AlertNet (LONDON) - Densely populated India has become a key battleground in the fight against AIDS. While the virus is far from under control among high-risk drug users and sex workers, it is now also on the rise among the wider population and in rural areas.
Ten percent of the world's HIV-positive population lives in India, according to the Global Fund to Fight AIDS, Tuberculosis and Malaria, a partnership that raises money to combat the deadliest global diseases.
If trends continue, nearly 49.5 million Indians will die of the disease between 2015 and 2050, more than in any other country in the world, according to estimates by the U.N. Population Division, which monitors population developments.
“India is a vast country,” said Annabel Kanabus, director of Avert, a British-based charity that funds community HIV/AIDS work in Africa and India.
“The numbers are absolutely enormous and tracking the disease and implementing effective programmes is a serious challenge for communities and authorities.”
Nearly four million Indians – out of a population of one billion -- are infected with HIV, according to the Global Fund.
“As...in most developing countries, more than 90 percent of people with HIV do not know that they are infected,” a statement on the Fund's website says.
CASES CONCENTRATED
Ninety percent of India's HIV-positive population is concentrated in six states.
In the south, HIV/AIDS is most prevalent in states with sizeable cities such as Hyderabad, Bangalore, Bombay and Chennai. In these states -- Pradesh, Karnataka, Maharashtra and Tamil Nadu, respectively -- the virus is predominantly transmitted through heterosexual sex.
In Manipur and Nagaland, on the northeast border with Myanmar, most transmissions come through intravenous drug use.
While high-risk groups account for the majority of AIDS cases in the country, the World Bank estimates that about one percent of India's general population is HIV-positive in a country where a fraction of a percentage mean millions of lives.
In some states, more than one percent of women tested at antenatal clinics have been found to be HIV-positive, and among injecting drug users HIV prevalence ranges from 39 percent to 70 percent, according to surveys by the by the National AIDS Control Organisation (NACO).
The U.N. Population Division estimates that India’s adult HIV prevalence will reach 1.9 percent in 2019.
Almost 90 percent of reported cases are among people aged 15 to 44 -- the most economically productive age group -- and one in four HIV-positive people in India are women, according to the World Bank.
”It is already in the general population," said Karl Sequeira, director of a free drug and alcohol rehabilitation clinic and AIDS centre in Hyderabad.
DANGER OF MARRIED LIFE
"Being a married woman is one of the highest risks now because of migration labour," Sequeira told AlertNet. "Men will go work in cities because we have a lot of drought and flooding and they will go have sex outside their relationship and then they will bring it back to their wives.”
In rural areas, where HIV is spreading, awareness of the virus is low.
A 2001 study by the NACO -- responsible for HIV/AIDS initiatives by the Indian government -- found that just 21.5 percent of rural women in the northern state of Bihar had even heard of AIDS.
Only 18.5 percent of the women surveyed understood that HIV could be transmitted through sexual contact.
According to the International AIDS Economics Network (IAEN), far more of India's resources are concentrated in its vast cities, leaving rural areas with low literacy rates, less money, and fewer NGOs.
"The estimates and tallies of the economic, cultural and political consequences of the AIDS epidemic are disastrous,” a statement on the IAEN website says.
LOW AWARENESS
As the virus has spread throughout the country, so has discrimination, fuelled by ignorance and cultural taboos, according to InfoChange, an online news service managed by a public trust to provide development information about India.
The group says prejudice against people living with HIV has been one of the main obstacles to providing education on HIV prevention.
"There is a fairly widespread view among educated people and opinion leaders in India that HIV/AIDS is primarily an African problem and that Hindu and Muslim culture will protect India from the most serious consequences of the virus," Feachem of the Global Fund told the Washington Post.
“The stigma attached to HIV/AIDS leads to discrimination against infected people and their families, " InfoChange says on its website.
“People living with AIDS internalise the stigma and this has a devastating impact psychologically.”
According to Sequeira, the health sector is dominated by private doctors who are not willing to put their livelihoods at risk by treating people in the community known to be living with HIV/AIDS.
“Most doctors don’t understand HIV transmission and so they don’t want to take them, hospitals don’t want to treat them,” he said. “People within the community will not go to a doctor if they find out he is treating HIV patients.”
