Battling AIDS in India

In a country of a billion people, about 4.6 million are HIV positive. If the problem is left unchecked, that number could reach 20 million to 25 million by the decade's end. A single country could have an HIV-positive population larger than the total populations of London, New York, and Tokyo combined. Ashok Alexander is the director of Avahan (Sanskrit for "call to action"), the India AIDS initiative launched in April 2003 by the Bill & Melinda Gates Foundation. He believes that India's epidemic can be stopped before it approaches the proportions seen today in sub-Saharan Africa – but only by building a vast network of public-private alliances on a scale rarely attempted. With each partner bringing distinct skills and assets to bear on the crisis, careful coordination is essential.

Conditions in India could promote the rapid spread of AIDS in coming years. Although among adults its prevalence ¹ is only 0.8 percent – compared with almost 39 percent in Botswana and 33 percent in Zimbabwe, the two most heavily stricken countries – overpopulation and widespread poverty are already straining the government's resources. The public-health infrastructure, facing a variety of gigantic health challenges, can't cope. Public and private attitudes continue to stigmatize people with AIDS and obstruct efforts to combat it. Already, it is spreading beyond the high-risk populations.

So far, India's response has been fragmented. The government spent about 11 cents a person on AIDS-related programs in 2003, compared with past expenditures of about $1.85 in Uganda and 55 cents in Thailand, two countries that have had some success in fighting the pandemic. Non-governmental organizations (NGOs) often lack the scale or management capabilities to face such a Herculean task and generally work in isolation from one another.

Against this background, the Gates initiative seeks to lower the prevalence of AIDS in India's high-risk populations and to stabilize the overall prevalence by 2008. Armed with a five-year, $200 million budget, the initiative focuses on high-risk groups, particularly the country's two million to three million commercial sex workers, as well as the five million truck drivers and their crews along the nation's highways. To mount a coordinated campaign, the foundation is forging alliances with dozens of public, corporate, and nonprofit organizations.

Alexander, who has led the program since its launch, is a former McKinsey director who brings 25 years' experience in corporate management to the task of tackling HIV and AIDS in India. We met with him at his New Delhi office to talk about his strategy and some of the lessons he's learned during this first year.

The Quarterly: What is the Gates Foundation trying to achieve in India?

Ashok Alexander: By 2008, we want to halt the spread of the virus that leads to AIDS. It's a huge and very complicated epidemic. There are 600 districts in India, each with a population roughly the size of Botswana's, so in effect we have 600 Botswanas. And then there's a lot of diversity and movement among risk groups. The core initiatives are centered on prevention programs. We are focusing on the highest-risk groups in the highest-risk geographies: commercial sex workers and truck drivers in some six states, where we've identified about 100 "hot spots," in approximately 55 districts.

In the first core initiative, which focuses on sex workers, we've enlisted some of their peers – that is, other sex workers – to work on outreach and advocacy programs that promote protected sex. We're also establishing clinics to help those with AIDS or STIs. ² The second core initiative targets truck drivers and aims to reduce the transmission of AIDS and STIs along key national highways, where we estimate that 100,000 to 200,000 sex workers are active. Here we are working with our partners to establish STI clinics, both fixed and mobile, at 40 to 50 truck stops. In some respects, we really have an STI program here, because STIs greatly increase the chances of passing on HIV. Transmission rates for HIV can go up by as much as a hundredfold in the presence of certain ulcerative STIs, such as syphilis. We're working with STI specialists because you can stop some STIs with one injection of penicillin or one dose of antibiotics. So cleaning up STIs can have a huge effect on cutting HIV transmission rates.

But those two initiatives alone would not be enough unless they were integrated with the four other elements of our strategy. The first is a consistent communications architecture: the different partners can't be running off saying contradictory things. We present our partners with broad communications guidelines and ask them not to go too far afield. We leave the creativity to the people at the grass roots.

Second, our advocacy program, which raises awareness and supports prevention programs, is extremely important. It might well be the most important thing, because there is a huge stigma attached to AIDS that really acts as a barrier to prevention; many people avoid testing and treatment, for example.

Third is building knowledge and evaluating the impact of our programs. Knowledge is needed to support the prevention program. For instance, there is not much research on the mobility of populations in India, and there is a lot of epidemiological evidence linked to that mobility. Good evaluation is needed to identify what works, both for us and for others who might want to use our initiatives as models.

The final element is building capacity. This includes technical capacity, such as effective communication with high-risk individuals, mobilizing community involvement, and providing quality STI services, and it includes grassroots capabilities, like putting people with project-management skills into those 55 districts.

If you don't have even one element of the six, everything will fail.

