Winter 2004    Vol. 12, Issue 2


India Looks to Stop HIV Epidemic in "Early" Stages

The HIV epidemic in India is growing steadily, albeit slowly and silently. More than 5 million adults are currently living with the virus, according to 2003 estimates released by the National AIDS Control Organization (NACO; Almost every Indian state and union territory has recorded the presence of HIV, with the heaviest impact in six “high-prevalence” states where HIV infection among pregnant women from the general population attending antenatal clinics is more than 1 percent. These states include Tamil Nadu, Andhra Pradesh and Karnataka in the south, Maharashtra in the west, and Manipur and Nagaland in the northeast.

A musical approach to HIV/AIDS education. The narrative starts:"....Kisi samay ki baat purani, ek tha raja ek thi rani!" or, "Once upon a time, there was a queen, and there was a king - and so the story begins...."

Poor recording of deaths in general and HIV deaths in particular makes it very difficult to assess the mortality impact of the epidemic. According to United Nations estimates, by year-end 2003, the combined number of adult and child deaths in India due to AIDS ranged from 160,000 to 560,000. Many see the epidemic as having the potential to reverse hard-won gains in national development, particularly due to the heavy adult mortality.

At the household level, research by UNICEF and the Innocenti Research Center has revealed an adverse social and economic impact on women and children. Indian households with HIV/AIDS deaths report reduced savings, reduced expenditures on durable consumer goods, and disposal of assets in order to raise or supplement income. On the social front, many of these households experience discrimination and send their children away to distant relatives and/or withdraw them from school, adversely affecting their access to both health and education.

Transmission, Tactics and “Treatment”
By all evidence, the epidemic in India is moving from high-risk behavior groups like sex-workers, truckers and intravenous drug users to low-risk behavior groups, including women and rural populations. In 2003, women accounted for 36 percent of total infections, while rural inhabitants comprised approximately 60 percent, according to estimates by NACO and the Indian Council of Medical Research. Meanwhile, youth are particularly vulnerable: Well over one-third of all the AIDS cases in India in 2002 were among individuals between the ages of 15 and 29.

Heterosexual contact remains the major route of HIV transmission in India, accounting for 86 percent of all cases; in the northeastern states, drug use through shared injections is primarily responsible for transmission. The 1990s saw more public discussion and serious research on sexuality and sexual behavior in India than ever before. Results from studies conducted in different parts of the country suggest that premarital and extramarital sex, including male-to-male sex, is not uncommon, although levels of risky non-marital sex vary widely across regions and socio-economic strata.

Continuing to fuel the epidemic are high rates of temporary labor migrations, as well as India’s extensive trucking system and the high-risk sexual behaviors of its drivers. Despite serious efforts to raise awareness, risk perception in India continues to remain low among the general population, and even a significant majority of high-risk behavior groups do not see themselves at risk, according to a 2003 NACO behavioral surveillance survey. Meanwhile, stigmas, particularly in the health care arena, continue to remain a matter of serious concern, report Vaishali S. Mahendra and Laelia Gilborn in an article on hospitals that are friendly to people living with HIV/AIDS in the 2004/2 issue of Sexual Health Exchange (

A focus on high-risk populations has contributed to the stigmatization and misleading messages about risk factors in India, so much so that AIDS is perceived to be the disease of “others” whose lifestyles are considered “wrong” and “immoral.” While it is essential to reach out to high-risk behavior groups due to the disproportionate increases in HIV/AIDS in this population, careful community-based programs must be devised for the general population, particularly for youth, who are at an elevated risk of infection. Inequitable gender norms and practices provide the larger societal framework within which men, and particularly young men, continue to practice risky sexual behaviors, including the perpetuation of violence and coercive sex against women, according to Population Council research.

Searching for Solutions
On paper, the actions of the Indian government appear timely and well organized. In the real world, however, they sometimes seem slow, inadequate and, according to many analysts, poorly executed. Policies and programs have placed too much precedence on medical solutions, and there is a notable absence of evidence-based behavior-change prevention initiatives. Most of the preventive programs are characterized by condom distribution with safe-sex messages — and little conceptualization of factors that are responsible for the continuance of risky behavior such as sexual norms, alcohol/drugs, peer pressure and easy access to sex.

Admittedly, there is no single solution to the evolving epidemic, particularly in a country like India, which is huge, diverse and complex. However, successful national programs, including the expansion of the Voluntary Counseling and Testing services, and vaccine and “care homes” initiatives, indicate that the involvement of community-based organizations in prevention efforts and the integration of prevention with care can help to promote protective behavior and make a big difference in the quality of life of those living with the virus.

The government’s intent to provide free antiretroviral drugs, including free diagnosis and treatment monitoring, to about 100,000 patients in India’s six high-prevalence states in 2004 is yet another major initiative that, done right, could have profoundly positive impact. Critics of the program, however, question the capacity of the health system to deliver the drugs and monitor the patients.

It is heartening to see that, despite serious resource constraints and criticism, India is attempting to curb the HIV epidemic. Commitment at the highest level is evident, and a large army of dedicated governmental, nongovernmental and civil society members is working single-mindedly for the cause. In fact, the eradication of poliomyelitis and the push for HIV/AIDS prevention are hailed as the most highly visible public-health programs in India, according to a report on the country’s response to the HIV epidemic in volume 364 of The Lancet. The challenge is to maximize this visibility to effectively curtail the epidemic and to improve the dignity of those who are currently living with the virus.

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