India's deadly secret: HIV/AIDS explosion
Virus has begun long-feared breakout Spreading uncontrolled among 1 billion
MARTIN REGG COHNASIA BUREAUMUMBAI—Setting off on her daily rounds, Alka Gaikwad heads through the city's labyrinth of slums to an unmarked home.
Inside the gloom, Bharti Dhamankar hunches over a makeshift shrine of fresh garlands draped over a faded portrait of a ruggedly handsome young man.
For five years, the man in the photograph lived with HIV/AIDS. Two weeks ago, he died of it. Along the way, the former truck driver infected his wife.
Now, his 31-year-old widow can think only of the medical death sentence facing her — and the destiny of her two young children who will become orphans. Choking on grief, she is unable to speak.
And so Gaikwad, in a bright floral print sari, steps into the silence. The volunteer counsellor goes on house calls well prepared, for she, too, is an HIV-positive widow — infected by her late husband a decade ago.
Gaikwad, 33, witnessed her daughter's death from the virus a few years later. But the survival of her teenage son has inspired her to keep living, and counselling.
"I want my son to grow up and stand on his own feet," she says. "Until then, I won't die."
Recruited by the foreign development charity World Vision, she comes face to face every day with what most Indians never see — and the world barely acknowledges: The uncontrolled spread of HIV/AIDS in a country of 1 billion people.
Since its arrival among prostitutes in the southeastern port city of Chennai nearly two decades ago, the virus has begun its long feared "breakout" — spreading from high-risk groups to the general population. Legions of truckers and millions of migrant workers are spreading HIV/AIDS from the red-light districts of India's big cities to women in the hinterlands.
More than 5 million Indians are infected with AIDS or HIV (the virus which causes AIDS) according to rough government estimates. Officially, the United Nations ranks India as the second-biggest hotspot on Earth, slightly behind South Africa's 5.3 million infected people.
But while the world's attention remains focused on Africa, many analysts and health workers think India is incubating a greater AIDS disaster of global proportions. The 5 million figure is too conservative, they say.
"The official statistics are wrong — India is in first place," warns Richard Feachem, respected executive director of the Paris-based Global Fund to Fight AIDS, set up in 2001 by the G-8 group of industrialized countries. India "is or is becoming the global epicentre for the pandemic."
By 2000, an estimated 2.8 million Indians had died of AIDS, and the U.N. projects another 12.3 million deaths by 2015. The U.S. National Intelligence Council has warned that 25 million Indians could be HIV-positive by 2010.
Yet, when the G-8 leaders grapple with Africa's AIDS crisis at their annual summit next week, India's hidden epidemic won't be high on the agenda. Indian Prime Minister Manmohan Singh is attending the summit in recognition of his country's emergence as a diplomatic power — but the talk will be of economic growth, not India's AIDS earthquake.
In fact, India's outbreak is at a critical stage, offering a historic window of opportunity to control the spread of the virus. If AIDS makes further inroads here, the consequences for the world will be enormous — with India ultimately overtaking all of Africa in the number of HIV-positive people.
Government data suggest an infection rate of 0.9 per cent — far less than the 21.5 per cent prevalence of South Africa, to be sure. But the nationwide figures mask a series of alarming regional epidemics of up to 5 per cent in some of India's southern states, where testing facilities and hospitals are more reliable.
"The more relevant figure is the trajectory of the epidemic, and we see a very steep trajectory," says Ashok Alexander, head of Avahan, the anti-AIDS group established in India by the Gates Foundation. "It's different from the African epidemic — we're going to see big explosions in clusters."
The result could be social and economic upheaval, yet "India is not even on the radar screen of the international community as far as HIV/AIDS, and that's a tragedy as far as I'm concerned," Ashok argues. "I think it will get worse before it gets better."
If the numbers are indeed understated in the rest of India, an AIDS disaster is in the making not only here but, eventually, everywhere. Every 1 percentage point increase translates to another 5 million infected people.
"We think it's much higher, obviously, than what the government is saying," says Anjali Gopalan, head of the non-profit Naz Foundation, which runs a home for AIDS orphans and HIV-positive mothers in New Delhi. "We have lost that window of opportunity."
As India braces for battle against AIDS, it is beset by familiar handicaps: endemic poverty, cash-starved health care, deep-rooted public prejudice and official neglect.
HIV-positive people are India's new untouchables.
Against that backdrop, India has one clear indigenous advantage: a world-class pharmaceuticals industry that produces high-quality anti-AIDS drugs known as anti-retroviral therapy (ARV).
But that head start has been squandered. Due to remarkable government foot-dragging, Indian-manufactured drugs are more widely available overseas than on the streets of Mumbai.
