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India faces off against AIDS epidemic

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In the 25 years since the first HIV-AIDS cases came to light, some countries have started to check the spread of the disease, while others, especially those in southern Africa, have witnessed its devastating effects: millions of deaths, millions of AIDS orphans, and whole societies hobbled by the disease.

For India, a country in the "next wave" of the disease, the disaster has only begun, and there are signs that it could follow the path of southern Africa, where as many as one in five people are HIV positive. Only a major boost in AIDS control programs can halt the death march, say observers.

“The government must do much more now, and dramatically scale-up,” says Taufiqur Rahman, team leader for South and West Asia under the The Global Fund to Fight AIDS, Tuberculosis and Malaria. “AIDS is now moving into the general population,” he adds. “We are talking about a major disaster.”

Some 5.1 million people in India are HIV positive, according to official 2003 estimates — in absolute terms it is second only to South Africa’s 5.6 million. And, some AIDS activists and experts believe, the number could be two to three times higher.

As a proportion of India’s total population, HIV infection remains around 1 percent — about the rate African nations saw in the early 1990s. But it is the current trends that are the most disturbing.

Death march

In India, where the first case of HIV was detected in 1986,HIV rates first soared among drug users and prostitutes. In Mumbai, home to one of the world’s largest commercial sex districts, the infection rate hit 64 percent by the late 1990s.

As in Africa a decade earlier, the disease is spreading into India’s general population from these high-risk groups, and into the rural areas from the cities.

As in Africa, truck drivers and migrant workers are often the conduits — passing on the disease upon return to their villages after contracting it in India’s cities. More than half of new infections are now in the countryside.

Families are now feeling the impact. About 85 percent of HIV-positive women in India contracted the virus from their husbands. Because of the social stigma, HIV-positive children are systematically forced out of schools. At least one-third of new infections are young people ages 15 to 25.

A U.N. study estimated that AIDS will cause as many as 31 million deaths in India by 2025.

Slow response

But India has reacted in slow motion to the staggering toll the disease is beginning to take on the nation. To date, says Rahman, there are only 15,000 people in India receiving anti-retroviral treatment for the illness.

The reasons are many and vary state-to-state in this vast, diverse country. Denial has been a big problem. Traditional taboos discourage open discussion of sex, much less homosexual sex.

As a result, the government in New Delhi and in some states, failed to act early despite the experience of other countries. Poor education and the low status of women only fed the problem.

“You can imagine in some of the most conservative parts of India, the whole idea is raising resistance,” Shanta Devarajan, chief economist of South Asia region for the World Bank, and an expert on the economic effects of AIDS in Africa.

This year, for the first time, Bollywood took on the taboo subject, casting one of its starlets as a sophisticated urban woman who contracts HIV from an old high-school flame, and only realizes it after he has disappeared. The film, called "Phir Milenge" or "We'll Meet Again," is certainly a sign that celebrities are starting to champion the cause, but the general public has yet to cope with it. According to local newspaper reports, many people booed or walked out of the film and it ran in theaters for only a short time.

Overall, though, sex education is scant, while young people receive an ever-increasing diet of sexual innuendo through MTV and movies.

Political contradictions

One of India's strong suits is its aggressive community of non-governmental organizations, which jumped on the problem of HIV/AIDS well before the government took it seriously.

But there have been serious setbacks for these groups. As recently as June, in the coastal city of Goa, the government cordoned off and then razed the large Banai red-light district under a High Court order to rehabilitate the sex workers, a move that left thousands of women homeless.

The action came despite the warnings of experts and non-governmental groups who had worked on AIDS prevention in Banai for a decade. The women, forced out of the area in search of new clients, reported rape and less ability to negotiate condom use. The move also dispersed the sex trade to a wider area, making it harder to educate prostitutes and their clients.

The case illustrates a dichotomy in India's public policy, says Vivek Divan, project coordinator for the Lawyers Collective AIDS/HIV unit in New Delhi, which works on preventing the spread of the virus and protecting the rights of those affected by it.

"On one hand, the government provides support for intervention programs, while on the other hand, Indian laws criminalize these populations that are most at risk," including prostitutes, drug users and homosexuals.

Divan adds that the criminal laws also make it potentially risky for anyone to provide services to these groups.

"If I am an intervention worker with gay men, and distributing condoms, I am in a sense encouraging gay sex, which is a crime. I'm aiding a criminal activity, which is a crime," he says.

The World Bank's Devarajan points out another systemic problem. Over the past decade, he says, “India was going through a similar phenomenon to southern Africa — of thinking of HIV/AIDS as mainly a health problem, for the Health Ministry to handle,” he says. But, he adds, Africa has shown that an effective fight against the disease requires the will of the whole government.

“At minimum, the finance minister has to be involved, because of allocation of resources (involved in) mitigating disease and caring for the ill," says Devarajan. "If trucking is how (the disease) is transmitted, you want the Transportation Ministry involved. The Education Ministry (should also be involved) since the schools can be a major opportunity for teaching children.”

Moving the bureaucracy

Finally, while India is the world's biggest democracy, it also has the world's biggest bureaucracy, which has, in a sense, hampered its ability to react to crisis.

The Indian government has applied for several AIDS-related grants from The Global Fund to Fight AIDS, Tuberculosis and Malaria since the fund's creation in 2002.

Three grants worth $315 million have been approved — for preventing mother to child transmission, for coping with the combined effects of AIDS and tuberculosis, and for a major increase in anti-retroviral treatment in six Indian states with the highest rate of HIV infection.

But the negotiation of the anti-retroviral grants — a process that takes three to six months in most countries — dragged out for 12 months in India because of myriad internal government approvals that were required, says The Global Fund's Rahman.

"In India, you cannot wait a year to approve a program," Rahman says. "It is conceivable that 300,000 people are getting infected in a year."

Hope for a sea change

Nonetheless, AIDS experts say these initiatives do lend credence to Indian Prime Minister Manmohan Singh's promise to devote serious attention and money to the problem.

If he does, it is not inevitable that AIDS will take a toll on India like that in Africa, says the World Bank's Devarajan.

"Africa is one end of the spectrum," he says. "But then there’s also Brazil and Thailand, two countries that seem to have contained the epidemic. India could go either way."

And, he says, India has some important advantages over Africa, including a nationwide health system that aspires to provide universal coverage.

The system has some serious problems, such as extremely high absenteeism among health workers, and at present it's not prepared to deal with AIDS. But, in the past, India has fought very effective campaigns to beat back other illnesses, notably polio and tuberculosis.

India also has a large pharmaceutical industry that makes key anti-retroviral drugs for the world market, even though delivering these drugs at a reasonable cost to Indians is a challenge.

"If we can get the political will to do something in a major way, and the resources for medication, I’m cautiously optimistic that the system can deliver it," says Devarajan. "In Africa, the system wasn’t there."

Government funding is also increasing, though it still lags behind AIDS funding from international donors. The international community is urging New Delhi to invest sooner rather than later because the costs of treating AIDS will expand exponentially over time.

And time is of the essence. As one Indian official told a local reporter, "We feel we have to take it up in a mission mode. Otherwise the thief is moving in a Ferrari and we are trying to catch him on a bicycle. That has to change."