Carmo Dias
AIDS Begins to Widen Its Reach in India Disease Spreading Beyond High-Risk Groups to General Population
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By John Lancaster Washington Post Foreign Service Wednesday, June 11, 2003; Page A01
PEDDAPURAM, India -- On a packed-earth lane known as Bangaraman Temple Street, a resident leads a macabre house tour, ticking off the names of the dead and the doomed.
Here is the tiny concrete hovel where Beeraka, the tea seller, died of AIDS last Saturday, leaving behind an 8-year-old son and a wife who almost certainly is infected with the disease. Three doors down, on the opposite side, is Budavarthi, 40, a mother with HIV who lost her truck-driver husband to AIDS three years ago. Around the corner is Rekha, 28, who was infected by her late husband and transmitted the virus to her son, now 6 years old.
And coming up an alley in the arms of her aunt is Devi, a solemn 3-year-old in a patterned cotton shift. She lost both her parents to AIDS -- her mother died in April -- and is infected with the virus. Her aunt says the disease has prevented Devi from learning to walk.
"So many people are sick in any neighborhood," said the tour guide, Bhavani Senapathi, 25, who works as a nurse in a nearby support center for AIDS victims. Her husband is bedridden with the disease, and she has HIV. "We have people dying every day."
Such scenes are increasingly common in parts of India, signaling the start of the long-awaited breakout of the disease from traditional high-risk groups such as prostitutes and drug users into the general population. Infection rates still pale compared to those of sub-Saharan Africa. But AIDS experts say that is changing.
Blood-test data from pregnancy clinics, considered a reliable cross-section of society, show infection rates as high as 5 to 8 percent in some localities in southern India, according to state AIDS control agencies and independent researchers. A September 2002 report by the CIA's National Intelligence Council predicted 20 million to 25 million AIDS cases in India by 2010, more than any other country.
"In some parts of India, particularly the states that are reporting the higher prevalence, the tipping point is long past," Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said in a telephone interview from Geneva. "I think there is absolutely no doubt that the virus is moving into the general population."
Despite efforts by private charities and some government health agencies, particularly at the state level, the national response to the disease has been spotty at best, according to AIDS specialists from international donors as well as Indian and foreign nonprofit groups. They cite, among other things, resource constraints, cultural barriers to AIDS-prevention campaigns -- including resistance to discussing condom use -- and bureaucratic obstacles such as a federal budget rule that caps the amount foreign donors can contribute to fighting AIDS.
"There is a fairly widespread view among educated people and opinion leaders in India that HIV-AIDS is primarily an African problem and that Hindu and Muslim culture will protect India from the most serious consequences of the virus," Feachem said.
As in other countries, "there has been a resort to the mythology of cultural immunity -- it can't happen to us because we're different," added Feachem, who toured the country this year on behalf of the fund, a quasi-U.N. agency that acts as a conduit for public and private funds. "I found on my visit a persistent tendency to minimize the current scale of the epidemic and the potential future growth."
Officials from India's Health Ministry and the National AIDS Control Organization, which coordinates federal and state prevention efforts, did not respond to repeated telephone messages and faxes seeking comment for this article.
By most reckonings, the AIDS epidemic in India is still at a relatively early stage, with an overall infection rate among adults estimated at 0.9 to 1.4 percent; the adult infection rate in the southern African nation of Botswana, by comparison, is about 35 percent. AIDS experts warn, however, that unless more is done to arrest the spread of the disease, the window of opportunity could soon slam shut, creating a far bigger problem down the road.
The disease is already exacting a high toll. As always in India, the problem is sheer numbers: In a country with a billion people, even a 1 percent prevalence rate among adults translates into 4 million infected people, according to U.N. statistics, which means that India has more HIV carriers than any country except South Africa. Many of those lives could be prolonged with antiretroviral drugs, which cost just $350 per year in India, far less than in the West. But even that is well beyond the reach of all but a tiny fraction of patients.
India can hardly be accused of turning a blind eye to the disease. Prime Minister Atal Bihari Vajpayee has delivered several speeches on the topic, and the government has orchestrated multiple ad campaigns promoting awareness and prevention. Here in the southeastern state of Andhra Pradesh, one of the hardest-hit areas, the state AIDS agency has been especially forthright, once inflating a giant condom outside the state legislature to dramatize its campaign.
