Manifestations of Shiva: The growing Indian AIDS epidemic

The growing AIDS epidemic in India calls for immediate action.
By Kenneth Mayer, M.D. (August 3, 2005)

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.

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