Between 1993 and 1998, it was believed that about 1.6% of the general population in Tamil Nadu was HIV-positive. By 2004 that had dropped to 0.5%. TANSACS's innovative information, education and communication (IEC) campaign was responsible for this dramatic drop. Laxmi Nair finds out more about the campaign
Five years after the first HIV-positive case in the country was reported in 1986 by the microbiology department of the Madras Medical College, physicians and policy makers in Tamil Nadu were still battling to make sense of the virus. Then, in 1993, the State AIDS cell began functioning with funding from the World Bank and the National AIDS Control Organisation (NACO). The same year the Government Hospital of Thoracic Medicine at Tambaram began its tryst with HIV/AIDS by admitting two HIV-positive people with TB co-infection.
The following year, the state AIDS cell became the Tamil Nadu State AIDS Control Society (TANSACS), based on the autonomous society model successfully introduced by the National Blindness Programme. Run by a civil servant rather than a medical professional, its policy making and purse strings are independent of the state health department and three NGO representatives sit on its board to ensure that their voices are heard.
TANSACS funds and supports 200 NGOs in programmes to create awareness, facilitate counselling, care, and treatment for people living with HIV/AIDS. This includes NGOs and capacity building organisations that work on interventions and advocacy, and networks of positive people like the Positive Women’s Network (PWN+) and the Tamil Nadu Network of Positive people (TNP+) who work more on care, treatment and support. An NGO adviser has been appointed to make interfacing easier. The major outcome of this partnership has been the capacity building that has come out of continuous focus group sessions and training in preparation and management of projects. Field visits and constant monitoring of progress make certain that goals are achieved.
Though the programme began in 1994, prevalence figures in the state showed no signs of receding till 1998. Information, education and communication (IEC) programmes then moved track and included care and support. Despite this, the ebb and tide continued till the trend truly became downward in 2002.
In 2000, the state government announced that the epidemic had begun to slow down, though it took another two years to actually show up in figures of prevalence as extrapolated from antenatal clinic attendees. These samples have been accepted by NACO and the state AIDS cells as being representative of the general population.
The prevalence among the general population which was roughly 1.63% in the period from 1993-1998, hovered around 1% from 1998-2000, saw a mild spurt to 1.13% in 2001 and reversed direction to 0.88% in 2002 and 0.75% in 2003, to stabilise at 0.50 by late 2004 (Source: NACO website)
An effective IEC programme
The state’s primary strategy was a massive, highly visible IEC programme that included billboards, leaflets, bus panel advertising, spot advertisements in cinemas, on television and radio. Door-to-door campaigning in slums and industrial areas by outreach workers and posters in hospitals and clinics helped to dispel misconceptions about the disease. Woven into folk arts and street plays, the message is constantly being reiterated to entrench itself in the common man’s awareness.
One of the key preventive strategies followed in Tamil Nadu, which worked well, was to target campaigns at both high-risk groups and the general public. The Tamil Nadu State AIDS Control Society (TANSACS) has roped in a panel of reputed advertising agencies with commendable work in social communication to spearhead the campaigns.
AIDS education in high schools and compulsory awareness campaign spots in cinema theatres led to an impressive 96.2% awareness rate among the general population by 1997, according to a Scope Marketing evaluation study. Though awareness soared, the high prevalence rate proved that it takes time for awareness to get translated into informed behaviour patterns and show up as a change in prevalence trends.
When HIV infection among pregnant women soared to 1.25 % in 1997, all concerned worked to spread awareness and effect prevention. What started as a fear-based campaign that said ‘do this and get the virus’, changed, as feedback from affected communities and social scientists came in. Condom promotion took centre-stage and TANSACS hired an international advertising agency to take the campaign forward.
In late 2003, the advertising campaign came out with a character called Pulliraja who helped promote condom use. The campaign was successful according to the Behavioural Surveillance Survey 2005 conducted by the Social and Rural Research Institute, New Delhi for the AIDS Prevention and Control Project (APAC), Chennai. The survey studied change among various groups targeted by intervention programmes. Nearly 16,000 people including commercial sex workers, injecting drug users (IDUs), men who have sex with men (MSMs) and truckers were interviewed. Several focus group discussions that followed up on the interviews revealed that condom use among sex workers had improved.
The study attributed the sudden spurt in condom sales and use at least partially to the high-recall Pulliraja campaign which screamed from billboards, bus panels, television screens and cinema halls. The campaign had by then started moving into the villages as well.
