace there were cases of discrimination leading, in some occasions, to loss of employment. The active part played by some non-Governmental organisations in bringing out public interest litigations against such cases of discrimination and the judicial pronouncements by courts in support of the rights of such people has helped in alleviating the misery of the affected persons.

The treatment options are still in the initial trial stage and are prohibitively expensive. While there is no vaccine in sight at least till the year 2000 AD, multi-drug protease inhibitor therapy, popularly known as 'cocktail therapy', is not a cure to the disease and may help only in prolonging the life of the patient. Therapeutic trials of these drugs are still in an elementary stage and there are fears of patients developing drug resistance and side effects if the therapy is not administered under proper medical supervision. There were instances of quacks taking advantage of the situation and promising cure through so-called herbal treatment and defrauding unsuspecting people who are infected with the virus of large sums of money.

b) Limited to 8% of the cases, is also a serious Transmission of the disease through blood, though issue as unsuspecting population can get infected through this route if safe blood is not ensured. Existence of a large number of small and medium blood banks, many of them in the private sector, also compounds the problem. The Supreme Court directive of May, 1996 has helped in phasing out unlicensed blood banks by May, 1997 and the prospective phasing out of professional blood donors by December, 1997. Compulsory testing of blood for HIV along with Syphilis, Malaria and Hepatitis B, which has now been introduced throughout the country will help in checking transmission of HIV virus through blood transfusion.

c) The problem of injecting drug users is not universal and is restricted to the north-eastern States and the urban pockets of metropolitan cities. The injecting needles which are the principal cause of transmission in such cases are used repeatedly by the drug users. The twin problem of drug addiction and HIV transmission pose a serious ethical and moral problem in the HIV prevention programme. Needle exchange programmes which have been taken up in other countries to ensure availability of sterile needles for drug users are frowned upon in India because of ethical and moral implications.

d) Although transmission of HIV through use of needles, razors and other cutting instruments in the thousands of beauty parlours, hair-cutting saloons and dental is insignificant, lack of hygienic practices in majority of these establishments also poses a health risk to the unsuspecting general population who visit these places every day. There is a great necessity in bringing these establishments to acceptable standards of hygiene to minimise and almost eliminate the chances of HIV transmission through the use of needles and sharp cutting instruments.

e) With about 14 million TB cases existing in India, HIV/AIDS also poses a twin challenge of HIV/TB coinfection. Nearly 60% of the AIDS cases are reported to be opportunistic TB infection cases. Treatment of TB among the HIV-infected persons is a new challenge to the National TB Control Programme which has now adopted DOTS strategy for control of TB infection. Some of the drugs which are recommended for TB treatment pose complications in cases of HIV-infected persons and had to be withdrawn in areas of high HIV prevalence. At the same time looking for HIV among TB infected persons will also cause the problem of scaring away of a large number of TB infected cases in the country from seeking treatment under the DOTS strategy. There is no risk of any TB patient getting infected with HIV unless he or she practises high risk behaviour or gets infected from transfusion of HIV-infected blood.

f) HIV/AIDS is not a disease which spreads randomly and is transmitted as a consequence of a specific behavioural pattern and has strong socio-economic implications. It not only costs huge sums of money in terms of controlling the opportunistic infections such as TB, Pneumonia and cryptococcal meningitis, but seriously affects individuals in their prime productive years causing serious economic loss to them and their families.

g) All these aspects provide an unusual challenge of HIV infection through various routes which comes with its long period of invisibility and does not show out with opportunistic infections till a few years. In India with a large population and population density, low literacy levels and consequent low levels of awareness, HIV/AIDS is one of the most challenging health problems ever faced by the country.

2.1 Soon after reporting of the first HIV/AIDS case in the country, the Government recognised the seriousness of the problem and took a series of important measures to tackle the epidemic. A high-powered National AIDS Committee was constituted in 1986 itself and a National AIDS Control Programme was launched a year later. In the initial years the programme focussed on generation of public awareness through mass communication programes, introduction of blood screening for transfusion purposes and conducting surveillance activities in the epicentres of the epidemic. In 1992 the Government formulated a multi-sectoral strategy for the prevention and control of AIDS in India. It is implemented through the National AIDS Control Organisation at the national level and State AIDS Cells/Societies at the State/UT levels. The programme concentrated on the following areas which conform to the global AIDS prevention and control strategy:-

i. Programme Management
ii. Surveillance and research
iii. Information, Education and Communication including social mobilisation through NGOs
iv. Control of Sexually Transmitted Diseases
v. Condom Programming
vi. Blood Safety; and
vii. Reduction of impact.

2.2 Five years into the programme, the Government can look back with a certain measure of satisfaction for its success in important areas like generation of awareness about HIV/AIDS among the urban and rural population of the country. Awareness levels which were almost insignificant have increased to about 70-80% in urban areas even though the level of awareness in rural areas remains low at about 30%.

2.3 Several important actions have been taken to ensure safe blood by modernisation and strengthening of blood banks, introduction of licensing system of blood banks and gradual phasing out of professional blood donors. Introduction of component separation facilities has also

helped in reducing the use of whole blood for transfusion. Some very successful intervention programmes among the high risk groups like commercial sex workers in the Sonagachi area of Calcutta, men having sex with men in Chennai and injecting drug users in Manipur were carried out through the dedicated involvement of non-Governmental organisations. Availability of good quality condoms through social marketing has made a significant increase in the last three years.

2.4 There are still many gaps left in the programme and many lessons have been learnt during the last 11 years. The inexorable spread of the disease from the initial epicentre to the rest of the country underscores the immediate need to have a paradigm shift in the response against HIV/AIDS at all levels making it imperative to formulate a comprehensive national policy on HIV/AIDS in order to cope effectively with the changed nature of the HIV/AIDS problem. The entire programme of prevention and control of HIV/AIDS needs a shift towards a more holistic approach looking at AIDS as a developmental problem instead of a mere public health issue.