Thursday, April 15, 2004
AIDS in India
One of the good things I noticed at the Rawalpindi test match between India and Pakistan was that everyone on the field (both teams and the umpires) were all sporting little red ribbons to raise AIDS awareness in both countries. Given the popularity of the cricketers, its a very positive step. However, I also think that unless some Indian politician steps up, takes over the bully pulpit and does what President Musuveni did brilliantly well in Uganda, I dont really see how the prevailing attitudes towards AIDS can be changed. Even well-educated Indians I know don't seem to care about the looming AIDS epidemic, despite my drawing their attention to the CIA report (calling AIDS a national security threat) that suggests that India could be looking at between 20-25 million HIV infections if corrective measures aren't immediately taken.
There are already 4.5 million Indians infected by HIV, a number second only to South Africa. Mind you, under reporting is a given and I am sure the actual numbers are probably higher. 4.5 million is a relatively small part of the population and therefore India has not quite felt the same economic pain as South Africa. However, if the Indian government thinks there are no economic costs to their pretending a disease that culls people in their productive prime (most of the infected are between 15 and 45) doesn't exist, it would be instructive to survey the destruction the epidemic has wrought in Botswana. A prosperous country with a high per capita income and life expectancy in excess of 70, Botswana has seen its life expectancy drop to around 30, thanks mainly to HIV infections rates that are between 35%-40%. In this context, I was glad that the Economist is carrying a special report on AIDS in India. Perhaps all those worthies at South Block who claim to read the Economist will take notice at long last?
the statistics, in the words of one onlooker, are “highly suspect”. Another, Dr Gilada, reckons 8m-12m Indians are HIV-positive, and he may be in a position to know: his clinic in Mumbai—one of the few where a patient can come for advice, testing, treatment, drugs, the lot—draws patients from all over India. Officialdom has an interest in keeping the prevalence rate below 1%: above that the outbreak is considered to have spread into the general population, not just the high-risk groups.
Even the official designation of only six out of 35 states as high-prevalence can be misleading: the population of the six (Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu) is 292m people, nearly 30% of the total. Three others (Goa, Gujarat and Pondicherry, with 53m people all told) have “concentrated” epidemics, with prevalence rates of 5% or more among the high-risk groups.
Admittedly, some of the statistics may overstate the problem. In general, the epidemic seems worse in the south, though it is acknowledged to be bad in parts of the north-east, close to Myanmar, where many people inject drugs with shared needles. The south is certainly where most of the effort is concentrated. Yet it is not clear whether comfort should be drawn from this coincidence of epidemic and effort. The south generally has better social indicators than the north, better health care, better education and probably better reporting. “Worryingly,” though, “not enough is known about HIV spread in the vast populous interior of Uttar Pradesh and other northern Indian states,” remarked UNAIDS last November. The situation there may be worse than is commonly appreciated.
And everywhere, north and south, the difficulties are formidable. Too much time has been lost. The country was in denial for five years while the disease was taking hold among certain groups. Survey after survey suggests that, despite much progress, much remains to be done. For example, some 61% of women in Orissa have never heard of AIDS, reported one survey in February. Though the proportion of truckers in Tamil Nadu who reported paying for sex declined from 38% in 1996 to 17% in 2001, it rose to 21% in 2002. Only 37% reported using a condom with a casual partner. And though 90% of female prostitutes in Tamil Nadu now say they use a condom, only 45% of male homosexuals report having used one in their most recent anal-sex encounter. And so on.
There are already 4.5 million Indians infected by HIV, a number second only to South Africa. Mind you, under reporting is a given and I am sure the actual numbers are probably higher. 4.5 million is a relatively small part of the population and therefore India has not quite felt the same economic pain as South Africa. However, if the Indian government thinks there are no economic costs to their pretending a disease that culls people in their productive prime (most of the infected are between 15 and 45) doesn't exist, it would be instructive to survey the destruction the epidemic has wrought in Botswana. A prosperous country with a high per capita income and life expectancy in excess of 70, Botswana has seen its life expectancy drop to around 30, thanks mainly to HIV infections rates that are between 35%-40%. In this context, I was glad that the Economist is carrying a special report on AIDS in India. Perhaps all those worthies at South Block who claim to read the Economist will take notice at long last?
the statistics, in the words of one onlooker, are “highly suspect”. Another, Dr Gilada, reckons 8m-12m Indians are HIV-positive, and he may be in a position to know: his clinic in Mumbai—one of the few where a patient can come for advice, testing, treatment, drugs, the lot—draws patients from all over India. Officialdom has an interest in keeping the prevalence rate below 1%: above that the outbreak is considered to have spread into the general population, not just the high-risk groups.
Even the official designation of only six out of 35 states as high-prevalence can be misleading: the population of the six (Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu) is 292m people, nearly 30% of the total. Three others (Goa, Gujarat and Pondicherry, with 53m people all told) have “concentrated” epidemics, with prevalence rates of 5% or more among the high-risk groups.
Admittedly, some of the statistics may overstate the problem. In general, the epidemic seems worse in the south, though it is acknowledged to be bad in parts of the north-east, close to Myanmar, where many people inject drugs with shared needles. The south is certainly where most of the effort is concentrated. Yet it is not clear whether comfort should be drawn from this coincidence of epidemic and effort. The south generally has better social indicators than the north, better health care, better education and probably better reporting. “Worryingly,” though, “not enough is known about HIV spread in the vast populous interior of Uttar Pradesh and other northern Indian states,” remarked UNAIDS last November. The situation there may be worse than is commonly appreciated.
And everywhere, north and south, the difficulties are formidable. Too much time has been lost. The country was in denial for five years while the disease was taking hold among certain groups. Survey after survey suggests that, despite much progress, much remains to be done. For example, some 61% of women in Orissa have never heard of AIDS, reported one survey in February. Though the proportion of truckers in Tamil Nadu who reported paying for sex declined from 38% in 1996 to 17% in 2001, it rose to 21% in 2002. Only 37% reported using a condom with a casual partner. And though 90% of female prostitutes in Tamil Nadu now say they use a condom, only 45% of male homosexuals report having used one in their most recent anal-sex encounter. And so on.