Of the 5 million Indians officially estimated to be HIV-positive, a mere 7,500 — including Gaikwad — are getting free ARV medicine, and another 23,000 are estimated to be obtaining it privately. That's less than 1 per cent of those in need.
In Gaikwad's case, the discovery that her daughter was HIV-positive brought discrimination and humiliation. A hospital doctor refused to treat the girl — an all too frequent reaction that sets a negative example for the general public.
"The medical profession in India has been at the root of much stigmatization and discrimination," says Alexander.
Fear of catching AIDS turns even family members against one another in a manner reminiscent of historical caste prejudices.
"Within my own family, we are treated as untouchables," says Chaya Jamadade, 30, another widow seeking help from Gaikwad. "We cannot touch the food, dinner plates or soap."
After she was widowed and found to be HIV-positive, family members ordered Jamadade's children to keep away and tried starving her to death. They withheld food for nine days, she says, until police intervened.
"They thought I would just die off or go live elsewhere. They kicked me out. They used to beat me until I couldn't bear it any more."
Gaikwad stepped in to help, bringing only an infectious smile into the household.
"I visited the house, talked to the family and neighbours about how HIV doesn't spread so easily," she recalls.
But the AIDS scare dies hard. A report by New York-based Human Rights Watch last year documented widespread discrimination against infected children and orphans in the classroom, hospitals and their own homes.
"You see people kicked out of their homes, and this I have not seen even in Africa," says Dr. Denis Broun, who heads the U.N.'s AIDS operations in India. "This is something that AIDS has done to India."
Irrational fears of AIDS transmission and taboos about sex have set back India's efforts to raise public awareness and detection. People who suspect they might be HIV-positive go underground, refusing even to be tested for the virus. That reticence has lethal consequences for HIV-positive people.
Without testing, people don't seek treatment; without widely available treatment, people have little incentive to be tested — they consider a positive result a death sentence.
"India is very much behind in terms of access to treatment," says Broun of UNAIDS.
"At least 500,000 people should be getting it."
The fact that ARV drugs are manufactured cheaply in India yet remain inaccessible to so many Indians exasperates Yusuf Hamied. As head of Cipla Ltd., which makes low-cost generic drugs, he has spent years trying to shame the Indian government into distributing medicines that could prolong lives.
At first, he encountered bureaucratic indifference — a feeling that India had to marshal its scarce resources for cost-effective prevention rather than costly treatment. He countered by slashing prices and offering free pills, but officials stubbornly refused to lower tariff barriers on his imported ingredients.
Belatedly, the government is funding a program to place 100,000 people on ARV by 2007, yet only a fraction of that target has been reached. Now that the government has mustered the political will, finding a practical way is proving difficult.
Across town from Cipla's sleek offices and modern production facilities, Mumbai's seedy brothels do a booming business. Women in heavy makeup line Falkland Rd. day and night, tempting new customers.
With her faded red nail polish, nose stud and long black hair, Shila Ramagauda pays close attention to her appearance — and her health. To maintain her earning power — about 100 rupees, or $3 a client — she starts her workday by packing both cosmetics and condoms.
"I know how to protect myself, but I'm still a little bit scared," says Ramagauda, 25.
With a 5-year-old daughter to support, she can't afford to die on the job. She counts on condoms for survival, gently persuading customers to co-operate.
"We are very clear about it. We tell them: `You have a family; this is not only for you, but also you have to protect your loved ones.' So this helps us deal with their anger."
What if customers claim to be unmarried?
"We tell them, `You may be young, but you will want to start a family one day, and you'll put them at risk without a condom.'"
If a client still refuses a condom, she puts one on herself — resorting to the alternative female condoms sold at subsidized prices by aid groups such as Population Services International. The female condom has more lubrication than standard male condoms, so in the darkness of brothels and the haze of alcohol, customers are often oblivious to their use.
After a slow start, there is optimism that a change in government last year has brought a shift in India's approach to AIDS.
The previous Hindu fundamentalist government nixed condom ads on TV, but Singh's new Congress-led government is not so squeamish.
The prime minister has given his blessing to a more provocative — and effective — marketing strategy led by the National AIDS Control Organization and promised to double its budget.
Now, NACO director S.Y. Quraishi is trying to kick-start the mammoth Indian bureaucracy.
Quraishi is determined to change the way Indians think about safe sex. His model is the multinational soft-drink giants that persuaded villagers to start drinking bottles of sugared, carbonated water.
"If everyone can be tempted to drink Pepsi, why not condoms, surely?" he asks, pointing to prophylactic condom packets and posters distributed by his office.
