I really need to do a fun post (wedding plans! all the great pictures I have after 5 weekends in a row on a plane to somewhere!)... but for today, here's an important article in today's NYT. (Aren't you glad to know that there are, like, 3 million fewer people worldwide living with AIDS than everyone thought? And I tell ya, the "experts" in my field slip a little more in estimation every day.)
June 7, 2007
India Has Fewer AIDS Victims Than Thought
By DONALD G. McNEIL Jr.
NEW DELHI, June 7 — India, which has repeatedly been accused of denying the size of its AIDS
epidemic, probably has millions fewer victims than has been widely
believed, according to a new household survey that has not yet been
released.
If the results of the survey — conducted under international
supervision with American financing — are correct, India is no longer
the world’s supposed leader, with 5.7 million people infected with the
virus in the official United Nations
2006 estimate; it would again rank behind South Africa with 5.5 million
infected people, and possibly behind Nigeria with 2.9 million.
Early analysis of the figures in the survey suggests that the
number of infected people in India is between 2 and 3 million,
according to several sources, including American epidemiologists who
know the data and the health ministry here.
“Everyone transiting through here says, ‘This is a pandemic,’ ” Dr.
Anbumani Ramadoss, India’s health minister, said in an interview here.
“But I am very confident that we will not turn into a generalized
epidemic.”
A nation’s AIDS epidemic is considered “generalized,” meaning it is
spreading throughout the sexually active population, when more than 1
percent of people are infected. India’s official rate has hovered for
years at 0.9 percent of its 1.1 billion people; the new survey suggests
that it may actually be as low as 0.3 percent.
That implies that India has managed to keep its epidemic more like
that of the United States, where the virus circulates mostly within
high-risk groups rather than generally in the population. In the United
States, the prevalance rate is 0.6 percent.
In India’s case, the high-risk groups are prostitutes and their
clients, especially truckers; men who have sex with men; and people who
inject drugs, especially in the northeastern part of the country near
the border with Myanmar.
Some experts on AIDS surveillance techniques have been saying the
same thing for years, arguing that Indians do not have the same kind of
sexual networks that are common in southern and eastern Africa, in
which both men and women often have two or more occasional but regular
sexual partners over long periods of time. Also, outside of
prostitution, “transactional sex” between teen-age girls and older men
in return for money, food or clothes is much less common in Asia than
in Africa.
James Chin, a professor of epidemiology at the University of California
at Berkeley, has argued that the typical way of estimating AIDS
prevalence rates — sampling the blood of pregnant women who come to
urban health clinics and the blood of high-risk groups — greatly
exaggerates national estimates.
He has been vindicated by more recent surveys, paid for by the
United States, that take blood samples in randomly chosen households in
rural and urban areas.
One of those, called the National Family Health Survey, produced India’s new figures.
Such surveys, country by country, have led the United Nations to
gradually reduce its world estimates of the total number of people
infected.
“This is a replay of what happened in Kenya,” Daniel Halperin, an
expert on AIDS infection rates at the Harvard School of Public Health,
said of the India report.
When Kenya was more carefully surveyed in 2004, Dr. Halperin said,
estimates of its prevalence rate were more than halved, to 6.7 percent
from the 15 percent that the U.N. AIDS agency had estimated in 2001.
But Dr. Halperin said that AIDS-fighting agencies have such a stake
in portraying the epidemic as an approaching Armageddon that they are
hesitant to make significant downward revisions in estimates.
India’s survey was finished last year, but Avahan, an AIDS group
here financed by the Gates Foundation, refused to discuss the figures
before their formal release, which has not been scheduled.
“If the total number of cases in the world is half of what you’ve
been saying, that’s a bitter pill to swallow,” Dr. Halperin said. “So
every year they lower the numbers a little bit, and retroactively
change the estimates of what it used to be. It’s sort of Orwellian.”
In Africa, infection rates range as high as 30 percent. South
Africa’s is about 22 percent, and that figure is considered relatively
accurate because the epidemic is older there than in India, and full
population surveys have been conducted.
Claims in recent years by prominent experts that India was in
denial about the scale of its AIDS problem have become a sore point for
Indian health officials.
Richard Feacham, until recently the executive director of the
Global Fund to Fight AIDS, Tuberculosis and Malaria, said in early
2005, when South Africa was thought to have slightly more cases, that
“the official statistics are wrong — India is in first place.” He
warned that India’s epidemic could shoot up to African levels, wiping
out the surging economy and leaving a nation of orphans.
But S.Y. Quaraishi, then head of India’s National AIDS Control
Organization, took offense, calling such projections “technically
incorrect and misleading.”
Richard Holbrooke,
president of the Global Business Coalition on HIV/AIDS said in a 2006
interview disparaged contentions by Indian leaders that their country
would not follow Africa’s path, and compared their political courage
unfavorably to that of China’s leaders.
And in 2002, when Bill Gates
visited India to donate $100 million to fighting its epidemic, the
country’s health minister at the time, Satrugan Sinha, accused him of
“spreading panic among the general public” by suggesting that cases
could reach 25 million by 2010.
Given the new survey results, Dr. Ramadoss, the current health
minister, was asked if India was owed any apologies. All he wanted, he
replied, was “that the world acknowledge the efforts India is making.”
Among them, Dr. Ramadoss said, was the $2 billion it is spending to
fight the disease, the 75,000 people who now receive free
antiretroviral treatment, the 2,000 centers around the country that
provide sex education and condoms to sex workers and clients, and the
3,600 free testing centers.
India sends government workers to hand out condoms outside theaters
showing pornographic films, even though the films are illegal. It has
created a government condom brand called “Dipper,” a play on the the
advice painted on the backs of many large trucks, “Use Dipper at
Night,” meaning that following drivers should switch to low-beam
headlights.
“India is glaringly not in a denial
phase,” Dr. Ramadoss said, adding that he was grateful for the pressure
on his country from critics because it had forced the country to move
faster. “We need to work with the Global Fund, not contradict each
other.”
Anjali Gopolan, executive director of the Naz Foundation (India)
Trust, which runs an orphanage and fights stigmatization of AIDS
victims, said she was skeptical of any estimate as low as 2 million.
But whatever the correct figure turns out to be, she said, “the
infection is here, and we have a huge burden — we are a very sexually
active culture, contrary to what the politicians want to project.”
AIDS is still a disease that carries tremendous stigma in India. In
recent weeks, newspapers have carried reports of an AIDS patient left
on the street outside a hospital to die, of five infected children
expelled from school, and of a woman beaten to death by her in-laws,
who feared she would infect the family.
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