Spring 1994

They now realize their mistake. Since 1988 HIV-1 seroprevalence has markedly increased among heterosexuals in western and southern India and among injecting drug users in the northeastern part of the country. The Harvard-based Global AIDS Policy Coalition estimates that the number of HIV-infected people in South and Southeast Asia -- more than 3 million, or 16 percent of the global total -- now exceeds the total number of infected people in the entire indus-trialized world, with Thailand, India, and Myan-mar bearing the brunt of the Asian epidemic.

With HIV-1 appearing in pockets around the country, health experts worry that India is already confronting an exploding epidemic. According to the World Health Organization, HIV-1 may infect 1.6 million people in India by 1995. And the Indian Ministry of Health projects that the number may reach 10 million just five years after that. Spurred by reports of skyrocketing infection rates, the Indian government has begun to respond. Yet many fear it may have waited too long. "Serious attention started only in the 1990s, "said Salim Habayeb, a senior public health specialist at the World Bank in Washington. "I wish we had caught it a few years earlier. "

Several elements threaten to undermine India's fight against AIDS. For instance, HIV-1 continues to endanger the country's blood supply despite the government's efforts. And spreading the word about AIDS has proved difficult in a society that discourages discussions of sexuality.

For now the total number of AIDS cases remains small -- in January, the official count stood at 707. But many cases go undiagnosed, masked as a rise in tuberculosis and other infectious diseases. The actual number could be as high as 50,000.

Without obvious signs of an epidemic, many people are ignoring the danger. "You don't perceive it as a problem until you begin to see AIDS patients, "said Manoj Jain of the Christian Medical College in India, who is currently at Boston's New England Medical Center. "You can talk all you want about there being a lot of HIV, but it's an asymptomatic disease for many years. Getting people -- from politicians to doctors -- motivated to take action is difficult. "

While India's health care system may seem better equipped to handle an AIDS epidemic than those of some African countries, the future still looks grim. "Right now we're just managing with what's available, "said Srikanth Tripathy, a senior research officer with India's National AIDS Research Institute and a research fellow at the Harvard AIDS Institute. "Within five years, though, the health care system may be burdened with the care of large numbers of AIDS patients. "

The first cases of HIV-1 infection in India were diagnosed among sex workers in the southern state of Tamil Nadu in February 1986, when researchers screening a group of 102 sex workers from Madras found that 10 tested positive for the virus. Within a month, researchers detected HIV-1 among sex workers in two other cities in the state. Within the year, they discovered HIV-1 among sex workers from Bombay and Pune, in the west.

Infection through other modes of transmission appeared shortly after. In July 1987, the first indigenous blood transfusion-related HIV infection was documented, and three months later serosurveillance data showed 145 people with HIV-1 infection, of whom 35 were foreigners. That same year, the first mother-to-child transmission of the virus was reported.

Regional patterns of HIV-1 infection have since emerged. In Bombay, the virus is associated with high-risk behaviors involving sex workers and people with sexually transmitted diseases (STDs). As in Africa, HIV-1 appears to spread primarily through heterosexual contact. In the cities of Madras, where the infection rate has climbed to 25 percent, and Vellore, HIV-1 is also spreading among sex workers and their clients, who are showing up at STD clinics. A 1993 survey revealed that more than 40 percent of Pune sex workers are now infected. In Manipur, an isolated region in the northwest that borders on Myanmar, HIV-1 infection has soared among injecting drug users to more than 50 percent.

As awareness begins to build, so does fear. "If people know someone has HIV, they try to avoid interacting with that person, "Tripathy said. When word leaked out in one village that a man had HIV-1, even the homeless stopped sleeping on his doorstep.

India's extensive blood industry has proved vulnerable to HIV-1 infection. In 1988, researchers discovered that blood products -- including those used by hemophiliacs -- had been contaminated with HIV-1. Subsequent tests revealed a high infection rate among professional blood donors. In Bombay in 1990, it was established that paid blood donors who gave blood several times each month had been infected through unsterile plasma-pheresis equipment. Excluded from the pool of commercial blood donors in Bombay, and with no other way to earn a living, HIV-infected blood donors offered their blood to transfusion centers in other cities. Within a year, the government ordered mass screenings of blood products and the blood supply. But the task is huge. India has more than 1,000 blood banks. And though the government claims that up to 80 percent of the blood supply is now screened, the World Bank's Salim Habayeb says that the number may be closer to 40 percent.