NAME AND SHAME
The International Labour Organisation says that it has come across cases where Indian hospitals have published lists in local newspapers of the names of people testing positive for HIV.
It also found that doctors have refused to perform Caesarean sections or help with deliveries out of fear of infection; and some hospitals have refused treatment in life-threatening situations.
“In a case from the town of Karur, a man was brought into a hospital for emergency neurosurgery,” an ILO report said. “The surgeon, finding out about his ‘high risk’ status, called for a blood test before beginning surgery. The report was negative but the patient was dead before he could be helped.”
The study also found that women face more discrimination, since society often assumes that women are either the source of the infection or that their failure as wives has caused their husbands to have sex with other partners.
“In India, the man is king,” Sequeira said. “If the man dies, it is not blamed upon the man that he got HIV, it is blamed upon the wife, and she is usually thrown out of the house. The only options they have are to find a shelter or go into commercial sex work.”
A survey by NACO found that 36 percent of respondents thought people with HIV should commit suicide and one-fifth of them thought it was a punishment from God.
Children of HIV-positive parents, even if they themselves do not have the virus, experience discrimination, and are often excluded from school and other activities.
HIGH-RISK GROUPS
While the general public and rural areas are now facing dramatic rises in infection rates, prevalence among high-risk groups such as sex workers, truck drivers and intravenous drug users has still not levelled out, and has soared to 70 percent in some states.
The World Bank says infection among drug users is on the rise, since many seem to be switching from inhaling to injecting.
While significant intravenous drug use is limited to northeastern states, major cases of HIV transmission through drug needles have increased in urban areas such as Mumbai, Kolkata, Delhi and Chennai, according to Avert.
Avert’s Kanabus told AlertNet there were cultural and religious difficulties with the kind of needle-exchange programmes that had proven successful in countries such as Britain. Such programmes allow addicts to swap used syringes for new ones.
AIDS infection is also still on the rise among sex workers.
Bombay has the country's largest sex-worker industry. Of an estimated 15,000 people selling sex in the city, Avert estimates that 70 percent are HIV-positive.
PEER EDUCATION
Kanabus said while it was sometimes difficult for NGOs to reach communities of sex workers controlled by pimps and madams, peer education movements were effective.
"But if you are helping them educate each other, this sort of community action can be effective,” she said.
Sex workers in the red light district of Calcutta in West Bengal campaigned successfully in the late 1990s to raise condom use to over 90 percent in 1992 from three percent in 1998, with the support of the government, NGOs and international agencies, according to the World Bank.
Avert says truck drivers are crucial in spreading sexually transmitted diseases, including HIV.
Between two million and five million truck drivers work on India's vast road network, stopping at "dhabas" or roadside hotels that offer lodging, food and often sex, alcohol and drugs.
Avert said a 1999 study found 87 percent of truck drivers had a frequent and indiscriminate change of sexual partners, and only 11 percent of them used condoms, although their AIDS awareness was fairly good.
Sequiera said India had facilities to provide HIV testing and counselling, but access to antiretroviral drugs that make it possible for people to live with HIV for decades was still limited even though India is one the world's top producers of generic antiretrovirals.
DRUG ACCESS
“I cannot understand why India manufactures the antiviral drugs but they are sold cheaper in Africa,” Sequiera said. “It costs people about 1,000 rupees ($22) per month. We cannot afford that.”
Because of the cost, coupled with inaccessibility to clinics providing drugs, he estimated that only 300,000 to 400,000 people were getting treatment.
On December 1, World AIDS Day, the U.N. World Health Organisation (WHO) approved the use of generic three-in-one pills combining the drugs lamivudine, stavudine and nevirapine made by Indian companies Ranbaxy Laboratories and Cipla.
The move drastically reduces the cost. For example, Cipla's generic Nevirapine -- called Nevimune -- cost 135 pupees per tablet ($3) in 2000, less than half the price charged by patent holder Boehringer Iingelheim.
WHO says simplified generic drug treatment regimes are crucial to fighting HIV on the frontline of extreme poverty.
India’s government took the opportunity of World AIDS Day to announce it would begin providing free antiretroviral drugs treatment in the six states where HIV has become a serious problem.
A labourer works at a roadside sugar manufacturing unit in the western Indian state of Gujarat December 16, 2009. The Kyoto Protocol which binds nearly 40 rich nations to limit carbon ...
