Tackling India's HIV epidemic: lessons from Africa

doi:10.1136/bmj.326.7403.1389

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Malcolm Potts, Bixby professor, population and family planning (pottsmalcolm@yahoo.com),
Julia Walsh, adjunct professor, international health and maternal and child health

Bay Area International Group, School of Public Health, University of California, Berkeley, CA 94720-7360, USA
Institute for Human Development, University of California, Berkeley

Correspondence to: M Potts

Accepted 10 April 2003

The rapid spread of HIV in sub-Saharan Africa is one of the greatest failures in the history of public health. Given our detailed understanding of HIV and the natural course of AIDS, the virus should have been controllable. Yet in some African countries 20% of people aged over 15 are HIV positive and 70% of them will eventually die from AIDS.1 India shares some of the same risk factors as Africa, including a similar pattern of health expenditure, an uneven health infrastructure, and prevalent high risk sexual behaviours (table A, bmj.com).2 By 2010 the number of HIV infections in India is predicted to rise from 4 million to 20–25 million1^–3 We discuss 10 important lessons from Africa that could limit the spread of HIV in India.

Methods

The views expressed in this paper are based on current literature reviews, economic analyses of the Berkeley International Group (http://big.berkeley.edu/), and extensive personal experience working on HIV, reproductive health, programme management, and international finance.

Involve high risk groups in all phases of programmes

HIV infection begins in the core groups of commercial sex workers, intravenous drug users, and men who have sex with men (table B, bmj.com). Mathematical models show both the benefits of early intervention and the importance of focusing on these core groups.4^–7 India remains a traditional society: its laws forbidding homosexuality derive from British legislation in the 19th century,8 and the sex industry relies on bribing the police to operate. The high risk groups are outside the political, social, and economic mainstream. Leaders must overcome prejudice and be prepared to include these groups in designing well funded programmes.

Focus on cost effective preventive programmes

Poverty is a major contributor to the spread of HIV and thus considered an important focus for preventive programmes. However, the prevalence of HIV can double within high risk groups in six …