The Quarterly: How did you develop and implement these six initiatives?

Ashok Alexander: I first looked at what programs in other countries had done. Unfortunately for us, in most countries the efforts came too late, so a prevention program never truly happened. Two countries are often cited for their successes: Uganda and Thailand. I've been to Thailand, and they've done remarkable things. But Thailand is very different. It's smaller than an Indian state, it's fairly homogeneous, and more than 90 percent of the commercial sex is in brothels, compared with only 5 percent in India. So there isn't scope for real pattern recognition, and we're really doing a series of considered experiments here.

At first we went through a very quick design exercise and laid out the strategy. I had six experts from around the world in epidemiology, communications, and other fields come together for this exercise, and we tried to get a grip on the problem. Then we broke the strategy into a set of six initiatives and looked at what types of partners could play the roles we prescribed. For instance, the Indian Oil Corporation, a state-owned company, is lending more than 4,000 of its gas stations along the highways to our program – as sites for clinics, condom distribution, banners urging protected sex, and so on. The Transport Corporation of India, a trucking company, has also offered its distribution network and access to its employees. Partnerships like these offer the potential to reach scale very quickly.

I would say it's practically impossible to tackle this problem without a large set of alliances. We were very careful not to do this on our own – that's the route to failure in India. We tried to convince the government that we had no hidden agendas and tried to work transparently. The public partner brings huge reach: government access, government infrastructure, government clout through the public-health system, the judiciary, and the police.

The private sector brings the last-mile link to the beneficiary. NGOs have grassroots organizations that can reach the people we are trying to help, while corporations have assets and infrastructure that can be used to fight the epidemic. Companies can also play an advocacy role. In India, business leaders have huge clout. Someone like Narayana Murthy ³ can pick up the phone and talk to the prime minister on an issue that matters. For such business leaders to stand up and speak out against the stigma or apathy is a huge step. If we couldn't bring these partners together, I couldn't conceive how you would even think of doing something like this.

Still, despite the wonderful support we're getting from our partners, I'm not satisfied with the pace at which businesses in India are coming to look at AIDS as a social and economic problem they need to help solve. ⁴ Barring the exceptional few leaders, businesspeople look at efforts to control AIDS as philanthropy, and that perspective will never work, because India is a country with a lot of problems. The real reason businesses should get involved with HIV goes beyond altruism: it's because they need to. Have we learned nothing from Africa here? Must we have that kind of disaster hit us in the face? Because it's less than a decade away.

Here, education is key. In India we are surprisingly poorly informed about AIDS. That includes businesses, the elites, all kinds of people. Also I think that if you get a few widely respected leaders of the business community to take on this challenge, other business leaders will follow. It's no coincidence that a third of my board members are business leaders.

The Quarterly: How has your business experience helped you tackle such a widespread social problem?

'We've tried to ask some basic questions – similar to those you ask in any business situation but on a much larger scale'

Ashok Alexander: From the outset, we've tried to ask some basic questions – similar to those you would ask in any business situation but on a much larger scale. You start with the goal, get to the objectives and initiatives, break the initiatives very clearly into activities that'll get you there, and measure everything. And you make everyone's role extremely clear. There's no magic here.

We've also tried to make AIDS a manageable problem. The first things you hear about the scale of the epidemic would convince you it can't be solved; it's so big, diverse, and complicated. For instance, people often talk about millions of sex workers in India. But we said, let's break that up into types of sex work. The person who is based at home and sees two clients a week – we don't believe that's a major factor in spreading the virus. How many sex workers are in the most vulnerable category: those who have more than, say, seven clients a day? We came down to a quarter of a million sex workers, from a target of three million. It's market segmentation in its most basic form. In the same way, we've gone from 8,000 kilometers ⁵ of national highways to targeting about 50 truck stops. We've attempted to reduce the scope of the task ruthlessly.

Then we tried to do some sensible analysis. We asked how much you would have to do of what to reach a figure of so many infections averted. We modeled how the disease could spread through the country and how various approaches might affect this. The process was sometimes painful for our partners, who weren't used to that kind of approach. When you're working in public health, there are emergencies happening and a lot of lives to save; measuring impact hasn't always been a priority.

Initially, my business experience made me frustrated at the pace of change. But we're bringing people from government together with people from the fast-moving private sector, and the speed has to be less than I expected – not because people are slower than they should be but because this is a public-health problem on a vast canvas. I've developed a little bit more patience. But at the same time, you often wake up and are seized by the notion that the country is at an inflection point and the virus isn't waiting for anyone.

The Quarterly: How are you tracking progress and measuring success?

