A Hidden Scourge
India's huge population disguises the growing number of HIV-infected citizens
MUMBAI, INDIA-- Lucky is not a word that would ever seem to apply to the young woman standing by the brothel doorway. At 22, illiterate and unskilled, cut off from her family, Shanu Abdul Sheikh has known little good fortune in her hard life. She is a widow with a 6-year-old daughter she supports by working in a brothel on Falkland Road, the city's most notorious red-light district. Twice a day, sometimes more often, she leads a customer down a narrow corridor to a small interior courtyard, up a flight of warped wooden steps, and into a decrepit room shared with other women. There is barely space for the three sturdy beds, separated by dangling strips of cotton fabric draped from the ceiling to create an illusion of privacy. Her price for sex is as little as 60 rupees, about $1.40, half of which goes to the brothel operator.
Yet, she is lucky, if that word can ever be used about her, in one respect: She so far has tested negative for HIV, the virus that causes AIDS. In Mumbai (formerly Bombay), an estimated 40 percent of the city's 25,000 commercial sex workers have HIV/AIDS, although most are unaware that they are infected. The statistical likelihood, then, is that three of the other six women working in her brothel are HIV-positive, spreading the virus and facing early death.
Even if Sheikh--born in a Bangladeshi village and married off in her early teens--doesn't fully understand HIV, government and private intervention efforts have reached into the brothels. She and other women know about the need for condoms (provided free by the government and private groups) but say they are dependent on the man's willingness to use them, which has been a major obstacle to limiting the virus's spread. On this, she says, there has been a change. "Now, they [the men] are using condoms because they are scared of AIDS."
That news is encouraging but by no means lets India breathe easier. Because of India's huge population, the national HIV/AIDS adult prevalence rate is deceptively low--less than 1 percent--which masks the problem's alarming scale. One in every 8 HIV-infected people worldwide is in India--and the number is growing by 500,000 a year, over 10 times the annual increase in infections in the United States. Officially, the country has at least 5.1 million infected people, second only to South Africa's 5.3 million, 21 percent of its adult population. "The official statistics are wrong," asserts Richard Feachem, head of the internationally backed Global Fund to Fight AIDS, Tuberculosis, and Malaria. "India is in first place."
This is a critical time for India: An optimistic scenario envisions containing the virus, spread here mainly by heterosexual contact, through education and prevention efforts. But there is an alternative scenario, put forward in 2002 by the CIA-affiliated National Intelligence Council, and it is horrible to imagine: as many as 25 million infected Indians by 2010, as the virus extends beyond high-risk groups such as commercial sex workers, long-haul truck drivers, and intravenous drug users--the kind of rapid, devastating spread seen in South Africa in the mid-1990s.
Tipping point. There are signs that HIV is starting to break out into the general population as, for instance, infected urban hotel and office workers return to visit wives who remained behind in rural towns and villages. In some areas of the country, the incidence rate has climbed as high as 4.5 percent, beginning to create Africa-like consequences such as shattered families and AIDS orphans. If that trend accelerates, India's already strained, underfunded healthcare system will be quickly overwhelmed, and its fast-growing economy hit hard. "We are moving toward a tipping point in this epidemic, but we aren't there yet," says Ashok Alexander, who heads the ambitious five-year, $200 million program of the Bill and Melinda Gates Foundation to help India avert an AIDS catastrophe.
The Indian government, long inhibited by conservative social traditions and political denial, is increasingly facing up to the alternative futures. In January, for instance, new Prime Minister Manmohan Singh met with newspaper executives to encourage more AIDS coverage. In addition, regional politicians are pressing for more action at the local level, such as medical conferences held recently in Bangalore. "There is a lot of political vision now being mobilized," says a longtime AIDS activist, I. S. Gilada, a physician who was among the first to sound the alarm after India recorded its first AIDS death in 1986. "But had the government been more active in the initial period of the epidemic, it could have changed things in a very big way."