"Information is the only vaccine we have, so we have to catch young people before AIDS catches them."
MARTIN REGG COHNASIA BUREAUMUMBAI—Setting off on her daily rounds, Alka Gaikwad heads through the city's labyrinth of slums to an unmarked home.
Inside the gloom, Bharti Dhamankar hunches over a makeshift shrine of fresh garlands draped over a faded portrait of a ruggedly handsome young man.
For five years, the man in the photograph lived with HIV/AIDS. Two weeks ago, he died of it. Along the way, the former truck driver infected his wife.
Now, his 31-year-old widow can think only of the medical death sentence facing her — and the destiny of her two young children who will become orphans. Choking on grief, she is unable to speak.
And so Gaikwad, in a bright floral print sari, steps into the silence. The volunteer counsellor goes on house calls well prepared, for she, too, is an HIV-positive widow — infected by her late husband a decade ago.
Gaikwad, 33, witnessed her daughter's death from the virus a few years later. But the survival of her teenage son has inspired her to keep living, and counselling.
"I want my son to grow up and stand on his own feet," she says. "Until then, I won't die."
Recruited by the foreign development charity World Vision, she comes face to face every day with what most Indians never see — and the world barely acknowledges: The uncontrolled spread of HIV/AIDS in a country of 1 billion people.
Since its arrival among prostitutes in the southeastern port city of Chennai nearly two decades ago, the virus has begun its long feared "breakout" — spreading from high-risk groups to the general population. Legions of truckers and millions of migrant workers are spreading HIV/AIDS from the red-light districts of India's big cities to women in the hinterlands.
More than 5 million Indians are infected with AIDS or HIV (the virus which causes AIDS) according to rough government estimates. Officially, the United Nations ranks India as the second-biggest hotspot on Earth, slightly behind South Africa's 5.3 million infected people.
But while the world's attention remains focused on Africa, many analysts and health workers think India is incubating a greater AIDS disaster of global proportions. The 5 million figure is too conservative, they say.
"The official statistics are wrong — India is in first place," warns Richard Feachem, respected executive director of the Paris-based Global Fund to Fight AIDS, set up in 2001 by the G-8 group of industrialized countries. India "is or is becoming the global epicentre for the pandemic."
By 2000, an estimated 2.8 million Indians had died of AIDS, and the U.N. projects another 12.3 million deaths by 2015. The U.S. National Intelligence Council has warned that 25 million Indians could be HIV-positive by 2010.
Yet, when the G-8 leaders grapple with Africa's AIDS crisis at their annual summit next week, India's hidden epidemic won't be high on the agenda. Indian Prime Minister Manmohan Singh is attending the summit in recognition of his country's emergence as a diplomatic power — but the talk will be of economic growth, not India's AIDS earthquake.
In fact, India's outbreak is at a critical stage, offering a historic window of opportunity to control the spread of the virus. If AIDS makes further inroads here, the consequences for the world will be enormous — with India ultimately overtaking all of Africa in the number of HIV-positive people.
Government data suggest an infection rate of 0.9 per cent — far less than the 21.5 per cent prevalence of South Africa, to be sure. But the nationwide figures mask a series of alarming regional epidemics of up to 5 per cent in some of India's southern states, where testing facilities and hospitals are more reliable.
"The more relevant figure is the trajectory of the epidemic, and we see a very steep trajectory," says Ashok Alexander, head of Avahan, the anti-AIDS group established in India by the Gates Foundation. "It's different from the African epidemic — we're going to see big explosions in clusters."
The result could be social and economic upheaval, yet "India is not even on the radar screen of the international community as far as HIV/AIDS, and that's a tragedy as far as I'm concerned," Ashok argues. "I think it will get worse before it gets better."
If the numbers are indeed understated in the rest of India, an AIDS disaster is in the making not only here but, eventually, everywhere. Every 1 percentage point increase translates to another 5 million infected people.
"We think it's much higher, obviously, than what the government is saying," says Anjali Gopalan, head of the non-profit Naz Foundation, which runs a home for AIDS orphans and HIV-positive mothers in New Delhi. "We have lost that window of opportunity."
As India braces for battle against AIDS, it is beset by familiar handicaps: endemic poverty, cash-starved health care, deep-rooted public prejudice and official neglect.
HIV-positive people are India's new untouchables.
Against that backdrop, India has one clear indigenous advantage: a world-class pharmaceuticals industry that produces high-quality anti-AIDS drugs known as anti-retroviral therapy (ARV).
But that head start has been squandered. Due to remarkable government foot-dragging, Indian-manufactured drugs are more widely available overseas than on the streets of Mumbai.
