Cases of AIDS have been reported in India since 1986. A public health response to AIDS had started earlier, in 1985 itself, with the setting up of the Working Group at the Indian Council of Medical Research. Subsequently the National AIDS Control Programme was initiated in 1987. This developed into significant proportions over the 1990s with the World Bank supported AIDS control project in two distinct phases. AIDS also evoked a massive civil society response from the very beginning. Thus, more social energy and resources have been mobilised in such a short time against AIDS than for any other disease. It has also been widely recognised that AIDS is more than a medical problem and a large sections of society and governmental-nongovernmental organisations have been brought into the battle against it. Several lessons have been learnt and innovations brought into AIDS control efforts. Yet, we do not seem to have come to grips with the complex issues that need to be addressed. The programme initiators themselves acknowledge many limitations and even negative consequences of the interventions undertaken. This project titled ‘Dialogues on Strategies for AIDS Control in India’ is one among the many exercises being undertaken to try and put our heads together to understand the issues before us better and strengthen our response to the challenge the AIDS epidemic poses before us.

The perspective with which the exercise began was that no amount of funds, whether from a ‘Global Fund’ or otherwise, can lead to an effective response to the problem if significant rethinking is not done. Conceptual issues related to the progamme need to be addressed, not merely the issues of implementation. Towards this, the problem of HIV/AIDS was viewed in the context of:

i) the processes of globalisation and democracy, and

ii) a holistic public health perspective.

While various dimensions of both have been discussed extensively in relation to AIDS, the grassroots strategies for AIDS control continue without taking into account much of these issues that we are aware of. In fact we seem to be repeating many of the mistakes we have made in all recent epidemics and other communicable disease control programmes, whether it was the cholera and plague outbreaks or the malaria and tuberculosis control programmes. Basically, the linkages between different aspects are still inadequately dealt with. Therefore it was felt necessary to discuss the strategies starting from a holistic public health perspective.

Public health deals with problems at the macro level and recognises the need to study the epidemiological, socio-economic and socio-cultural dimensions of any problem in an integrated, interdisciplinary manner. However, within public health there are several diverse streams. They range from the very bio-medically centred, to the statistics centred, the management centred to the environment centred, the lay behaviour centred to the social action centred and various combinations of these. The basic principles of a ‘holistic’ public health perspective were delineated for examining strategies for AIDS control. It requires consideration of all the dimensions outlined below:

a) Consideration of a ‘societal’ response, as against a ‘programmatic’ perspective: This means viewing the organised / managed programme as one component of a larger cultural process. It requires the involvement of lay people of all sections in society as well as experts and administrators as active agents in the processes by which human societies have always explained and dealt with health problems. The existing resources of all kinds – economic, cultural, infrastructural, technologies and manpower – must form the starting point for any planning as the most societally ‘cost-effective’ way of dealing with any problem. Strengthening these existing resources and building new processes around them is necessary for long-term, sustainable outcomes. This must include the lay people’s existing ways of handling health-related issues and all their life concerns which impinge upon their health.

b) Integrated prevention and treatment strategies: Prevention and treatment strategies must be considered as an integral whole, for a number of reasons – because early diagnosis and treatment form a basic component of most disease control programmes, e.g. tuberculosis, malaria, leprosy. Also because treatment is often the primary felt need related to any disease, treatment gives confidence that the disease can be dealt with, and treatment services provide credibility to a health service or programme which is important for the success of any prevention programme.

c) Planning for multiple levels: Planning with a macro perspective for intervention at all levels – the macro level (i.e. at the international, national and state level), meso (i.e. community, group and sub-group level) and micro levels (i.e. household and individual level). Action at all levels must be conceptually interlinked in an integral manner so that each one supports and strengthens the efforts at the other levels.

d) Interlinking of multiple dimensions: A comprehensive interlinked consideration of the multiple dimensions influencing the extent and nature of suffering at all the levels, i.e. the social, economic, cultural, psychological, and biological dimensions influencing health and disease, together with the technological, infrastructural, and quality dimensions of health services and programmes.

e) Addressing diverse social segments: Consideration of the diverse social contexts of different sections influencing these dimensions in a society, e.g. by class, caste, ethnicity, gender, and of the interlinkages between the diverse sections.

f) A comprehensive macro approach: A comprehensive approach and holistic strategies to tackle the problem to be developed after evaluating various optional interventions, technologies and delivery systems in the light of all the points discussed above.

Viewed from this Holistic Public Health perspective several issues were identified as significant for consideration. It was recognised that Public Health has two faces – an egalitarian, humane face and a coercive one. Both of them are equally evident in AIDS control activities. All documents have explicitly espoused the non-stigmatising approach while the dominant activities, wittingly or unwittingly, promoted the stigmatising approach. Therefore, there is a need to delineate the detailed features and societal determinants of the two faces of public health in terms of AIDS action, so that one does not get promoted in the name of the other. The reiteration of human rights in relation to HIV/AIDS often appears more rhetoric than reality. Yet, the discourse does allow for efforts towards strengthening the humane and egalitarian perspectives within public health. How can this be done within the Indian context, with all its diversity and its specificities? Almost all spheres of human life become relevant for consideration from this perspective. For this dialogue we identified three spheres for strategies of AIDS control—sexual behaviours and sexuality, the medical system and communication.

Some background research was undertaken before the workshop (‘dialogue’) reviewing existing literature on these themes, primary research on AIDS related interventions among commercial sex workers and women in prostitution, and analysis of AIDS control policy and programme approaches. The results of this research as well as additional papers invited from other scholars, AIDS activists, AIDS control programme administrators and AIDS care providers constituted background material for the workshop.

The following pages provide (i) the background note setting out the issues from a holistic public health perspective which was circulated while inviting participants, (ii) an edited version of the transcript of recordings of the initiator’s presentations and discussions organised by the major themes for the sessions, and (iii) an executive summary of the proceedings. The editing was done with a view to keeping alive the main issues discussed while maintaining the live flow of the discussion, taking care to do away with undue repetitions.