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Sunday, Dec 05, 2004

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Opinion - Leader Page Articles

A ticking time bomb?

The HIV/AIDS epidemic in India is no longer confined to high-risk groups. There are warning signs that it is women, especially the young, who are among the most vulnerable, writes N. Gopal Raj.

Reducing the risk to women should be the priority if India is not to face an AIDS epidemic. — Photo: AP

SINCE THE first case of HIV (Human Immuno-Deficiency Virus) in India was documented in Chennai in 1986, the disease has grown to epidemic proportions in many parts of the country. Official estimates by the National AIDS Control Organisation (NACO) of the number of Indians living with HIV show a progression from 200,000 in 1990 to 3.86 million in 2000 and 5.1 million by 2003.

The worry is that the epidemic might be poised to shoot out of control, as has happened with tragic consequences in Africa. The United States National Intelligence Council warned two years ago that the number of HIV-infected persons in India could grow to 20 million to 25 million by 2010.

But NACO points out that its estimates showed an increase of only 5.3 lakh HIV infections in 2003 compared to 6.1 lakh infections the previous year. "This shows that there is no significant upsurge in the number of new infections, and in fact the rate of growth of HIV has registered a slowing down," it observed.

Others are less sanguine. A few months ago, Richard Feachem, executive director of the Global Fund to Fight AIDS (Acquired Immune Deficiency Syndrome), Tuberculosis and Malaria, declared in New Delhi: "The HIV/AIDS epidemic in India is extremely grave. It is a ticking time-bomb. The epidemic is rising rapidly and could soon get out of control unless the response is scaled up massively."

`Tipping point'

"Perhaps the single most important question concerning national prevalence trends is whether the epidemic will pass a `tipping point'," points out a report on India that was published last year by the AIDS Policy Research Center at the University of California in San Francisco (UCSF).

"This tipping point represents the transition from an epidemic that is largely confined to high-risk groups to one that has spread into the general population. Once this transition has occurred, the epidemic is far more difficult to control and the scale of devastation will be far greater."

HIV initially spread in India among high-risk groups such as sex workers and their clients, those with sexually transmitted infections, intravenous drug users and professional blood donors.

Warning signs

But the epidemic in India is no longer confined to high-risk groups or urban populations but is gradually spreading into rural areas and the general population. As it does so, there are warning signs that it is women, especially the younger women, who are among the most vulnerable.

"The number of women infected is steadily rising: one in every four AIDS cases reported is a woman," according to NACO. NACO figures for the total AIDS cases in the country up to August 2004 show that only about 22 per cent of the cases in the age group of 30 years and above are women, but they make up 37 per cent of the cases in the sexually active age group of 15-29 years.

Moreover, a report from the United Nations Children's Fund (UNICEF), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO) suggests that in 2001 over 60 per cent of the HIV-positive young Indians (15-24 age group) were women.

Rural women are particularly vulnerable to being infected as they have less access to health care and information on HIV/AIDS. NACO's estimates of HIV/AIDS prevalence in the country last year show that village women form the same proportion (over one-third) of the HIV-infected rural population as their city sisters form of the HIV-infected people in urban areas. This is an ominous portend considering that three-quarters of India lives in its villages.

If women fall victim in ever increasing numbers to HIV/AIDS, it would propel the Indian epidemic towards the dangerous `tipping point.' The tragedy is that it is marriage, not promiscuity or other high-risk behaviour, that makes the vast majority of Indian women vulnerable to HIV.

"Eighty per cent of the [Indian] women infected [with HIV] have only a single partner," points out Suniti Solomon, founder-director of Y.R.G. Centre for AIDS Research & Education (YRG CARE) in Chennai.

Scientists at the National AIDS Research Institute at Pune studied women attending two clinics for sexually transmitted infections in the mid-1990s. They reported that, other than sex-workers, more than 90 per cent of the women had only one lifetime sexual partner and the sole risk factor for such women becoming HIV-positive was through their husband.