Of the 5 million Indians officially estimated to be HIV-positive, a mere 7,500 — including Gaikwad — are getting free ARV medicine, and another 23,000 are estimated to be obtaining it privately. That's less than 1 per cent of those in need.
In Gaikwad's case, the discovery that her daughter was HIV-positive brought discrimination and humiliation. A hospital doctor refused to treat the girl — an all too frequent reaction that sets a negative example for the general public.
"The medical profession in India has been at the root of much stigmatization and discrimination," says Alexander.
Fear of catching AIDS turns even family members against one another in a manner reminiscent of historical caste prejudices.
"Within my own family, we are treated as untouchables," says Chaya Jamadade, 30, another widow seeking help from Gaikwad. "We cannot touch the food, dinner plates or soap."
After she was widowed and found to be HIV-positive, family members ordered Jamadade's children to keep away and tried starving her to death. They withheld food for nine days, she says, until police intervened.
"They thought I would just die off or go live elsewhere. They kicked me out. They used to beat me until I couldn't bear it any more."
Gaikwad stepped in to help, bringing only an infectious smile into the household.
"I visited the house, talked to the family and neighbours about how HIV doesn't spread so easily," she recalls.
But the AIDS scare dies hard. A report by New York-based Human Rights Watch last year documented widespread discrimination against infected children and orphans in the classroom, hospitals and their own homes.
"You see people kicked out of their homes, and this I have not seen even in Africa," says Dr. Denis Broun, who heads the U.N.'s AIDS operations in India. "This is something that AIDS has done to India."
Irrational fears of AIDS transmission and taboos about sex have set back India's efforts to raise public awareness and detection. People who suspect they might be HIV-positive go underground, refusing even to be tested for the virus. That reticence has lethal consequences for HIV-positive people.
Without testing, people don't seek treatment; without widely available treatment, people have little incentive to be tested — they consider a positive result a death sentence.
"India is very much behind in terms of access to treatment," says Broun of UNAIDS.
"At least 500,000 people should be getting it."
The fact that ARV drugs are manufactured cheaply in India yet remain inaccessible to so many Indians exasperates Yusuf Hamied. As head of Cipla Ltd., which makes low-cost generic drugs, he has spent years trying to shame the Indian government into distributing medicines that could prolong lives.
At first, he encountered bureaucratic indifference — a feeling that India had to marshal its scarce resources for cost-effective prevention rather than costly treatment. He countered by slashing prices and offering free pills, but officials stubbornly refused to lower tariff barriers on his imported ingredients.
Belatedly, the government is funding a program to place 100,000 people on ARV by 2007, yet only a fraction of that target has been reached. Now that the government has mustered the political will, finding a practical way is proving difficult.
Across town from Cipla's sleek offices and modern production facilities, Mumbai's seedy brothels do a booming business. Women in heavy makeup line Falkland Rd. day and night, tempting new customers.
With her faded red nail polish, nose stud and long black hair, Shila Ramagauda pays close attention to her appearance — and her health. To maintain her earning power — about 100 rupees, or $3 a client — she starts her workday by packing both cosmetics and condoms.
"I know how to protect myself, but I'm still a little bit scared," says Ramagauda, 25.
With a 5-year-old daughter to support, she can't afford to die on the job. She counts on condoms for survival, gently persuading customers to co-operate.
"We are very clear about it. We tell them: `You have a family; this is not only for you, but also you have to protect your loved ones.' So this helps us deal with their anger."
What if customers claim to be unmarried?
"We tell them, `You may be young, but you will want to start a family one day, and you'll put them at risk without a condom.'"
If a client still refuses a condom, she puts one on herself — resorting to the alternative female condoms sold at subsidized prices by aid groups such as Population Services International. The female condom has more lubrication than standard male condoms, so in the darkness of brothels and the haze of alcohol, customers are often oblivious to their use.
After a slow start, there is optimism that a change in government last year has brought a shift in India's approach to AIDS.
The previous Hindu fundamentalist government nixed condom ads on TV, but Singh's new Congress-led government is not so squeamish.
The prime minister has given his blessing to a more provocative — and effective — marketing strategy led by the National AIDS Control Organization and promised to double its budget.
Now, NACO director S.Y. Quraishi is trying to kick-start the mammoth Indian bureaucracy.
Quraishi is determined to change the way Indians think about safe sex. His model is the multinational soft-drink giants that persuaded villagers to start drinking bottles of sugared, carbonated water.
"If everyone can be tempted to drink Pepsi, why not condoms, surely?" he asks, pointing to prophylactic condom packets and posters distributed by his office.
"Information is the only vaccine we have, so we have to catch young people before AIDS catches them."
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