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AIDS: Facing the second wave
India's methods of combating the disease could provide examples –
positive, as well as negative – for developing countries
By Pramit Mitra
January 21, 2005
New Delhi - Eighteen years after the first AIDS diagnosis in the country, India
has entered a critical period in its fight against the disease. And the
country's strategy in combating the pandemic in the coming years will hold
lessons not only for other "second-wave" countries grappling with the HIV
virus, but also for neighbors in South Asia, who share similar socioeconomic
characteristics.
By any measure, India has a serious problem on its hands. The government
estimates that 4.58 million people – the second largest number in the world –
were infected in 2003. Like China, where the HIV/AIDS epidemic may infect 10 to
20 million people by 2010, India will also face a gargantuan problem within
five or six years. Considering India's population of 1 billion, even a small
shift in the prevalence rate can result in tremendous numbers. With a weak
public health infrastructure, a complex social structure, and high mobility
(within the country and, increasingly, around the world), India's response to
this looming "breakout" – a stage when the infection is no longer confined to
the high-risk populations and breaks out into the general population – will
show others how to proceed and the pitfalls to avoid.
Political leadership in the second-wave countries will be crucial, and on this
front, there is some good news. The epidemic is now recognized as a major
threat to India's health and economy by elites throughout the country. As in
China, where Premier Wen Jiabao took a stab against the stigma associated with
the disease when he publicly shook hands with three AIDS patients in December
2003, India's political leaders have also demonstrated a strong commitment.
Sonia Gandhi, leader of the ruling Congress party, represented India at a UN
General Assembly special session and at the 15th International AIDS conference
in Bangkok, where she and Nelson Mandela presided over the closing session.
Prime Minister Manmohan Singh, having spoken eloquently in private about the
importance of preventing an HIV/AIDS catastrophe, has decided to take a more
visible leadership role in combating the disease.
While the country's political leadership may be taking a more public stance,
India's case also illustrates how an absence of social leadership can hamper
efforts to counter the stigma attached to the disease. In addition to political
figures, countries like India and China need a prominent cultural figure to do
what American pro-basketball player Magic Johnson did in the United States:
Come forward as a role model, and speak out against discrimination. The Indian
film industry, a powerful cultural influence, has been slow to take up the
HIV/AIDS issue. Despite the recent release of a feature film called Phir
Milenge (We Will Meet Again), which addresses the AIDS issue, more needs to
happen.
Almost all experts agree that deep-rooted stigma against HIV-infected patients
makes the fight against the pandemic especially difficult, especially in
second-wave countries where the middle class, by and large, is yet to
acknowledge the danger posed by the virus. In India, like in many parts of the
world, such as the Middle East and Northern Africa, complicated social norms
and conservative attitudes make the fight against prejudices especially hard.
In many countries affected by the epidemic, the silence and taboo surrounding
discussions on sex has prevented open discussions about AIDS.
As a result, infected people are ostracized, and helpless groups – women, lower
castes, and marginal populations – are too afraid of negative social
consequences to take measures to protect themselves. Of particular importance
is the understanding and addressing the special vulnerabilities of women.
India's epidemic is becoming increasingly "feminized," yet women face a host of
special difficulties in both prevention and access to care and treatment.
Discussions about sex also remain off limits in most Indian households – even
in elite private schools in big cities. AIDS is often seen as a disease
restricted to a marginal, morally suspect population, which has "brought it on
themselves." Even at the best medical facilities, there have been troubling
cases of turning away HIV-positive patients.
Often, the emphasis on biomedical measures for fighting HIV/AIDS has tended to
take attention away from the equally necessary task of fighting social stigma.
Public understanding of specific ways to prevent infection, though rising,
remains very low in the general population. One survey, for instance, indicates
that more than 60 percent of Indians still mistakenly believe that they could
contract AIDS by mosquito bites, sharing a meal, or shaking hands with an
HIV-infected person.
On the treatment front, India's laudable efforts provide a solid example for
other nations. Last April, the Indian government began providing antiretroviral
drugs (ARV) directly to HIV-positive parents, children, and patients in
government hospitals in the six most affected states. The Global Fund to Fight
AIDS, Tuberculosis and Malaria contributed US$165 million to the program.
India's plan distributes several fixed-dose combinations (FDCs) of ARV drugs
that have been approved for use by the World Health Organization (WHO),
including several made by Indian pharmaceutical companies. The program, which
originally envisaged reaching 100,000 patients through fifteen delivery points,
has opened eight and has begun offering treatment to 1,000 people. This slow
start is a prudent response to the enormous challenges the program faces,
including training doctors and dealing with extremely ill and often
malnourished patients.
How India reconciles scale with diversity will also be an important development
to watch. The country's enormous population includes countless regional and
social microzones, each with its own dynamics – India has 22 officially
recognized languages, in addition to English and Hindi. The challenge for
policymakers is to move from targeted awareness and successful interventions
among high-risk groups to developing country-wide strategies that can be
tailored to local characteristics. The experience of meshing a huge state or
national structure with small programs, which may need to be adapted to local
circumstances rather than simply expanded, will undoubtedly provide lessons for
dealing with epidemic elsewhere.
There are many ways of measuring the potential disaster, but one of them can be
found in a July 2004 report by the Asian Development Bank and UNAIDS, which
estimated that the Asian economic loss due to HIV/AIDS totaled US$7.3 billion
in 2001 alone. There is still time to avert disaster, provided that India
mobilizes relentlessly and the international community responds.
India needs help, but it also has lots to share. Its AIDS program produces
satisfying success stories and demonstrates agonizing shortcomings. Democratic
politics in India have complicated the fight against HIV/AIDS because many
issues that figure so prominently in the epidemic – particularly those dealing
with sexual behavior and marginalized populations – are not easy topics for
discussion. Yet this picture is slowly changing, and there are signs that AIDS
is becoming a political issue in selected areas. How Indian politicians handle
a sensitive subject like AIDS in India's conservative society will offer clear
guidelines to lawmakers in other second-wave countries. The world community
will do well to keep a close eye on India's fight against the HIV/AIDS pandemic
and avoid the pitfalls.
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