The Hindu Business Line : Battling the HIV scourge

A recent World Bank study estimates that about 60 per cent of the 5.5-6 million people in South Asia infected with HIV/AIDS live in India. With its concerns on the potential huge economic cost in terms of economic growth, the review provides a basis for rigorous, evidence-based HIV policy and programming in South Asia. RASHEEDA BHAGAT on the report.

A recent World Bank study on the prevalence of HIV/AIDS in South Asia and its impact on the populations of eight countries, including India, Pakistan, Bangladesh, Sri Lanka and Nepal, makes depressing reading. The report, presented at the international conference on AIDS in Toronto last week, estimates that about 5.5-6 million people in south Asia are infected with HIV/AIDS, and about 60 per cent of those infected live in India.

A couple of months ago, a UN report declaring that India "has become the HIV/AIDS capital of the world", with its 5.7 million infections surpassing South Africa's 5.5 million, caused a furore, with many Indian officials questioning the numbers. But one thing on which all those involved in the HIV/AIDS prevention and control — activists, NGOs, health workers and government officials — agree is that we are yet to make a headway in effectively controlling the spread of HIV infection.

But before taking up the latest World Bank report on south Asia, with a natural focus on India, let's take a look at the published statistics.

According to a UNAIDS report, by the end of 2005 an estimated 40.3 million people were living with HIV worldwide, of which 4.9 million were new cases, that had been infected in the course of 2005. Reflecting the ignorance of preventive strategies and thanks to what those working in the area of HIV/AIDS in India term the "denial syndrome", about 95 per cent of people living with HIV and AIDS belong to the developing and poor countries.

For instance, while sub-Saharan Africa has 25.8 million infections of HIV/AIDS and South and South-East Asia about 7.4 million infections, adding up to 33.2 million of the estimated 40.3 millions infected worldwide, Western Europe has only 720,000 infected people and the whole of North America just 1.2 million.

Economic cost

Here is the economic cost of such a huge number of HIV-infected people, as projected by UNAIDS: "HIV/AIDS can have a devastating economic impact on countries with severe infection rates. Estimates suggest when the prevalence of HIV/AIDS reaches 8 per cent — about where it is today for 13 African countries — the cost in terms of economic growth is estimated at about 1 per cent a year."

The latest World Bank report on South Asia, discussed at the Toronto conference, expresses concern about the response from various South Asian countries in tackling the problem. "Because the HIV epidemic is highly heterogeneous, designing informed, prioritised, and effective responses necessitates an understanding of the epidemic's diversity between and within countries. This review was undertaken to provide a basis for rigorous, evidence-based HIV policy and programming in South Asia," says the report.

Eyebrows are definitely going to be raised on the comment that HIV infections in India are concentrated in eight States, "particularly in a cluster of Southern and Western States, including Tamil Nadu, Karnataka, Andhra Pradesh, Goa, and Maharashtra, where sex work is the critical driver of HIV transmission."

It also talks about high prevalence rates in the North-Eastern states of Mizoram, Nagaland, and Manipur where addicts injecting drugs abound, spreading the virus through infected needles. For long, health-care administrators and NGOs have argued that the more "developed States", such as Tamil Nadu, Karnataka and Maharashtra, throw up more HIV/AIDS cases because of better screening and surveillance work and not because these States are particularly prone to high risk behaviour. One is yet to find a logical answer to why and how could a Bihar or Uttar Pradesh report a lower number of HIV infections in a country where the sexual route of transmission, mostly through sex workers, is the most common.

Situation in South-Asia

In the other south Asian countries, the report notes, the epidemic may be as severe in parts of Nepal, where transmission occurs largely through sex work and injecting drug use. Both Bangladesh and Pakistan face growing epidemics, particularly among injecting drug users (IDUs), "but HIV rates remain relatively low among sex workers in those countries, providing an opportunity to avert a major heterosexual epidemic.

HIV prevalence in Sri Lanka remains low, even among vulnerable groups. In all of these countries, men having sex with men (MSM) represents an important vulnerable population, but much more information is required to better understand their role in the dynamics of HIV transmission."

In a violence-torn country like Afghanistan, data on anything, including HIV transmission and prevalence, is difficult to come by, but the experts who prepared the report warn that "the country must act urgently to curb rapidly growing HIV infection in its large population of IDUs, especially where drug use and the sex trade intersect."

But an interesting point this report makes, and which should be given some attention by our policy-makers, health-care administrators and NGOs working in the HIV/AIDS area, pertains to how the prevalence varies across districts, sub-districts and even villages in the same block. If we can decode the pattern, we would be that much closer to offering localised prevention and control measures.

The diverse range of structural factors that heighten vulnerability and risk to HIV, include "widespread poverty and inequality, illiteracy, low social status of women, trafficking of women into commercial sex, a large, structured sex work industry, porous borders, and international migration, high levels of mobility and stigma and cultural impediments" to tackling the epidemic.

Women more vulnerable

In the fight against HIV/AIDS, it has always been acknowledged that women are particularly vulnerable to the virus — whether they are commercial sex workers who often lack the power to ensure that their clients use condoms or the unsuspecting housewife whose husband might be buying sex from sex workers or indulging in extra-marital sex.

A UNAIDS study confirmed this aspect, while commenting on the ignorance about HIV/AIDS that abounds in the poorer countries.

For example, in Sub-Saharan Africa, "where three girls are infected for every boy, half the teenaged girls interviewed in one survey did not realise that a healthy-looking person could be HIV-positive. In the Ukraine, 39 per cent of teenagers had never heard of AIDS or still believe that HIV can be transferred through supernatural means."

Laying stress on prevention programmes for the high-risk category, such as sex workers, IDUs and MSM, the report says that targeted preventive measures have worked in some regions of South Asia.

It has a word of praise for India when it says, "Countries such as India are making strides in tackling stigma and discrimination, although much remains to be done. The AIDS community is gaining experience on how to work through key sectors other than health, such as the transportation sector, to effectively reach potential clients of SWs."

But the disturbing fact, as pointed out in a recent issue of Fortune magazine, is that on June 5, the 25th anniversary of the first known case of AIDS, an estimated 40 million people will be infected by HIV, double the number of infected in 1995, despite the $8 billion spent last year to fight the scourge.

(Response may be sent to rasheeda@thehindu.co.in)