To give the campaign a rural flavour, folk arts such as Oilattam and Therukkuthu were made the vehicles for information transfer. (Oilattam is a street corner dance drama while Therukuthu is a long play, usually performed in the evenings). This infotainment module which is woven into the extended folk format gives ample time for messages to be aired, and was initially launched in the two backward districts of Cuddalore and Villupuram. This TANSACS-sponsored programme got such an overwhelming response that it was extended to all 30 districts of the state.
Officials and outreach workers say that street plays and puppet shows continue to draw large crowds in villages with the audience responding with queries on facts and fiction regarding the virus. Information pamphlets, audio and video cassettes are disseminated with the help of the strong networks of NGOs, the positive community and peer educators. The video-on-wheels programme which has been under way for more than a decade has helped dispel several misconceptions about the disease, especially in low literacy areas.
The campaign, which was undertaken by the government in association with Population Services International (an NGO that addresses health problems of low income and vulnerable populations in developing countries), did come in for criticism from some quarters. In a bid to stem risky behaviour and promote faithfulness, it warned of the risks of visiting commercial sex workers when there was a wife at home. Critics termed this anti-woman because according to them it “made the woman the carrier and transmitter of the virus”. Both the accolades and the blame, however, helped to keep the debate alive, giving it the much needed space in the minds of the urban and rural public.
Making treatment available
With the emphasis shifting to women and children, IEC on Prevention of Parent to Child Transmission gathered momentum and made its way into rural Tamil Nadu. With heavy lobbying from the HIV-positive community, the emphasis on treatment, care and support increased in the late 1990s. The information that there was an increased chance of an HIV-positive mother delivering an HIV-negative child with the help of the drug Nevirapine, was widely disseminated. Information about addressing opportunistic infections and practising hygiene was also introduced. As AIDS rendered several women and children homeless and orphaned, new campaigns on legal rights, especially property rights of AIDS widows, came into focus.
Dr Suniti Solomon who was head of the microbiology department at Madras Medical College when the first case of HIV in the country was recorded there, explains that the campaign’s success owes much to the thrust on treatment, care and support, in the late 1990s. “If you do not give patients drugs and talk of prevention in your campaigns, no one is going to listen to you. Instead, you give them medicines, information on care and nutrition and then they end up being peer educators and ambassadors in the fight against the spread of the virus.”
However, there is still a long way to go when it comes to addressing stigma and discrimination, says Dr Solomon, who now heads YRG CARE in Chennai. Though treatment, especially antiretroviral therapy (ART) was in the hands of the private sector and NGOs till December 2004, its availability generated hope among affected communities that the virus can be combated.
An ART centre was set up in Madurai in 2004, and a district level co-ordination committee (DLCC) followed to function as a nodal agency for HIV/AIDS management for migrant labourers. The DLCC had labour and trade union representatives as members. However, erratic drug supplies and irregular functioning of the ART centre affected the credibility and functioning of the DLCC.
This was obvious during a visit to the Madurai centre in 2004. In the serpentine queue of patients were many who had been referred from TB or STD outpatient departments without being told why they were sent to the ART centre. There was just one doctor and nurse in attendance.
It was only when the centre began functioning properly two years later, and drug accessibility was assured that the DLCC's work of disseminating HIV/AIDS related information became easier to implement, says P Rajendran of APAC. (APAC works to prevent and control the spread of HIV/AIDS through the sexual route. It is jointly funded by the United States Agency for International Development and NACO). Without drugs and accessibility, the DLCC's work was just shallow talk which Positive people did not take seriously, Rajendran said.
Factoring all these aspects into a relatively balanced campaign with prevention, care and support has seen AIDS progress from an inevitably fatal condition to a manageable and treatable chronic illness. With the Sentinel Surveillance Report showing prevalence falling to 0.5% in 2005, Tamil Nadu is poised to stake a claim to be shifted out of the high prevalence category to that of a moderate prevalence state.
Shifting focus to care and needs
P Koushalya of the Positive Women’s Network (PWN+) says there is no dearth of IEC material on prevention and advocacy in the state. With a free legal aid cell having been set up in Namakkal and another ready to begin operations in Madurai, material on legal rights for HIV-positive persons - especially women - is also being circulated widely. What is needed now is more information and dissemination of such information highlighting the importance of good nutrition for HIV-positive people to live healthier lives.
According to TANSACS, nearly 75% of HIV transmission in the state is sexually communicated, so safety and faithfulness messages are very visible both in rural and urban areas. Clinicians Dr C N Deivanayagam and Dr S Rajasekharan say that the drop in prevalence rates is due to higher levels of safety in sexual behaviour.
