Ref: BMJ Artilce on AIDS in India: Please retract your Article

[Guest guest]

Please retract your Article on AIDS in India

Dear Drs Potts and Walsh,

I read you recent article " Tackling India's HIV epidemic: lessons from

Africa " in BMJ volume 326, 1389-1392. While parts of the article presents a

reasonable point of view, there are so many issues that I feel will have

very significant backlash. I feel strongly enough to request that you

withdraw the article. The most important reasons for this plea are the

following:

1) CIRCUMCISION: It takes someone completely unfamiliar with India and the

Hindu culture to even consider, much less recommend, circumcision. A very

significant way to distinguish between Hindus and Muslims in India (as

painfully brought out during Hindu Muslim riots) has been male circumcision.

This distinction is very deeply ingrained in the minds of people of both

> religions. Thus, the small (maybe 10-30% reduction in transmission rates

compared to a factor of 2-3 due to the control of other STDs) role of

circumcision in preventing HIV is not sufficient to convince the majority of

Hindu mothers or fathers to have their male children circumcised. The public

outcry at such a recommendation by " Americans " will further set back

HIV/AIDS intervention very significantly, perhaps by years.

2) " CONFRONT LOBBYING FOR INCREASED USE OF ANTIRETROVIRAL DRUGS " : The

cost-effectiveness of prevention versus treatment is very well known and

documented. The issue a policy maker has to consider is what fraction of a

limited budget is spent on treatment and what fraction on prevention when

there are 4 million HIV+ people in India and with the kind of estimates of

growth made by National Intelligence Council. Do you abandon the 4 million? Do

you give them band aids? Do you treat them as in Brazil or as in the US and

the industrialized world? The lesson from San Francisco (which the authors

should be very familiar with) is that PWHA are among the most effective

change agents. Creating these change agents and removing the stigma

associated with PWHA and HIV/AIDS requires access to treatment and social

acceptance of HIV as another terminal but manageable disease. India already is

suffering tremendously, and failing in its HIV control, because HIV+ people

are considered immoral and thus marginalized. The recommendations made by

you will only help the government shrug its responsibility by quoting

eminent scholars who doubt the efficacy of treatment.

My question to you is -- Why does the medical establishment in the US not unite

and fight against large pharmaceutical companies that are keeping the cost of

these drugs high?

3) " RELIGIOUS LEADERS " : All religious leaders in India - Hindu, Christian,

Muslim - have been advocating abstinence and upholding high moral standards

throughout. I have not met any religious leader outside of fringe groups

who do otherwise in public, even though many lead very interesting sex

lives. In fact they are some of the most vocal proponents of the morality

issue that continues to fuel the stigma. What message would you like them

to give to their congregation?

4) " URBAN VERSUS RURAL " : you seem to indicate that risk begins once people

move to the anonymity of urban life. You say India remains a traditional

society. But what are the patterns of sex and sexuality in this

" traditional " society? Rural India enjoys and suffers sex - the details

would fill volumes - much of which you would classify as very high risk sex.

In short, the risk of HIV is very large once the infection enters any community

in India!

5) " PRESCRIPTION REGULATIONS IN RURAL INDIA " : I wish there was an

enforcement of prescription regulations in rural India or anywhere for that

matter!

6) " TARGETED INTERVENTION " . Targeted intervention as a policy has not been

successful even in the US. I include a more general argument below on why

the window of opportunity for it has passed in India. Here, I state my

reasons for why it should not be recommended even in the US, nor is it

working in practice. The label of HIV as a gay disease set back the US

response by years and even now a significant fraction of the public makes that

connection and therefore denies risk to them or to their family. The rise of

infections in the 15-24 year old heterosexuals in the US shows that the

infections are spreading in this so called " low risk " group. The advocacy

for a nationwide school education program, which targets all students in the

US, is certainly a universal approach and not one based on immediate high risk

behavior or group.

I will now spell out in some detail why we should not think in terms of

" targeted intervention " in India. I have also made this case to NACO

recently. I believe that as a National Policy the window of opportunity for

targeted intervention has passed. The National policy should be aimed at the

entire population for the following reasons.

Targeted intervention as a policy relies on four fundamental concepts:

1) The target populations are small

2) The target populations are well defined

3) These target populations accept their identity and are recognized by it

4) The infections are still mostly contained in this population

I believe that with respect to HIV/AIDS and the current level of

spread of HIV/AIDS, these four conditions no longer apply in India.

1) The high risk groups are not small

commercial sex workers = 2-8 million (or more if you count casuals)

men who have sex with men = (assuming 5% of adult sexually active

males ~ 15 million)

injecting drug users = guess 1 million

street children/child labor = 40-50 million

truck drivers, cleaners,.. = 3-5 million

migrant labour = over 200 million (agriculture and

industrial)

clients of sex workers = (excluding the above) ???

and so on .... = partners of the high risk groups

THUS, EVEN BY NACO COUNT/LABEL WE ARE ALREADY TALKING

ABOUT HALF OR MORE OF THE SEXUALLY ACTIVE POPULATION

AS BEING PART OF THE VERY HIGH RISK GROUPS

2) THESE TARGET GROUPS ARE NOT WELL DEFINED. Many truck drivers/assistants work

in the trucking industry for only a few years or do other work which they accept

as their primary identity. Many sex workers are also wives/husbands. Street kids

and child laborers are just children. A large fraction of migrant labor is

seasonal or does migratory work for short periods of time (few months) only and

sporadically. Most cities and villages have sex workers, but only very

few live and work in well defined areas or brothels. (I could give many

more examples.)

3) Of these groups, the majority of the CSW, MSM, IDU, children, do not have an

identity and certainly would not accept or respond to the label we assign them.

They would not come forward if we call them using these labels. Also, each of

these categories are stigmatized, so labeling them has added to the problem.

PEOPLE HAVE MULTIPLE IDENTITIES AND ARE LEAST LIKELY TO ACCEPT IDENTITIES

THAT LABEL THEM AS HIGH RISK AND ARE STIGMATIZED.

4) The infections have spread out of these high risk groups as data from

ante-natal clinics show.

So the national policy has to be aimed at the full population. The perception of

risk by the public, based on my interactions with thousands of people, is that

HIV/AIDS is still a problem of the immoral -- the high risk groups. People have

not come to understand how large this population is and how many people at some

time in their lives have risky sex, or come in contact with blood or needles or

medical instruments that are infected.

The concept of targeted intervention is important in the implementation.

The most effective workers within these high risk groups are peer

educators, peer counselors, and peer health workers. This requires that

treatment be a very important and significant part of the policy. The next

most successful are NGOs with a holistic portfolio who integrate HIV/AIDS

work into their activities. The funding of NGOs should reflect this.

This distinction between policy and strategy of implementation should

be clarified otherwise denial, and ignorance of risk will continue and

the infections will continue to spread.

I hope I have convinced you of the need to retract your paper. I will be

happy to discuss issues of HIV/AIDS in India with you if you think it

useful.

Sincerely

Rajan Gupta

E-mail:<rajan@...>