Fact and fiction about AIDS

By Siddarth Dube

TO HEAR the fiction about India's AIDS epidemic, speak to our politicians, bureaucrats, and journalists. The vast majority will assure you: ``There is simply no disease called AIDS. It's a myth! Anyway, even if it exists, it's not a problem in India, unlike Africa or the West. And if there are so many thousands dying in India of this disease, where are they, why don't we notice? AIDS gets so much attention only because of those U.N. agencies and foreign donors - and those socialites looking for a fashionable cause. Anyway, why worry, no respectable, useful people are getting infected - only prostitutes, homosexuals and the poor''.

To hear another variant of this fiction, speak to the bureaucrats who head the National AIDS Control Organisation and its State- level equivalents. They will assure you: ``Yes, AIDS is a problem, but we have it firmly under control. So you don't need to worry. The U.N. agencies are absolutely incorrect to say that lakhs of Indians are dying each year of AIDS. We are the only source for statistics! No, the U.N. is also wrong to say that five lakh Indians are contracting HIV every year - only 1.6 lakh Indians got infected in 2000.''

If only fiction were fact. Unfortunately, the facts are many orders more harrowing. Here are the facts, as I understand them based on over a decade of working on AIDS, access to restricted documents at the World Bank and other agencies I have worked for, and conversations with impartial experts.

AIDS now kills about three lakh Indian adults each year. This is roughly 15 times the number of people killed in the Gujarat earthquake. And in the past 15 years, since HIV first surfaced in India, some 20 lakh to 25 lakh Indians have died of AIDS, that's a 100 or more Gujarat earthquakes.

AIDS is already the second largest killer of Indian adults, second only to TB. But in a couple of years, AIDS-caused deaths will outstrip TB. At that point, just from the numbers of Indians currently infected - even if not one more Indian is infected from today onwards - well over 10 lakh adults will be dying each year from AIDS, that's about 50 Gujarat earthquakes each year! AIDS will then be India's foremost killer disease. At a minimum, between 40 lakh to 50 lakh Indians are currently infected, not including the 20 lakhs to 25 lakhs who have already died. Another five lakh Indian adults are getting infected every year - one new adult every minute!

Three States - Maharashtra, Andhra Pradesh and Karnataka - are in the midst of full-blown epidemics, with well over two per cent of all adults infected. Another three States follow just behind - Tamil Nadu, Manipur and Nagaland. In about eight to ten urban areas of these six States, three to five per cent of adults are infected. These include such major cities as Pune, Kolhapur and Hyderabad. These are among the most severely affected areas outside Africa, on a par with Thailand, which has been battling a severe epidemic for a decade. And every year, the number of States with worsening epidemics swells - Kerala just crossed the one per cent infection level amongst adults, and even remote Orissa is nearly there.

It is not just the poor who are contracting HIV. For proof, look at the members of the ``Positive People's Groups'' that are mushrooming in every major urban area, from Delhi to Bangalore to Vijayawada - they are middle and upper income, not blue-collar, not poor.

India's epidemic is running far, far ahead of the Government's response. Even in our six worst-hit States, we are not doing one- tenth of what Thailand did before it could curb its epidemic - and spending only 1/15th of what that country invested in AIDS prevention. Across India, we are in a vicious cycle of doing far too little far too late: to date, only a tiny fraction of prostitutes - or for that matter, injecting drug users, homosexuals, migrants or young people - are getting the information and support they need to protect themselves and others. And another vicious cycle of overwhelming financial needs that continue to sky-rocket - witness the Government's argument that it simply cannot afford to pay for hospital- based care, let alone universal anti-retroviral treatment! (Similarly, the Government maintains a convenient silence about how the soaring number of children orphaned by AIDS will be cared for.) And yet another vicious cycle of having very low absorptive capacity for even whatever money is available.

The World Bank and the Indian Government's own calculations are that if use of the Bank's loan for AIDS control is as successful as possible then by 2005 there will be 80 lakh Indian adults infected, roughly twice as many as are infected today! (Because so many Indians are already infected, the epidemic will grow even if the most effective prevention begins immediately.) And if the loan performs indifferently, then their conservative projection is that about 1.4 crore Indian adults will be infected by 2005! And if there is complete failure, three crore to four crore Indians could be infected by 2005, that is five per cent of all adults.

These are bone-chilling statistics and facts. They are all true and correct, certainly as ballpark estimates. We should ask: where are the headlines, the front-page stories, about these facts and the seriousness of the situation? And why aren't our politicians and bureaucrats shouting out that we are already in a state of crisis with HIV/AIDS? And why does NACO continue only to dispute or bury these facts?

And we should urgently ask: is the Government's response at all adequate, as the bureaucrats at NACO and the State-level AIDS agencies keep assuring us? What should we be insisting they do if we are to save India from having an Africa-scale AIDS epidemic? India will not be able to avert an epidemic unless our politicians, bureaucrats, and journalists immediately end their knee-jerk response to AIDS. An essential first step is to end our foolish denial that our society is somehow impervious to AIDS, that it cannot go the way of Africa.

We then need to insist that our health care system is improved, right-away. The Government simply has to find the money and commitment to ensure that every Indian has access to decent health services, including prevention and care for sexually- transmitted diseases and TB. HIV/AIDS cannot be fought where health services barely exist.

We also need to insist that NACO is moved from the Health Ministry to an inter-ministerial council chaired by the Prime Minister, with the Health Minister as deputy. (In parallel, at the State level, Chief Ministers have to make the state AIDS agencies report directly to them.) And that NACO be run in a committed, transparent and participatory fashion, serving the needs of all Indians, not as the high-handed, secretive, stonewalling bureaucracy that it is now.

We need a NACO that is dedicated to ensuring that no more Indians get infected, and that no more die because they cannot afford treatment with anti-retrovirals and other medicines.

We also need to insist that all Indians be given comprehensive sex education that will dispel the confusion about HIV/AIDS and enable them to protect themselves. In addition, young people everywhere must have regular face-to-face counselling on safe sex. (Politicians who believe that they are our moral police should be told firmly that we value lives, not misplaced prudery.)

And we also need to insist that laws and policies are changed to empower and protect people already infected or those from especially vulnerable groups. No more police raids on prostitutes, no more forced testing on the orders of feudal- minded judges, bureaucrats and politicians! Commercial sex work needs to be decriminalised. So does homosexuality. The Supreme Court ruling suspending the right of marriage of infected people must be repudiated. Discrimination in the private sector against infected people must be made illegal. Does our AIDS epidemic warrant such far- reaching changes? Absolutely yes.

(The writer is a health policy expert.)

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