Spending in India on HIV/AIDS programs is increasing with help from the United Nations, the U.S. government, and private donors such as the Gates foundation, which estimates that a fully funded HIV- prevention and care program in India would require $1 billion a year. India's actual numbers fall far, far short of that: Spending on HIV/AIDS programs totals less than $150 million a year, or about 29 cents a person--much less, for instance, than Uganda's per capita spending of $1.85 or even Thailand's 55 cents. Thailand's success at holding its prevalence rate below 2 percent--even given its commercial sex industry--is taken by activist groups such as the Gates foundation as evidence that intervention can reverse the spread of the HIV epidemic.
Still, even some well-educated Indians consider all the foreign attention overblown considering that far more Indians now die from dirty water and common diseases than die from AIDS. Vinod Mehta, editor-in-chief of the newsmagazine Outlook, contends that the AIDS alarm reflects a combination of western phobias about the Third World and Indian eagerness to attract foreign financial aid. "It is a scare which is blown completely out of proportion," he asserts.
The truth is that the numbers are uncertain--but not in the way he suggests. Some AIDS experts say that many AIDS deaths are attributed to other opportunistic diseases such as tuberculosis and that the government understates the real infection figure. The Gates foundation is planning a three-month effort to collect blood samples from 30,000 people in high-risk groups to establish a reliable baseline from which to assess counter-HIV measures. The foundation program Avahan (Sanskrit for "call to action" ) is funding local intervention efforts that include clinics aimed at providing the most active sex workers and truck drivers with condoms, testing, counseling, and treatment for sexually transmitted diseases (because those infections can increase the transmission of HIV).
Along Falkland Road, a chaotic street crowded day and night with pedestrians and honking traffic, women beckon from curtained doorways. Some 4,000 prostitutes work the area. Some of the older ones are joginis from impoverished families who, following an ancient (now banned) tradition, were "married" to a deity before puberty and designated to live as prostitutes. In Sheikh's brothel, the sole decoration is an 8-by-10 picture of the joginis' deity, the goddess Yellamma. Others here have been sold into prostitution (sometimes after being abducted), are victims of rape or incest, were abandoned by husbands who absconded with their dowries, or are in the brothels because they have no other way to survive or pay off debts.
Sheikh, who came to Mumbai from Bangladesh when she was 8, says she is one of the last group, without any good alternatives. Dressed in a pale-blue sari, she shows a smooth complexion and shy, girlish smile that defy the downward arc of her life. It's not clear how much she understands about AIDS. After being tested, she was unable to read the report and put it away with her few possessions until someone could read it for her.
Outreach. She pulled out the papers during a visit by Gilada, who for more than 20 years has been an advocate for providing health services to the city's sex workers. And in recent years--with limited outside funding--his Peoples Health Organization has run an acclaimed peer education program that provides condoms, information, and testing for the Falkland Road women. Establishing a network of outreach workers among older prostitutes, his Saheli Project has helped spread AIDS awareness with, for instance, testing facilities and with posters inside the brothels comparing using condoms to wearing protective gear when playing cricket. Prevention efforts are doubly important because few Indians, once infected, can get life-extending antiretroviral drugs. Ironically, India has been a leading global supplier of generic copies of HIV/AIDS drugs, but few Indians can afford them, and the government has lagged in promises to provide for the needy.
At his private infectious-disease clinic a short drive from Falkland Road, Gilada sees about 10 new patients a week for HIV tests, mostly middle-class office or shop workers. About 1 in 4, he says, tests positive. He is concerned that infected patients, even with counseling, rarely tell their wives and live in denial. "It is seen as a disease of sex workers, truck drivers, and drug users," he says, "not as a disease of everybody."
If that broader reality is not apparent now, sadly, it may be very soon.
HIV in India
1981-2004
Number of infected (estimates in millions)
'81 0
'04 5.1, 5.3*
[Other labels] 0, 1, 2, 3, 4, 5, 6
'90, '94, '98, '99, '00, '01, '02, '03, '04
*Global Fund to Fight AIDS, Tuberculosis and Malaria estimate
Sources: United Nations, Indian government
USN&WR
This story appears in the July 25, 2005 print edition of U.S. News & World Report.