A recent study in south India showed again that nearly 90 per cent of the HIV-infected women were monogamous and marriage was their only risk factor for HIV.

Men who visit sex workers, have sex with multiple partners, sex with other males or use intravenous drugs risk catching HIV and passing it on to their wives. A recent study carried out in Chennai by YRG CARE and U.S.-based researchers indicates that drinking increases the chances of men indulging in risky sexual behaviour.

Another problem, as Dr. Solomon points out, is that women do not see themselves as being at risk of getting HIV from their husbands. But even if women become more aware of the possibility of contracting HIV from their husbands, their options for avoiding or minimising that risk could be limited.

Traditional pressures

For one thing, there is the pressure of tradition that requires women to bear children after marriage.

"The pressure to bear children is so intense that when a woman must choose between avoiding becoming infected with HIV by her husband but remaining childless and conception with the possibility of becoming HIV-infected, she often chooses the latter. As a result, three-quarters of HIV-positive women in India were infected within a few years of marriage," observes a paper published earlier this year by Dr. Solomon and other researchers.

Prevention problems

HIV/AIDS prevention measures such as abstinence, mutual monogamy (or at least reducing casual sex), use of condoms, and avoidance of high-risk practices require effective communication between husband and wife. But sex and sexuality are not usually frankly discussed by married couples in India. Studies have shown that the social norm of men being dominant and women being subservient makes such discussion and negotiation difficult.

"Women's lack of access to and control over education, employment and decision-making make it difficult for them to negotiate conditions of sexual intercourse, such as condom use," says Suneeta Krishnan, who is a faculty member at the UCSF's Department of Obstetrics, Gynaecology and Reproductive Sciences and works in Bangalore as Women's Global Health Imperative's director of programmes in India.

Although condom use has increased in India over recent decades, barely more than three per cent of sexually active people use condoms. They do so mainly for contraception rather than protection against HIV and other sexually transmitted infections, according to the United Nations Population Fund.

Protecting women

These are problems that women in many other countries also face. There is a search for methods to protect women from HIV infections during sex, which do not require the cooperation of their male partners. Considerable research is going into the development of microbicides that could be applied as a gel, film, sponge, lubricant or suppository.

Researchers are also looking at other options, such as the diaphragm and the female condom. "No single method may be suitable in all situations and so women need choice," says Dr. Krishnan.

Moreover, interventions to stop the spread of HIV/AIDS in India have "tended to focus on `high-risk' communities, ignoring monogamous women" who are at risk through unprotected sex with infected spouses, observes the report from UCSF's AIDS Policy Research Center.

There is a failure to link HIV/AIDS in women to the larger issue of their access to reproductive health care, points out Lester Coutinho, country programme advisor to the David and Lucile Packard Foundation in India.

Sexually transmitted infections, for instance, greatly increase the chances of women getting and transmitting HIV. But the HIV/AIDS programmes of the Government as well as those of some important private donor agencies tend to function as isolated systems.

Primary health care

"A good and well-equipped infrastructure for primary health care, which can educate and help people, is essential for stopping the HIV epidemic in the country," believes Imrana Qadeer of the Centre for Social Medicine and Community Health at the Jawaharlal Nehru University, Delhi.

India's HIV infection rates are now similar to that in Africa about 12 years ago, warns Gita Sen, Sir Ratan Tata Chair Professor at the Indian Institute of Management in Bangalore. In those 12 years, the epidemic has exploded in Africa and India stands on the brink of a wave that would send HIV infections sweeping through the general population.

"At a time when infection rates among women are rising rapidly because they are powerless to say `no' to sex if their infected husbands insist, a more integrated approach to reproductive health and sexual and reproductive rights is needed," she told The Hindu . "We must sensitise ordinary people, especially young people, and change their behaviour," says Dr. Sen.

As Bill Gates once remarked: "The choice is now clear and stark: India can either be the home of the world's largest and most devastating AIDS epidemic — or, with the support of the rest of the world, it can become the best example of how this virus can be defeated."

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