Between theory and policy comes practice. Practice is the implementation and execution of theories that can inform the direction and nature of policymaking. Tackling HIV and AIDS in India has several well-established theoretical underpinnings, based on a proven track record of interventions deployed all over the world. What differentiates the outcomes of these interventions is not the theory but the application of the basic theoretical framework to local contexts and the creation of an enabling environment that allows these interventions to flourish.

The practice of theory—the implementation model and the management approach—is the key driver of program success. Policy should be informed by this practice, not only by theory.

The Indian HIV Epidemic: An Overview

The first HIV case in India was discovered in 1986 in a female sex worker in Chennai, a city in southern India’s Tamil Nadu state. Since then, the epidemic has mushroomed. In 2004 the National AIDS Control Organization of India estimated that 5.1 million HIV-positive people, or one of every eight cases worldwide, live in India. With a national infection rate of 0.9 percent, India seems to be at an early stage of an HIV/AIDS epidemic.

The situation may be more grave than this statistic reveals, however, as this number does not describe the multiple sub-national epidemics where the virus has already spread rapidly. For example, a district in the state of North Karnataka with a population of more than 2 million could have an adult HIV infection rate as high as 4 percent—that is, one in 25 adults is infected with HIV. In six Indian states (Tamil Nadu, Andhra Pradesh, Karnataka, Maharashtra, Manipur, and Nagaland), the epidemic has been classified as a “generalized” one—where greater than 1 percent of the attendees at pre-natal clinics are HIV positive, and prevalence among those attending sexually transmitted infection (STI) clinics is greater than 5 percent. These six states account for an estimated 75 percent of India’s total number of HIV-infected individuals.

Heterosexual transmission is the primary cause of the Indian epidemic. Unprotected sexual contact with sex workers, both male and female, is the primary driver. Groups that are most at risk of acquiring and spreading the infection are known as “core groups,” traditionally including male and female sex workers, men who have sex with men, and intravenous drug users.

India is still at an early stage of the epidemic, and an investment in prevention today can avert a potential socio-economic and public health crisis in the future.

Tackling HIV: The Theory

Working with core groups to reduce their risk of transmission is a well-accepted method of HIV control. The basic model of intervention with high-risk groups is proven and accepted in the world of HIV prevention and disease control. The model consists of five main components.

The first is behavior change interventions, such as community-level interventions by the peers of sex workers, structural interventions, counseling, and testing. The second is effective diagnosis and treatment of sexually transmitted infections among sex workers. Third, prevention requires condom promotion, such as offering free condoms for sex workers and subsidizing condoms for their clients. Fourth, cooperation with key stakeholders creates an enabling environment necessary for the intervention to flourish. The police, government officials, community organizations, and others must contribute to an environment conducive to prevention and care efforts. Finally, prevention efforts must be linked with the provision of care and treatment to those already infected with HIV.

We have learned that these basic components are crucial. But as Ronald Valdiserr, Lydia Ogden, and Eugene McCray have argued, “the biggest challenge to the science of HIV prevention is the need to implement in full what has been learned already.” Theories of HIV prevention exist; what has been missing is the practice of these theories to their fullest extent. Historically, many programs using this basic theoretical approach have fallen short primarily because they either have not been implemented to scale or have failed to empower the communities with which they work.

Working at scale in this context implies both breadth and depth of intervention coverage, or in other words, the saturation of the market with a quality product. Prevention intervention services—the five measures described above—should be provided to all of the riskiest groups, geographically and typologically. This requires covering the locations where the epidemic is being fueled and targeting all types of risk groups, including male and female sex workers, as well as intravenous drug users and their sexual partners. Depth means the provision of high-quality services through high-level technical input. This demands that intervention managers train local practitioners at the “grassroots” level, conduct site assessments, and engage in micro-level planning of daily outreach efforts to ensure high levels of rapport with the community. In addition, resource constraints require the identification of the appropriate set of levers that result in scaled impact: for example, focusing on select clusters of districts that are disproportionately important in the transmission dynamics of the virus, and creating alliances of implementing agencies to allow ready access to large high-risk populations.

The second often-missing element is community empowerment. Interventions heavily focused on such high-risk groups as sex workers have historically ended up stigmatizing these already marginalized groups. For example, Indian truckers have had a history of “targeted” interventions aimed at them; they are highly stigmatized as carriers of HIV to the extent that some face difficulties in getting married because the parents of potential wives fear infection. Instead, working through the communities most affected by HIV by mobilizing them and empowering them to undertake efforts with capacity-building support from NGOs reduces social isolation and provides a sustainable model for interventions.

The missing link in HIV control program implementation has been taking this framework to the next level—practicing all five of the above intervention components, at scale and through the modus operandi of community mobilization and empowerment.

This type of operation requires a level of management focus that many programs to date have lacked. Providing a service to 20 people is one thing; reaching 200,000 requires management expertise and the capacity-building of human resources. Here, the field of public health has faced some of its greatest challenges. While there are some success stories, including polio eradication in India, public health delivery mechanisms at scale have faced severe difficulties in implementation.