The burgeoning Indian AIDS epidemic

India, home to one-sixth of the human race, has an AIDS epidemic. Five million Indians are living with HIV infection. The stakes are high; the government is racing against time.

In Mumbai, India, there are close to half a million HIV-infected people, making it the greatest urban epidemic on earth. On ward rounds last week at a hospital in Mumbai, formerly Bombay, I saw dozens of desperately ill AIDS patients receiving fine medical care, despite the resource-constrained circumstances. The head of the hospital's AIDS program told me she was optimistic about the National AIDS Control Organization's plan to make life-saving medicines and clinical care available to 100,000 people across the country who desperately need treatment. But in the same hospital, we saw a patient going blind because of the lack of affordable medical treatment for cytomegalovirus retinitis, a late complication of AIDS, and potentially toxic antifungal medications had to be dripped in via an antiquated intravenous catheter, under the watchful gaze of nurses, because of the unavailability of automated pumps and monitors.

India is racing against time and needs to mobilize now. Already 5 million Indians are living with HIV, and the virus is spreading rapidly in vulnerable urban populations. In one study, two of three sex workers in Mumbai, a city of 16 million, were found to be HIV-infected, and in the northeast near the Burma border, in Manipur and Nagaland, injection drug users have high infection rates. At the same time, over the last decade or so, as the Indian economy has grown, truckers, laborers and businessmen in several southern states have acquired HIV through extramarital sex and infected their wives and infants. The face of AIDS in India is increasingly that of young married women who are under pressure to have children or be abused, abandoned or worse. Outside of a few major cities, there is no organized gay community. Homosexual male sex is not uncommon, but since it is illegal, it is not discussed in public, limiting effective prevention efforts.

Community-based organizations have risen to address the complex needs posed by the epidemic, ranging from homes for AIDS orphans to services for battered women to comprehensive care centers. One model program, YRGCare, in Chennai, treats more than 7,000 people living with HIV, providing services and medications on a sliding scale. Although they now have more than 2,000 people on antiretroviral therapy, they estimate that they follow an almost an equal number who need treatment but lack the means to pay. Chennai's state, Tamil Nadu, may have a half million HIV-infected people and tens of thousands who will die soon if they do not have access to medications.

The stakes are high. An unchecked HIV epidemic can undermine the impressive economic gains of the world's largest democracy and lead to a resurgence of tuberculosis and other health problems, with consequences beyond those experienced by the HIV-infected population. The Indian government has created several centers of excellence, ranging from public hospitals to former TB sanitaria. But these programs need to be replicated across this large, densely populated and ethnically diverse nation with sufficient speed to avert a public health disaster. The Indians have engaged a variety of partners in their efforts, ranging from the UNAIDS Program, to the U.S. Centers for Disease Control, to the Clinton Foundation, but more resources are needed.

India is the home of several generic drug manufacturers, whose combination pills and drug price cuts helped to spur the ethical imperative to treat millions of people living with AIDs throughout the developing world. I saw people who had started antiretroviral therapy and were coming in for their follow-up visits. Their vitality was a testimonial for the efficacy of the medications. The key question is: How many others can be treated before it is too late? When Robert Oppenheimer, father of the atomic bomb, saw the first atomic bomb blast, he quoted the sacred Hindu text, the Bhagavad Gita: “I am Shiva, destroyer of worlds.” With an increased awareness of the stakes involved, let us hope that concerted action will prevent AIDS from becoming the most malignant incarnation of this Shiva in the home of one sixth of humanity.

Kenneth H. Mayer, M.D., is a professor of medicine and community health at Brown Medical School and directs the Brown University AIDS Program. He also serves as medical research director at Fenway Community Health in Boston and as an advisor to Health Action AIDS, a project of Physicians for Human Rights.