The Indian subcontinent is bordered on the west and south by the Indian Ocean and the Arabian Sea, on the east by the Bay of Bengal, and on the north by Pakistan, Nepal, China and Bangladesh. Just over 1 million square miles are home to 1.1 billion people — one-sixth of the world’s population, with more than 60 percent living in rural areas.
Once a colony of the British Empire, the country gained independence in 1947. Now a federal union, the Republic of India has 28 states and seven union territories that are self-governing and a prime minister who is the elected head of the country.
The country is characterized by its diversity in language, culture, landscape and heritage. Fertile lands and river valleys support agriculture, which employs about 60 percent of the labor force.
The face of HIV
Migrant laborers and truck drivers, who spend days to months on the road, are among the most vulnerable groups for HIV/AIDS infection. According to the National AIDS Control Organization (NACO), India’s central HIV/AIDS agency, there have been 124,995 officially reported cases of AIDS from 1986 to August 2006, though that number may be grossly underestimated because many people do not report their cases. Of those who have reported being infected, 58 percent live in rural areas and about 39 percent are women.
Just over half of all reported cases of HIV/AIDS are in two southern states: 52,036 in Tamil Nadu and 15,099 in Andhra Pradesh. In fact, those two states, along with the southern state of Karnataka and the western state of Maharashtra, which together make up 30 percent of India’s population, account for about 75 percent of HIV cases.
Migrant workers and truck drivers who reside in southern India and engage in sex with commercial sex workers or with other men account for the high prevalence rate there.
In the northern states, HIV is often transferred by intravenous drug users; AIDS prevention programs targeting that population have made inroads.
However, according to the most recent report from UNAIDS, the Joint United Nations Program on HIV/AIDS, 5.7 million Indians were living with HIV/AIDS by the end of 2005. The disparity between cases reported and official figures by UNAIDS highlights one of the difficulties facing those working to stop the spread of AIDS in India. Heterosexual behavior is the leading cause driving the epidemic in India.
Among other challenges in fighting HIV/AIDS is the government’s ability to provide health care especially in states considered vulnerable to the epidemic and the guiding social framework found in rural north and central India.
Challenges to fighting the HIV epidemic
Poverty proves to be a major hurdle in combating the spread of HIV/AIDS in India. About 350 million people, or more than 34 percent, live below the international $1 a day poverty level, and nearly 80 percent live on less than $2 a day. HIV/AIDS services are poor in rural areas, where most of the infected Indians live. Outreach is difficult. And many patients are unable to access services and medicine at the municipal hospitals because there is no funding for bus fare.
Social practices and taboos are serious challenges facing India as well. Stigma about those with the disease and discrimination force many who have AIDS to remain quiet about their status.
Another roadblock to delivering AIDS services is a law on the books dating from British colonial rule that says conviction for a homosexual sex act can carry a penalty of a fine and up to 10 years in jail. Because of that 1860 law, homosexuals are less likely to seek medical attention.
Those working to combat AIDS consider the law to be one of the greatest obstacles in combating the spread of the infection. Men who have sex with men (MSM), as they are commonly referred to, are a marginalized and vulnerable group at high risk of contracting the HIV virus. The law pushes the community underground, making medical outreach more difficult, according to AIDS prevention activists.
Workers for several organizations, such as the Naz Foundation (India) Trust, devoted to reducing the spread of HIV and other sexually transmitted infections in India, have faced police harassment, extortion and even jail time while attempting to reach MSM and other vulnerable communities. Naz attempted to repeal the law in Indian courts, but its petition was dismissed in November 2004.
As of August 2006, however, the government, with the support of Sujatha Rao, the current director of NACO, has been reviewing the law again. “Laws and regulations that target commercial sex workers, men who have sex with men or intravenous drug users only result in making these groups invisible and push the infection underground,” Rao said, “making it virtually impossible for NACO to intervene effectively in ensuring primary prevention or access to treatment.”
Indian government response
In 1992, the Indian government, with financial help from the World Bank, began Phase I of the National Aids Control Project (NACP), a public health program to implement a national HIV/AIDS prevention program. The first phase, which ended in 1999, coordinated the states and territories in monitoring the epidemic, developing effective prevention programs and reducing the rate of infection. The second phase, which runs through 2006, involves regional workshops bringing together state government leaders, nongovernmental organization leaders, health care professionals and others to create plans to implement prevention and treatment programs. Monitoring the programs and focusing on prevention and care are also major components of the second phase. In addition to NACP, the Indian government provides free medicine to AIDS patients such as new mothers, infected children and those who receive treatment at government hospitals.
U.S. government response
Since 2004 India has received nearly $77 million from the President’s Emergency Plan for AIDS Relief, the five-year, $15 billion U.S. initiative to combat HIV/AIDS. That is the highest amount allocated to a country that is not among PEPFAR’s 15 “focus countries”, which together account for more than half of the world’s HIV infections. PEPFAR funds are used to support programs implemented by NACO, such as one program that creates social centers for truck drivers who travel along the Chennai-Bangalore highway. In two of India’s states hardest hit by the epidemic, the U.S. Agency for International Development helps fund programs such as the AIDS Prevention and Control Project in Tamil Nadu and the Avert Society in Maharashtra.
The U.S. has provided technical assistance through the Centers for Disease Control and Prevention to upgrade the ART [antiretroviral treatment] Centre and Laboratory in Chennai, which treats more than 3,000 patients a year; antiretroviral treatment has transformed HIV/AIDS from a fatal condition to a manageable illness The U.S. National Institutes of Health also is involved with operational research into HIV/AIDS in India by helping to fund clinical trials of vaccines and evaluation of using antiretroviral treatments to lower the risk of transmission between couples where one person is HIV-positive.
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