In general, however, Indian officials have played down the threat.
For example, India's Planning Commission, a government body that sets spending priorities for the country, says in its 2002-2007 economic plan that the disease is likely to "plateau" in 2010 and has caused "only a small reduction in expected improvement in longevity." Government spending on AIDS has remained flat for the last several years. And government officials have reacted angrily to suggestions by outside experts that the disease is getting out of hand.
The National Intelligence Council prediction, for example, was denounced as "completely inaccurate" by Shatrughan Sinha, then the health minister. He subsequently accused Microsoft Chairman Bill Gates of "spreading panic" when Gates warned during a trip to India last fall of the potential for an AIDS explosion in the country; Gates had traveled to India to announce a $100 million grant for fighting the disease.
As in any country, cultural attitudes have shaped the national response. Last December, the communications minister, Sushma Swaraj -- a senior leader of the Hindu-nationalist Bharatiya Janata Party that heads India's governing coalition -- pulled the plug on a television campaign stressing the protective benefits of condoms; conservatives had complained that the ads encouraged promiscuity.
The ads have since been retooled to emphasize abstinence and faithfulness, in some cases avoiding any mention of condoms. One recent spot, for example, shows a village councilwoman warning other women about the dangers of AIDS and urging them to be faithful -- but says nothing about how they should protect themselves if their husbands fail to follow the same advice. Swaraj, who is now the health minister, told the Times of India this month that she favors a "holistic" approach to AIDS prevention.
One significant constraint on India's ability to marshal resources against the disease is bureaucratic.
For the most part, the government insists that money contributed by foreign donors flow through its coffers, rather than directly to private groups (it made an exception for Gates). The problem, according to officials with donor agencies, is that the Planning Commission sets annual ceilings on the amount of money -- government or otherwise -- that can be spent on various programs, including those related to AIDS.
That puts India in the seemingly bizarre position of refusing some of the money that donors are eager to give.
"Donor commitment and available resources are greater than the plan ceilings allow," said Tim Martineau, the senior health adviser for Britain's foreign aid agency in New Delhi. "I believe that some states could absorb more resources and that ideally resource allocations should reflect the epidemiology of the disease."
Indian officials defend the system. They say it is up to them and not foreign donors to set the health care agenda in a country where AIDS is one of a number of chronic diseases -- such as malaria and tuberculosis -- that claim thousands of lives each year. "If the government gives free rope to one sector, then the other sectors will suffer," said N.N. Kaul, a Planning Commission spokesman. "What is the priority of the central government? What is the priority of the state government?"
AIDS is clearly a priority in Andhra Pradesh, a coastal state where the rate of infection among prostitutes in some cities approaches 50 percent, according to a 2001 study funded by the British government. Many prostitutes have passed on the disease to their clients, who infected their wives, who infected their children. By all accounts, the state has moved aggressively to combat the disease, both through public education and more practical initiatives such as distributing free condoms to prostitutes.
"I don't go anywhere without them," said Mani Devaradi, 25, pulling a foil package from her sari as she waited for customers at a busy intersection in the coastal city of Kakinada recently.
Kasaraneni Damayanthi, who directs the state program, said in a phone interview from the state capital, Hyderabad, that as a result of such efforts, infection rates have begun to stabilize in some areas. But she added: "We need much more than what we've been getting, because the problem is really massive. It has very much gone into the general population."
That much is clear from a visit to this sweltering farming town roughly 700 miles southeast of New Delhi.
Parvathi Vorra, a somber, slender woman in a blue sari, got the virus from her husband and then passed it on to her son, 3-year-old Sunil. She knows nothing of antiretrovirals and couldn't afford them anyway. Now her husband is too ill to work, and she has taken over his job as a sweeper in a local cinema, despite fevers that sometimes last for days.
"I don't have any fear for myself," Vorra, 20, said during an interview at St. Paul's Trust, a local charity that provides her with food and medicine to treat secondary infections associated with the disease. "I only want my husband and child to be happy."
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