However, material on caring for the infected is still not commonly seen, though TANSACS has released a few advertisements to address this issue. There also seems to be a real paucity of material when it comes to the special needs of infected and affected children and paediatric antiretroviral therapy.
Religious organisations have been roped in to strengthen the message as was seen in the Inter-Faith Workshop on HIV and AIDS held in early 2007. Its focus was on dispelling myths surrounding the virus and fighting stigma and discrimination. Several corporate enterprises under their new slogan of corporate social responsibility have been helping to spread awareness and to address issues of stigma and discrimination by organising short lectures and interactive sessions at the workplace. Posters and information booklets are also visible in common areas like food courts and recreation areas in cities and suburbs.
Red Ribbon Clubs have been set up in schools and colleges to train young student volunteers to make information on sexuality, teenage pregnancies, and sexually transmitted infections (STIs) widely accessible. This is conveyed through interactive, lively events like role-plays, brainstorming, street theatre, elocution, debates, poster-making etc.
The compulsory AIDS education component in the state’s high schools has evoked a mixed response. P Kothai, a senior secondary school teacher in Kancheepuram is apprehensive: “It is not at all easy to talk of the issue in a classroom. I agree that it is important that students who are potentially sexually active adults should have clear factual ideas on sexual education and HIV and AIDS without the old wives tales they usually imbibe.” Nancy Mathew, a biology teacher in the same school felt that it was in the vehicle of dissemination that the problem lies. “If we were to put HIV and AIDS as a chapter in the biology textbook alongside reproduction and reproductive health, it will be a hassle-free exercise. The current separate status for the subject leads to most teachers asking the students to read through it on their own.”
P Koushalya of PWN+ pointed out that because teachers were so obviously uncomfortable with the subject, students read about it with much more interest so the purpose of information dissemination was achieved nonetheless!
The story of AIDS education in the state capital, Chennai, is however different. The Chennai AIDS Prevention and Control Society (CAPACS) has trained headmasters, teachers and two students each as peer educators in 65 municipal corporation schools through their school AIDS education programme. This process started in late 2006 has also seen the formation of Junior Red Ribbon Clubs, where students become information ambassadors not only on issues related to HIV and AIDS, but also for health and hygiene.
Factors for success
Clinicians like Dr Solomon and representatives of positive people like P Koushalya feel that the success of the Tamil Nadu model is partly due to the strategic shift from the ‘victim’ and ‘fear’ concepts to a happy, feel-good campaign that does not, in any way, dilute the seriousness of the issue.
Fortunately, change in government in every election since 1985 has not affected commitment to the AIDS programme. Notwithstanding mutters in bureaucratic circles about HIV/AIDS assignments being punishment postings, TANSACS project directors, without exception, have maintained continuity in policy planning and implementation.
Programmes and projects have been consciously moved out of the state capital. The voices of most stakeholders are being heard to a great extent. Specific groups like men having sex with men (MSMs) and injecting drug users (IDUs) still complain that their interests are not being heeded, but the general direction seems right. The emphasis on co-opting community networks and non-governmental organisations and realising the efficacy of peer educators has also helped significantly.
Though there are still miles to go before HIV/AIDS becomes just another disease, the integrated IEC campaign has been sustained and that is a positive sign. An ORG-MARG and Scope Marketing evaluation in 2001 showed that the general awareness about HIV and AIDS increased from 23% in 1992 to 96.2% in 2000. The survey attributed this to the efficacy of the IEC programme which reached 32% of the audience through releases and advertisements in the press. Though television also had a wide reach, it was found to be more urban specific. Radio messages proved to have the deepest penetration, especially in rural areas, reaching nearly 75% of people. Interestingly, bus panel advertising also managed a decent reach of 38 %.
Another interesting fact that came out in the study was that condom use among commercial sex workers had increased to 66%. This finding, however, is open to debate, as the power of the woman to negotiate sex is still unclear. To counter issues arising out of this, NACO launched female condoms in the state capital Chennai in March 2007, as part of its pilot project to understand social acceptability among sex workers.
With more IEC material under preparation on the female condom, blood safety and opportunistic infections - especially HIV-TB co-infection - to supplement its HIV/AIDS programme, Tamil Nadu today presents a strong claim to be a model state for HIV and AIDS management.
(Laxmi Nair is Chennai-based web editor and manager (monitoring and evaluation) with Panos South Asia)
Infochange News & Features, February 2008