The Hindu : The spectre of AIDS

Online edition of India's National Newspaper
Saturday, Aug 17, 2002

Opinion

Opinion - Leader Page Articles

The spectre of AIDS

By N. Gopal Raj

An increase of a mere 0.1 per cent in the prevalence rate in India means half a million more people have fallen prey to AIDS.

AIDS, THE Acquired Immune Deficiency Syndrome, and the Human Immunodeficiency Virus (HIV) which causes it, is rarely perceived as a major public health problem in India. After all, the prevalence rate of the disease among adults is still under one per cent when some countries in Sub-Saharan Africa have prevalence rates of over 20 per cent.

But, with India's huge population, the low prevalence rate hides the fact that nearly four million Indians are estimated to be currently living with the disease and the number is growing. The only country in the world with more HIV/AIDS sufferers is South Africa with five million. An increase of a mere 0.1 per cent in the prevalence rate in India means half a million more people have fallen prey to the disease. No wonder, then, that the World Bank warns of a "narrowing window of opportunity" to confront the epidemic before it becomes overwhelming.

Since the first HIV-positive case was detected in India in 1986, the virus has moved beyond the confines of high-risk groups, such as sex workers, and entered the general population. The most worrying sign of this is the growing numbers of pregnant women who turn out to be HIV-positive.

In India, heterosexual contact remains the most common mode by which HIV transmission occurs. Since women in India tend not to have sex outside marriage, their risk of contacting HIV ought to be minimal. But, the husbands can get infected by visiting sex workers or indulging in relationships outside marriage, and then pass on the virus to their wives. A recent nationwide behavioural surveillance study carried out by the Central Government's National AIDS Control Organisation (NACO) showed that nearly half the clients of sex workers were married and most of them were currently living with their wives.

In India, married women are at the end of the line of HIV transmission, points out Jacob John, a leading expert in infectious diseases, formerly with the Christian Medical College, Vellore. Commercial sex workers have the highest risk of getting HIV/AIDS, their clients less and married women have the least risk. So, the proportion of pregnant women with HIV/AIDS indicates how much the disease has spread among society at large.

More than one per cent of the pregnant women being HIV-positive puts a State in the high-prevalence category. In 1994, only Maharashtra was in this category. It has since been joined by five more: the three southern States of Andhra Pradesh, Karnataka and Tamil Nadu, and Manipur and Nagaland in the northeast. HIV/AIDS is slowly spreading its tentacles in India, and cases are being reported from every State.

It is not just those visiting sex workers who risk picking up HIV, observes V. Ravi, Head of Neurovirology at the National Institute of Mental Health and Neuro Surgery (NIMHANS) in Bangalore. Now any multi-partner sex is high-risk behaviour, he says. The myth that HIV/AIDS would be principally an urban phenomenon too has exploded. Hospitals were now regularly seeing people from really rural areas, he points out.

The stigma associated with HIV/AIDS, which still tends to be seen as the wages of sin, is only one of the problems faced by those unfortunate enough to get infected. Still without a cure or an effective vaccine, HIV/AIDS condemns its victims to a lifetime of medical expenses. Indian drug companies offer some of the lowest prices anywhere in the world for anti-retroviral drugs which can check the virus' growth in the body. Even so, such therapy still costs about Rs. 1,600 a month. Since the drugs do not rid the body of the virus, it is medication which the person has to take for the rest of his or her life.

So, conscientious hospitals and clinics consider starting anti-retroviral drugs only when the patient's immune system is judged by suitable blood tests to have weakened to the point where opportunistic infections could easily set in. That could happen five to eight years after a person is first diagnosed with HIV, says N. Kumarasamy, Chief Medical Officer of Y.R.G. Care, a leading Chennai-based charitable organisation providing HIV/AIDS care.

Even when this point is reached, these hospitals insist on extensive counselling before prescribing anti-retroviral therapy. Apart from the question of being able to afford the lifelong treatment, the drugs can have side-effects and the patients should be capable of adhering to the prescribed drug regime. About half of the 4,000-odd patients coming regularly to Y.R.G. Care probably need anti-retroviral drugs, but they can be prescribed for only 30 per cent of them, according to Dr. Kumarasamy.

Anti-retroviral therapy can increase a HIV-infected person's lifespan and improve his/her quality of life. Those without anti-retroviral drugs are likely to develop opportunistic infections more quickly. Some of the treatments for these infections are themselves very expensive, says Dr. Ravi.

Now, the representatives of Indian drug companies are said to have started aggressively marketing the anti-retroviral drugs within the country. There are also reports of doctors prescribing these drugs for short periods, such as for just two weeks, and following non-standard regimes. The experts this correspondent spoke to confirmed that they had seen such prescriptions or heard of such practices.

If so, it is a dangerous trend and one which requires that doctors throughout the country be educated as a matter of urgency. HIV is notorious for the speed at which it mutates and thereby changes its genetic make-up. So drug resistance can develop quite rapidly. Already, 10 per cent of new infections with HIV-1 strains in the United States and Europe are resistant to at least one class of anti-retroviral drugs. Prescribing non-standard treatment regimes will hasten drug resistance. The spread of multi-drug resistant tuberculosis in India is a cautionary lesson. Monitoring drug resistance in Indian HIV infections has also become vitally necessary, and several groups are just establishing facilities for this purpose.

The Central Government has recently decided that by the end of this year all major hospitals, public and private sector, would be able to offer anti-retroviral drugs to pregnant mothers who are HIV-positive, says Dr. Ravi, a member of the National AIDS Committee. It was a very welcome measure which would reduce transmission of the HIV infection from the mother to her unborn child. There were different short-course treatments possible for the purpose, and studies abroad indicated that they did not lead to drug resistance developing, adds Dr. Kumarasamy.

But this is still a far cry from Brazil which in 1996 gave its citizens the right to free medication for HIV/AIDS. On the other hand, the problem in India is already of a larger magnitude. There were over one lakh people receiving anti-retroviral drugs in Brazil at the end of 2001. In India, there might be a million people who currently need such medication, believes Dr. Kumarasamy. In that case, the annual bill in India for providing anti-retroviral drugs would be over Rs. 1,900 crores, ten times the present Central budget allocation for the entire National AIDS Control Programme.

"We have the will, we want the money," India's new Health Minister, Shatrughan Sinha, reportedly said at the recently concluded International AIDS Conference in Barcelona. It is understandable that India should seek international help. What is less easy to understand is why India does not do more for itself. A country that is willing to spend over Rs. 76,000 crores for its defence, allocates just one per cent of that amount for its Centrally funded public health programmes.

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