The blood bank owner speaks for millions of Indians when he dismisses the presence of HIV in his country. But at the same time India struggles to cope with the attendants of a nascent epidemic--denial, ignorance, fear, and stigmatization--it faces the fastest growing HIV epidemic in the world.

"At the end of the century, India will have the dubious distinction of being the country with the largest number of HIV infections," says G. V. Satyavati, director-general of the Indian Council of Medical Research. Some believe that distinction has already been met. While some experts predict that five million people in India will be infected with HIV by the year 2000, others place that number at thirty to fifty-five million--or even higher.

The HIV epidemic in India is a patchwork, one that reflects the country's richness and complexity. India--whose civilization stretches back thousands of years--is home to 900 million people, the world's second largest population. It is in India, where sacred cows amble through city streets, that factors as disparate as goddesses, monsoons, and tea stalls can propel the spread of HIV.

"At what stage is the HIV epidemic in India?" asks L. M. Nath of the All India Institute of Medical Sciences. "It's at every stage, depending on where you are."

Since the initial detection of HIV in 1986 among female sex workers in Tamil Nadu, India's southernmost state, the virus has surged through eastern and western coastal cities, then eddied outward into surrounding towns and villages. In the northeastern state of Manipur--where an epidemic among injection drug users began in 1989--HIV has spread more rapidly than anywhere in the world. Today, while Tamil Nadu, Manipur, and the western state of Maharashtra remain epicenters, it has become clear that the HIV crisis in India is actually a swirl of smaller epidemics.

Throughout the country, high-risk populations--female sex workers and their clients, truck drivers, men who have sex with men, blood transfusion donors and recipients, and injection drug users--are in the thick of HIV transmission. As the first groups to bear the brunt of the epidemic, they are perceived as both reservoirs of the virus and vectors of transmission to the general population.

A Thriving Sex Industry
From the cage girls of Bombay to the dancers in Calcutta's pleasure houses, from the tribal women along Rajasthan's highways to the call girls of New Delhi, India's sex industry is extraordinarily varied. "Want some high-risk entertainment for the evening?" asks Smarajit Jana, manager of an HIV intervention program in Calcutta's red light district. "Step out into the street and take your pick--female prostitutes, male prostitutes, child sex workers, housewives, college students, starlets, virgins, fresh Nepali girls."

In Bombay--a city that has nearly twice as many inhabitants as New York yet almost twenty times as many sex workers--the narrow lanes of the Falkland Road area serve as viewing galleries. In the gloom, girls peer mutely from between the bars of five-foot-high cages.

"When I am here, alone and waiting, I pray for a merciful client who will take me away," says fifteen-year-old Shalini. "But when outside, things seem worse and I want to return to the security of my cage."

When a client selects a cage girl, her pimp collects the payment, then escorts them to a private room. After sex, the pimp quickly returns the girl to her cage. She receives no pay, and there is no discussion of safe sex; condoms are used only if the client requests one. Like many other cage girls, Shalini is infected with HIV.

The inability to negotiate safe sex and the necessity to sell sex to survive have rendered sex workers throughout Bombay vulnerable to HIV: their seroprevalence rate shot up from less than 2 percent in 1988 to 52 percent in 1994.

To the south of Bombay, in the city of Pune, the red light district resembles other neighborhoods during the day, with children playing in alleys and old men hawking sweet potatoes from open carts. Tenement doorways are crowded with clusters of young women who sell sex, though, and spent condoms are pitched in the street with rotting fruit and broken glass.

In Pune, condom use has risen in part from the outreach efforts of the Indian Health Organization, a nongovernmental organization whose mottos include "AIDS spreads in sex, blood, and ignorance" and "condoms prevent unwanted births and unwanted deaths." Yet while more than 26,000 free condoms are now distributed in the city's red light district each month, already half the sex workers there are HIV positive.

Farther south in India, festivals and even monsoons can regulate the sex industry--and therefore the ebb and flow of HIV. During festival months in the temple town of Palani, for example, women earn their living by selling food, flowers, and amulets to the religious pilgrims. Yet when the festivals end, the stream of pilgrims dwindles and the women are forced to sell sex to support themselves.