HIV-2, the second AIDS virus, made its appearance -- in Bombay, Madras, and Visha-khapatnam -- in 1990, a year after the government began its blood screening program. So in 1992, the blood banks began using a test to screen blood for HIV-1 and HIV-2.

As the government struggles to control the spread of HIV-1, many health experts charge the medical community with lagging behind. In the late 1980s, before the numbers had begun to escalate, physicians opposed devoting resources to AIDS, Tripathy said. They argued that India had other, more pressing medical problems, such as malaria, tuberculosis, and malnutrition. "Even today, many clinicians are still not willing to look after AIDS patients, "he added.

Jain agrees. "The learning process needs to happen for doctors and other health staff, "he said. In India, dermatologists have traditionally cared for patients with STDs -- and now care for people with HIV-1. Dermatologists may not be prepared to handle the medical demands of an AIDS population, Jain noted, yet those trained in internal medicine have shied away from the task. "When they begin to see 15 to 20 percent of their beds filling up with AIDS patients, they will be concerned, "he added.

Most of what researchers know about HIV-1 in India comes from studies in urban areas. They know relatively little about the virus's path through the vast rural regions. Yet a 1993 survey of 44 AIDS patients at an urban STD clinic showed that almost 25 percent came from a rural background, suggesting that HIV-1 is rapidly spreading to rural areas.

Many of those now infected are migrant workers who travel to the cities for work, leaving their families behind. Once there, they may have had sex with infected sex workers, then returned home and infected their wives. Of particular concern are India's long-distance truckers, who drive across the subcontinent, visiting sex workers en route. Driving from town to town, they act as efficient couriers of HIV-1.

Despite its flourishing sex industry, India is in many ways a conservative country. Open discussions of sex are taboo. Even India's popular movies rarely depict sex. Only within the past few years have they contained scenes where the main characters even kiss, Jain said. "If you don't talk about sex, talking about HIV may be useless. "

"In India, people really haven't talked about sexuality, "said Radhika Balakrishnan of the Ford Foundation, a sponsor of AIDS programs in India. "One of the problems in AIDS policy is that not enough time is spent studying the cultural issues. "She noted that researchers are only beginning to look at homosexuality in India.

Another barrier to preventive education is India's high illiteracy rate, particularly among women. "You can't run information campaigns using written materials, "Balakrishnan said. She added that some groups are using cartoons and street theater to reach people who can't read.

By the early 1990s, the government had begun to gather steam. It had created the National AIDS Control Organization (NACO) with the help of an $84 million loan from the World Bank, part of a total loan package of about $100 million. Among its efforts, NACO set up an HIV-1 surveillance network that operates on a state-by-state basis. It also promotes public awareness through media campaigns, using government-sponsored radio and television spots.

In addition, the government has begun a massive training campaign for health care workers to prepare them for the coming epidemic. It has also enlisted the aid of non-governmental organizations to reach groups that might avoid official efforts. The government has further targeted STD clinics to improve treatment of diseases that facilitate the spread of HIV-1, such as genital ulcers, and is working to guarantee a steady supply of low-cost quality condoms.

As elsewhere, HIV-1 is striking hardest among the most productive segment of the population -- those aged 25 to 48. Habayeb said that for every person who dies of AIDS, the Indian economy may lose about $8,400. The United Nations Development Programme estimates that by the year 2000, AIDS may cost India up to $11 billion a year.

HIV-1 in India seems to be following the route of the epidemic in sub-Saharan Africa -- spreading through sex workers and their clients to the rest of society. Yet important differences may redirect its course. Jain noted that Indian AIDS control efforts began before the disease cut a swath through the general population. "We have a window of opportunity, "he said. "There are still places where HIV hasn't spread. "

"India will probably be luckier than Africa because they have started to do something sustainable to reduce the spread of HIV, "Habayeb said. "We are cautiously optimistic. "