Write-up on HIV/AIDS in India in British Medical Journal

[Guest guest]

http://bmj.com/cgi/content/full/324/7331/182

BMJ 2002;324:182-183 ( 26 January )

Editorials

Can India avoid being devastated by HIV?

Yes, by scaling up local prevention efforts targeted at the most vulnerable

groups

HIV has reached epidemic proportions in India. Many predict that this nation

of one billion people will soon see infection rates soar if current prevention

programmes are not scaled up.1 India may be next in line after sub-Saharan

Africa to be devastated by the virus.

The Indian government estimates that in 2000 3.86 million Indians were infected

with HIV, the second largest number of infected people after South Africa.2

Although the prevalence of HIV in India may seem relatively low0.7% of the

general adult population compared with rates of 20% and over in South Africa,

Zimbabwe, and Botswanathe infection has now been detected in all states and

union territories. It is no longer confined to vulnerable groups, such as sex

workers and transport workers, or to urban areas.

If effective prevention efforts are not implemented immediately, and sustained

long term, the World Bank warns that India could have 37 million people infected

with HIV by the year 2005.3 This is roughly equal to the total number of HIV

infections in the world today. Rising HIV rates are also likely to fuel India's

epidemic of tuberculosis. Tuberculosis was already a major cause of death in

India before the HIV epidemic, and it is the most common opportunistic infection

in Indian patients with AIDS. 4 5 In an analysis of deaths between 1987 and

1997 in Mumbai in people aged 25-44 years, tuberculosis related mortality

increased by 70-140%probably related to Mumbai's worsening HIV epidemic.

The focus of prevention efforts in India must be on preventing unprotected

heterosexual intercourse with an infected partner, the predominant mode of HIV

transmission, accounting for nearly 83% of the total.7 India is particularly

vulnerable to an explosive growth in HIV infection because of the many obstacles

to HIV prevention campaigns, including widespread poverty and illiteracy and

social inequalities based on caste and gender. Sex is a taboo subject. There has

been a lack of strong political commitment to deal with HIV and a persistent

denial and disbelief among many policy makers, public health specialists, care

providers, and the general public about the size of the HIV epidemic.

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. Interventions should focus on vulnerable " core transmitter " groups,

such as sex workers, rather than on widely dispersed groups, such as male

clients of sex workers. This approach has been central to every successful

prevention effort in India. For example, the STD-HIV intervention project in

Kolkata targets women sex workers based in brothels. Peer volunteers, themselves

sex workers, counsel the women about HIV prevention, and the women receive

treatment for sexually transmitted diseases and education about using condoms

and in negotiating skills.

The HIV prevalence rate among these sex workers has remained below 10%.8 In

contrast, in Mumbai, where there have been no similar interventions, HIV

prevalence among sex workers rose rapidly from below 10% in the early 1990s to

over 50% by 2000.

The targeted approach has also been used successfully at state level. Tamil

Nadu was once considered an epidemic " hot spot. " Since the mid-1990s, however,

the state has raised public awareness of HIV and has identified the vulnerable

core transmitter groups, who received the same interventions as those received

by the women in the Kolkata project. These groups have shown substantial changes

in their behaviour,10 a prerequisite for the epidemic to slow down. Indeed,

the latest round of surveillance in antenatal clinics suggests that the epidemic

in Tamil Nadu may be slowing down.10

There are some promising signs that India could find the political will to

control its HIV epidemic. For example, the prime minister, Atal Bihari Vajpayee,

has spoken publicly of the need for HIV control, has met infected people, and

has urged the corporate sector to respect the rights of infected employees. The

success story in Tamil Nadu was partly due to successive chief ministers

actively supporting HIV control. But a few success stories are not enough to

reverse or even slow India's HIV epidemic. For this, at least 80% of vulnerable

core transmitter groups need to be reached.11 They must be mapped, identified,

and enrolled into peer based interventions. Such mapping will require a reliable

database, drawing from different kinds of surveys and surveillance systems.

Better planning and funding at the national level and by the states with the

highest HIV prevalence are needed to establish this database. States must show

a stronger commitment to direct and fund HIV control programmes: they should

look to countries like Thailand, where HIV was controlled through surveillance

and targeted interventions.12

S Ramasundaram, joint secretary.

Department of Commerce, G

Government of India, Udyog Bhavan,

New Delhi 110011, India (ramasundaram@...)

Footnotes

The opinions expressed here are not necessarily those of the Indian government.

1. Ratnathicam A. AIDS in India: incidence, prevalence, and prevention. AIDS

Patient Care STDS 2001; 15: 255-261[Medline].

2. National AIDS Control Organisation. Country scenario:1999-2000. New Delhi:

Ministry of Health and Family Welfare, 2000.

3. World Bank. Project appraisal document on a proposed credit in the amount

of SDR 140.82 million to India for a second national HIV/AIDS control project.

Washington, DC: World Bank, 1999.

4. Hira SK, Dupont HL, Lanjewar DN, Dholkia YN. Severe weight loss: the

predominant clinical presentation of tuberculosis in patients with HIV infection

in India. Nat Med J India 1998; 11: 256-258[Medline].

5. Lanjewar DN, Anand BS, Genta R, Maheshwari MB, Ansari MA, Hira SK, et al.

Major differences in the spectrum of gastrointestinal infections associated

with AIDS in India versus the west: an autopsy study. Clin Infect Dis 1996;

23: 482-485[Medline].

6. Hira SK, Srinivasa ASR, Thanekar J. Evidence of AIDS related mortality in

Mumbai, India. Lancet 1999; 354: 1175[Medline].

7. Jha P, Nagelkerke JD, Ngugi EN, Prasada Rao JV, Willbond B, Moses S, et

al. Reducing HIV transmission in developing countries. Science 2001; 292:

224-225[Full Text].

8. Jana S, Bandyopadhyay N, Mukherjee S, Dutta N, Basu I, Saha A. STD/HIV

intervention with sex workers in West Bengal, India. AIDS 1998; 12 (suppl :

S101-S108.

9. Salunke SR, Shaukat M, Hira SK, Jagtap MR. HIV/AIDS in India: a country

responds to a challenge. AIDS 1998; 12 (suppl : S27-S31.

10. Ramasundaram S, Allaudin K, B, Gopal K, Krishnamurthy P,

Poornalingam R, Warren D. HIV/AIDS control in Indialessons learned from Tamil

Nadu. Geneva: Commission for Macroeconomics and Health, World Health

Organization, 2001. www.cmhealth.org/docs/wg5_paper25.pdf

(accessed 21 Nov 2001).

11. Jha P, Vaz LME, Nagelkerke N, Plummer F, Willbond B, Ngugi EN, et al. The

evidence base for interventions to prevent HIV infection in low and

middle-income countries. Geneva: Commission for Macroeconomics and Health, World

Health Organization, 2001. www.cmhealth.org/docs/wg5_paper2.pdf (accessed 26 Nov

2001).

12. KE, Celentano DD, Eiumtrakol S, Hoover DR, Beyrer C, Supraset S,

et al. Changes in sexual behaviour and a decline in HIV infection among young

men in Thailand. N Engl J Med 1996; 335: 297-303[Abstract/Full Text].

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Lalit Dandona, MD, MPH

Director, Health Policy

Centre for Social Services

Administrative Staff College of India

Bella Vista, Raj Bhavan Road

Hyderabad - 500 082

India

Email: dandona@..., lalit_dandona@...

Tel: (+91 40) 331 0952, ext 285

Fax: (+91 40) 331 2954

http://www.asci.org.in

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