On the outskirts of Palani, where the commotion of town gives way to the tranquility of sugar cane fields, many people earn their living by working the crops. Their income is assured during Tamil Nadu's wet season, which is sustained by the northeast monsoon. When the wet season ends, however, both fields and sources of income dry up. The men then migrate to the neighboring state of Kerala, where the southwest monsoon provides rain and plentiful work. Separated from their wives, they spend a large part of their wages on local sex workers, and only occasionally send rupees to their families. At home, wives sell sexual favors to support themselves and their children.

Throughout the country, whether in temple towns like Palani or cities such as Bombay, the rise in HIV seroprevalence among female sex workers has been mirrored by increased rates of infection among their clients. HIV infection among these men is detected when they seek treatment for other sexually transmitted diseases (STDs); one study found that HIV infection among male STD patients in Vellore rose from .36 percent in 1986 to 4.24 percent in 1992. An even more dramatic change was found last year in Pune, where 21 percent of male STD patients tested positive for HIV.

HIV in the Fast Lane
As dusk falls and laughter erupts from the tin-roofed cinema hall, village women in Tamil Nadu signal their availability to passing truckers by draping saris on the trees that line the highway. Millions of truckers drive India's highways daily, transporting nearly half of the country's goods from the southern ports to the plains of the Ganges, from the Himalayan foothills to the markets of Bombay. The truckers often stop at roadside tea stalls for a dish of curry. They also stop for sex.

The truckers' practice of hiring sex workers en route stems not only from the extended periods of separation from their wives, but also from the prevalent myth that spending long hours behind the truck's engine heats up the body. Many truckers believe they can rid themselves of this harmful heat by having frequent sex.

Studies show that India's long-distance truckers average 200 sexual encounters each year; at any given time, 70 percent of them have STDs. Preliminary surveys estimate that nearly one-third of them are infected with HIV. With India's impressive network of roadways--the largest in the world--penetrating the country's remotest corners, the truckers act as efficient couriers of HIV as they drive from town to town.

In the small town of Nammakkal, the affluent seat of southern India's trucking industry, where freshly painted trucks and gasoline tankers gleam in the sun, the mood is uneasy. "Most of this community consists of truckers' families," says Elangova, a local schoolteacher. "All this talk of truckers and AIDS is creating panic and denial here."

But the denial cannot last. Suniti Solomon, director of the YRG Centre for AIDS Research and Education, recently found that among truckers in Madras who request testing because they have STDs and are concerned about their high-risk behaviors, HIV seroprevalence rates rose from nearly 60 percent in 1993 to 91 percent in 1995.

An Underground Culture
Every evening, hundreds gather along the shores of the Marina beach in Madras, a popular meeting place for men seeking sex with men. "When I want to send out a signal that I'm looking for a partner, I generally roll up a newspaper and carry it under one arm," says Balu, a college student who cruises the beach and local parks in search of the "perfect man." Balu knows about HIV and uses condoms, but he belongs to a small, educated group of volunteers who conduct AIDS awareness programs. For most of Madras's three thousand homosexual men, retaining their anonymity takes precedence over seeking lifesaving information, counseling, and condoms.

In India, the illegal status of homosexuality has created an underground culture where HIV and STDs are rampant. While few studies exist on HIV seroprevalence rates among men who have sex with men, one 1995 study found that, among a sample of this group in the Sangli district of Maharashtra, half were infected.

Away from the Marina beach, a group of hijras--eunuchs and transsexuals who sell sex--linger on the edge of a slum near one of Madras's busy markets. Dressed in nylon saris and wearing make-up, they proposition passersby. Whenever a policeman approaches, the hijras disappear into the shadows of the huts behind them.

"The police treat us like dogs," says the group's leader. "They blame us for spreading AIDS. Our huts were set on fire to drive us away." The hijras, who average four clients a night, do not use condoms, which they strictly associate with family planning. Already, an estimated one in three hijras is HIV infected.