Ashok Alexander: You have to accept that when you want to halt the spread of an epidemic, no line on a graph is going to go down suddenly. That takes a long time. You have to be able to say, in some intelligent way, what the spread would have been without intervention. I wish you could have an intervention so dramatic that you brought incidence, not prevalence, to zero in a short time. But it normally takes so much time – sadly, generations of dying – before the incidence starts falling to zero.

You must have very clear intermediate measures to keep a team motivated when the ultimate goal is so far away. In HIV, you'll see lower prevalence seven or eight years into the intervention. But you'll see behavioral changes within 12 to 18 months. In other words, you may see figures showing "protected sex with last irregular partner" going up to, say, 70 percent, from 40 percent. But even 18 months is a long time. And we have people on staff who are committed to working with the program for only a year or two. This means you have to get into straightforward measurements of activity, such as the number of interventions or contacts with high-risk individuals, and make the team feel that this is a huge success. If your goal is to halt the spread of an epidemic, that's too big to grasp, so you have to break that goal down into pieces you are accountable for and into time frames in which you can see things happening.

The Quarterly: What do you think you'll bring back to the corporate sector from your involvement in the AIDS initiative?

Ashok Alexander: For one, the notion of community involvement, as opposed to an answer coming from the outside. There are problems so complex you cannot solve them unless the community finds the solution. If you want to reach large consumer segments outside the conventional marketplace – segments a product or service can't reach directly – you'll have to get the community together to invent its own solution. I could see this happening in health care. Community ownership and mobilization are big parts of our program. We're exploring ways, for instance, for sex workers to fund their own clinics, and maybe truckers can do the same.

Community involvement, for instance, is needed to get sex workers to change their behavior. The answer is not education – that's necessary, of course, but barely sufficient. If you go to Kamathipura, the red-light area in Mumbai ⁶, and ask the eight AIDS-awareness questions recommended by the World Health Organization, you'll find 94 percent awareness. But the real issue is more about social and economic power. The sex workers know what the right behavior is, but they don't have the power to say no to a client who'll offer 50 rupees ⁷ more for having unprotected sex when the normal rate is 30 rupees.

So a key way to reach sex workers is to address the larger issues about their social and economic well-being. A commercial sex worker does not have the economic power to stand up to the client, because of the system around her: her madam, the pimp, local enablers. They all work against her. You have to have a solution that persuades all of them that the good health of the sex worker is in everyone's interest.

Here's an example of how community involvement might benefit companies and communities. There's all this debate about ARVs ⁸ being so expensive. And there's a stalemate: You have the pharmaceutical company that's entitled to protect its intellectual property and to sell at the price at which it can recover its investment. You have the disenfranchised sex workers, truckers, and other populations who could never afford that price. But the pharma companies tell you that if you assure the kind of volume we would potentially see in India, their prices could drop tremendously because pharmaceutical production is based on steady run rates. But is there a way that vulnerable communities, such as groups of HIV-positive people, can come together to create a fund that would finance their own treatment needs? Few individuals can pay for treatment alone, but at a community level it should be possible. We may never get ARVs to poor people unless they find a solution within their own community.

The Quarterly: What attracted you to this job in the first place?

Ashok Alexander: I couldn't believe I was being asked to fill a position where I could potentially have such a huge impact. I came from an environment where people got their kicks from making a big, big difference. This was my chance to make the kind of difference I'd never dreamed of. I don't want to dramatize the problem, but we are trying to halt the spread of a virus that could be deadly to India's future.

On a personal note, people in India like myself – from the so-called elite and privileged class – have taken a lot out of the system. We have absorbed a lot of public subsidies for education and in other areas. It's a good chance to give something back in a very direct way.

The Quarterly: Are you certain you will reach your goal?

Ashok Alexander: I wouldn't be doing this if I didn't genuinely believe we can do it. Having said that, I know how rocky the road ahead is. We could fall flat on our faces...who knows? I lie awake some nights worrying about what could go wrong, but the great thing about this job is that, most often, I lie awake for the right reasons – because there is so much to do and the possibilities are so exciting.

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1 Prevalence is defined as the percentage of the 15- to 49-year-old age group who are HIV positive.

2 Sexually transmitted infections.

3 Chairman of the Indian IT-services and -consulting company Infosys Technologies. For more information, see Gautam Kumra and Jayant Sinha, "The next hurdle for Indian IT," The McKinsey Quarterly, 2003 special edition: Global directions, pp. 42-53.

4 Rajat K. Gupta and Lynn Taliento, "How businesses can combat global disease," The McKinsey Quarterly, 2003 special edition: Global directions, pp. 100-3.

5 About 4,900 miles.

6 Formerly Bombay.

7 About a dollar.

8 Antiretroviral drugs.