HIV has reached epidemic proportions in India and it is predicted that this nation will be next in line after sub-Saharan Africa to be devastated by the virus. India has had a sharp increase in the estimated number of HIV infections, from a few thousand in the early 1990s to a working estimate of about 3.8 million children and adults living with HIV/AIDS in 2001 (the second largest number of infected people after South Africa). With a population of one billion, the HIV epidemics in India will have a major impact on the overall spread of HIV in Asia and the Pacific and indeed worldwide. Although the prevalence of HIV in India may seem relatively low (0.7% of the general adult population compared with rates of 20% and over in South Africa, Zimbabwe, and Botswana), the infection has now been detected in all states and is no longer confined to vulnerable risk groups, such as sex workers and transport workers, or to urban areas. Most of the Indian states have a population greater than a majority of the countries in Africa.
Most of the Indian states have a population greater than a majority of the countries in Africa. When the first case of HIV was discovered in Chennai in 1986, the Indian Government responded to the HIV epidemic immediately. Recognising the seriousness of the situation, the Government launched a National AIDS Control Programme in 1987 but a two year delay in testing blood donors is estimated to have resulted in over 350 000 HIV infections. The situation was similar to China, which also has a poorly regulated blood donor system. Because of delays in testing blood donors, in the first quarter of 2001 there was an 67% increase in new HIV infections, and the number of HIV infected individuals in China is expected to reach over 10 million in the next decade. By 1990, HIV levels were rising in India, amongst high-risk groups such as sex workers in Maharashtra and IV drug users in Manipur. In 1992, the Government established the National AIDS Control Organization (NACO) to formulate policy, prevention and control programmes. In that year, the Government launched a Five -Year Strategic Plan for HIV/AIDS prevention and established sentinel sites across the country, to monitor the spread of HIV amongst the general population. When surveillance systems in Tamil Nadu, (home to some 60 million people), showed that HIV infection rates among pregnant women were tripling between 1995 and 1997, the State Government acted decisively. This included hiring a leading international advertising agency to promote condom use without offending the many people who do not require them and encouraging compassion for those affected.
HIV infection in India is currently concentrated among poor, marginalized groups, including commercial sex workers, truck drivers, and migrant labourers but if effective prevention efforts are not implemented immediately, India potentially could have 37 million people infected with HIV by the year 2005. To put this another way, this figure is roughly equal to the total number of HIV infections in the world today. Unfortunately, this rising HIV rate is also likely to fuel India's epidemic of tuberculosis as this pathology is the most common opportunistic infection in Indian patients with AIDS. Evidence from successful AIDS control projects around the world shows that targeted intervention programmes by peer educators among the groups most vulnerable to HIV are the most effective way to contain the rapid spread of HIV infection. Other interventions, such as Brazil's AIDS treatment program with antiretroviral drugs have also been successful. In 1997, the Brazilian Government started producing generic AIDS medicines and distributing them to HIV patients, free of charge. Although controversial at the time, the decision stands as a turning point in the battle against HIV and Latin America's most populous nation has become a showcase in the fight against the disease. Two decades ago, when the first cases of AIDS emerged in Brazil, health experts forecast that by now, the human immunodeficiency virus would afflict at least 1.2 million Brazilians. Instead, infection rates have returned to 1995 levels. Over the past five years, the number of AIDS-related deaths has plummeted in Rio de Janeiro and Sao Paulo, the regions most deeply affected. In Rio de Janeiro, deaths fell by 40 percent; in Sao Paulo, they dropped by 53.6 percent. Brazil will spend $400 million this year to distribute medicines to 81,000 AIDS patients.
There are promising signs that India, like Uganda will find the political will to control its growing HIV epidemic. The Prime Minister, Atal Bihari Vajpayee, has spoken openly about the need for HIV control, has met infected people, and has urged the corporate sector to respect the rights of infected employees. Uganda's blunt public HIV prevention campaign, resulted in greater than a 50% reduction in HIV seroprevalence over four years. Several other developing countries are recognised for their successful public health response to HIV/AIDS. Thailand's ministry of health established a policy that all pregnant women should be provided with voluntary counselling and testing for HIV, offered zidovudine; and infants born to HIV-infected mothers are given zidovudine. In contrast, the South African government determined until recently that antiretroviral therapy for perinatal HIV prevention was too expensive (a decision, which cost over 70 000 infant lives each year). Despite this, many people feel that the current trajectory of the HIV/AIDS epidemic in India is unlikely to change short term and the nation has only a small but rapidly closing window of opportunity for stemming the epidemic. India's socio-economic status, cultural myths on sex and sexuality and a huge population of marginalised people make it extremely vulnerable to the HIV/AIDS epidemic. If they fail, the AIDS situation in India could become like that in many of the worst affected African countries.
For India to respond effectively to infection trends and limit the costly social and economic impact of HIV and AIDS, its efforts need to be accelerated, intensified and expanded while the country remains at a low prevalence of HIV and there is still time to slow the spread of the epidemic. Around 70% of India's population lives in rural areas, once though to be relatively immune to the epidemic, but recent studies, however, suggest that HIV has already begun to spread in several rural areas. The epidemic is now moving beyond its initial focus among sex workers and drug users and is shifting towards the general population. With HIV prevalence doubling every one to two years in certain groups, there is still only a narrow window of opportunity over the next few years in which to prevent the HIV epidemic from becoming much harder to control.
The Indian Government and individual state Governments have launched prevention programmes to reduce high-risk sex and there is evidence that in some states these programmes are resulting in safer behaviour. An intervention programme among commercial sex workers in Sonagachi, Calcutta has been able to increase condom use from 0% in 1992 to more than 70% in 1992-1994 and sustained this at over 70% until 1998. If current prevention efforts can be scaled up and sustained, India may just be able to bring down the rates of HIV infection and avert a disaster. We await the progress.
HIV/AIDS Situation in India:
FACT: The World Health Organization of the UN now estimates that India has more HIV positive individuals living within its borders than any other country in the world.
FACT: Teenagers and those in their early twenties now constitute 50% of new cases testing HIV positive according to the Chennai based DEGA institute
FACT: Since most HIV positive people belong to the age group of greatest economic development, the UN Development Program calculates that it loses India's economy presently loses about $14 billion a year.
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