Transfusing Danger
Each year, India's more than one thousand blood banks transfuse approximately two million units of blood. Throughout the country, the demand for blood outstrips supply, due in part to the fear of contracting HIV through blood donation, which is coupled with a superstition that losing blood leads to impotence. Half of India's blood supply therefore comes from people who sell their blood for a living. Their desperation has opened the door to HIV infection, however; a Bombay study found that 86 percent of commercial blood donors screened in 1992 were seropositive. Some commercial blood donors engage in unprotected sex to earn income; others may have been infected through unsterile plasma-pheresis equipment.

Although it is estimated that 12 percent of the country's HIV infections have been acquired through blood transfusion, a highly placed government official in Madras says, "How many have contracted HIV through blood transfusion is anyone's guess. All we can do is supply the HIV kits and hope they will be used."

As illustrated by the owner of the Bihar blood bank, not all of India's blood banks comply with mandatory screening laws. To date, none has had its license revoked for transfusing HIV-contaminated blood.

A Deadly Price for Drugs
In northeastern India, against a backdrop of political and ethnic turmoil, injection drug users (IDUs) are at the center of a raging HIV epidemic. For years, the region's hill tribes had smoked opium for medicinal and recreational purposes, but by late 1989, heroin of injectable quality had flooded the state of Manipur from the nearby Golden Triangle of Myanmar, Thailand, and Laos. Manipuri youth switched from smoking opium to injecting heroin--with disastrous consequences.

Within six months of the initial detection of HIV in Manipur in 1989, seroprevalence among IDUs shot up to 54 percent. The government responded by banning the sale of hypodermic syringes, so the IDUs began sharing ink droppers instead of syringes. To avoid wasting a single drop of the drug, the IDUs inject themselves with heroin from the droppers, draw out their blood, and reinject the mixture several times before passing the paraphernalia to the next user. By the time this process is complete, they have exchanged considerable amounts of blood.

The Indian Council of Medical Research (ICMR) has estimated that in the state of Manipur alone there are at least 15,000 IDUs. Principally male students and unemployed youth, they gather near highways and border areas where heroin of over 90 percent purity can be bought relatively cheaply.

Swaroop Sarkar, assistant director of the ICMR AIDS Unit in Manipur, reports HIV seroprevalence rates in northeastern India of up to 90 percent among IDUs, 6 percent among spouses of IDUs, and 1 percent among prenatal women. "We have now documented the first perinatally infected child in Manipur," Sarkar says.

Finally, HIV-infected youth in Manipur face an even more immediate danger than the virus itself. Fanatic militant groups who are waging a war of secession against the Indian government gun down the infected IDUs for what they consider to be bringing dishonor to the nationalist struggle. And, although some AIDS service organizations have begun public education programs to counter the tide of discrimination, the Manipur government continues to incarcerate IDUs--many of whom are seropositive and need medical attention--in the name of rehabilitation.

The Virus Radiates Outward
As most data on India's HIV epidemic derive from limited studies among IDUs and urban residents, health ministry officials concede that they do not know how many people are infected in the country's small towns and villages, where more than 75 percent of the population resides.

Many of those in India's increasingly mobile work force--estimated at nearly 190 million men--are from rural areas. These workers constitute nearly 30 to 40 percent of the population in India's cities at any given time. Alone and away from the watchful eyes of community elders, many of these workers take advantage of the anonymity of big cities. They now make up a significant portion of the clientele in red light districts. During periodic visits home, these men unknowingly bear HIV to their loved ones. As with the truckers, their mobility accelerates the spread of HIV to rural areas.

The virus is not only radiating outward from India's cities to its villages, but it is also moving from people considered to be at high risk for infection to those perceived to be at low risk. I. S. Gilada, secretary general of the Indian Health Organization, points to evidence of this pattern, as the HIV prevalence among housewives in Bombay is now double what it was among sex workers there in 1986. Moreover, a 1994 study by the National AIDS Research Institute found that 14 percent of married women in Pune who reported no history of sexual contact outside their marriages tested positive for HIV.

