Can India avoid being devastated by HIV?BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7331.182 (Published 26 January 2002) Cite this as: BMJ 2002;324:182
Yes, by scaling up local prevention efforts targeted at the most vulnerable groups
- S Ramasundaram, joint secretary ()
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 low—0.7% of the general adult population compared with rates of 20% and over in South Africa, Zimbabwe, and Botswana—the 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.6
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.7 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 2000.9
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
The opinions expressed here are not necessarily those of the Indian government.