The Emerging Face of AIDS
As increasing numbers of people progress to AIDS, the HIV epidemic is becoming a more visible part of life in India. Some experts predict that one million Indians will have progressed to AIDS by the year 2000. Already, it is estimated, tens of thousands of people in India have developed AIDS. The current official figure of 2,009 AIDS cases is believed to be a reflection of chronic underreporting.

The AIDS epidemic is already placing great stress on India's health care system. In Manipur, young people with AIDS who cannot afford the medicines needed to prolong their lives are dying of tuberculosis and diarrheal diseases. And, in Bombay, the number of people with AIDS will soon exceed the number of hospital beds, according to S. R. Salunke, director of health services of Maharashtra State. "The public health machinery will be one of India's first casualties of AIDS," Salunke says.

Another casualty may be the economy itself, as HIV is striking hardest among the most productive segment of the Indian population--those aged 25 to 48. The United Nations Development Programme estimates that by the year 2000, the AIDS epidemic may cost India up to US$11 billion a year.

One of the most pressing problems that HIV poses to India, though, is how to manage the interplay between the virus and the country's raging tuberculosis epidemic. Currently more than 500,000 Indians die of tuberculosis each year, 14 million have an active infection, and over half the population carries the tuberculosis bacillus. As the immune systems of more Indians become compromised, increasing numbers of active tuberculosis cases are expected.

"We are sitting on dynamite and waiting for HIV to light the fuse," says Ramachandra Prabhakar, who heads the tuberculosis research center of the ICMR in Tamil Nadu.

A Nation Responds
Like countries around the world, India initially responded to the HIV epidemic with a call to ban sex with foreigners, to isolate HIV-infected people, and to return to traditional values. By 1992, though, the government had drafted a national prevention and control plan and formed the National AIDS Control Organisation (NACO). Although NACO has since formulated and issued guidelines for information campaigns, blood safety, STD control, and condom promotion, officials admit that implementation of these guidelines leaves much to be desired.

"The Indian government is, in many ways, strolling behind a galloping epidemic," says Ashok Row Kavi, editor of India's first gay magazine. Nongovernmental organizations around the country are seeking to buttress the government's efforts. But those trying to foster behavior change in India must overcome tremendous challenges.

Raising awareness about AIDS, for example, is extremely difficult. Despite its extensive sex industry, India is in many ways a conservative country, and open discussions of sex are taboo. In addition, India has no one language that is intelligible to the entire population, and only half the population is literate. The country's enormous linguistic and cultural diversity also thwarts education efforts, which necessitate skillful and sensitive translation of AIDS information.

But awareness is not enough, as many other problems demand immediate attention. For example, many of the groups identified as high risk for HIV suffer from social stigmatization and legal sanctions. HIV risk reduction efforts for these groups--such as needle exchange programs for IDUs--are believed to amount to tacit acceptance and promotion of illegal acts. The resultant inaction is allowing seroprevalence rates to escalate. Also, while AIDS service organizations have tried to promote condom use, they continue to receive frequent complaints of condom breakage from target communities. Indian condom manufacturers have been slow to upgrade condom quality, despite a government directive that is over a year old.

Perhaps the most important challenge for those fighting the epidemic in India, however, is conveying the dangers of a new, poorly understood virus against the backdrop of dire poverty. HIV--which causes symptoms only after years of infection--is too abstract and distant a threat to persuade many Indians to change their behavior. "Have you heard of AIDS? Do you know that it can kill people within a few years? These questions have little relevance in the slums," says Jimmy Dorabjee, a New Delhi-based social worker. "Here, they answer, they would be dead anyway. Starvation and other diseases will claim them before AIDS does."

While the government, AIDS service organizations, activists, and the international community wage a desperate battle against the epidemic, the virus continues its sweep through a nation for whom AIDS will soon become an all-too-tangible reality. As is gradually becoming clear the world over, HIV can and does make its home everywhere--even in the birthplace of Buddha.