June 23, 2003 Berkeley - The epidemic of HIV/AIDS in India is following the same pattern as that of sub-Saharan Africa in the 1980s, and it could become just as devastating unless preventive action is taken now, according to researchers from the University of California, Berkeley, in a paper to be published Saturday (June 21) in the British Medical Journal.
"In hindsight, opportunities were missed to stem the explosive growth of AIDS in Africa," says Dr. Malcolm Potts, professor of population and family planning at UC Berkeley's School of Public Health and lead author of the paper. "It would be a tragedy if we don't apply the lessons learned from the failure to control the spread of HIV in Africa to the current situation in India. It is very painful to watch history repeating itself."
According to the Joint United Nations Programme on HIV/AIDS, 20 percent of people over 15 in some sub-Saharan African countries are HIV-positive, and 70 percent of them will eventually die from AIDS.
Recent estimates indicate the HIV prevalence rate in India, which has a population of 1 billion people, is less than 1 percent, but the low rate belies the looming pandemic on the horizon, according to the paper's authors.
Part of the change comes from the shifting demographics of India over the past few decades. Like in Africa, large numbers of men in rural areas are migrating to the cities for work and being exposed to changing cultural values, the researchers say.
"Certain sexual practices that were inhibited in a village suddenly become easier with the anonymity that comes with living in a large city," says Potts. "Men also start earning more money, so they have disposable income. And because the ratio of men to women is so low, the men spend their money on prostitutes, which contributes to the spread of HIV."
A report from the CIA's National Intelligence Council projects that the number of people infected with HIV in India will jump to 20-25 million by 2010. There is already evidence that, in some parts of India, HIV infection is moving from the core high-risk groups of prostitutes and intravenous drug users into the general population, the researchers say.
"In sub-Saharan Africa, not enough resources went towards effective prevention programs in these core high-risk groups," says Potts. "The situation in India today parallels that of Africa 15 years ago."
The authors are part of the Bay Area International Group (BIG), a family planning and reproductive health research group at UC Berkeley. Based upon an extensive literature review, original economic analyses and personal experience working in the fields of HIV prevention and international finance, the researchers concluded that current efforts to target high-risk groups in prevention programs fall far short of what is needed.
The paper notes that the public health expenditures for both India and sub-Saharan Africa fall below 6 percent of the gross domestic product. "Both India and Africa face similar challenges in that a large proportion of the population lives in poverty, and limited resources are available to help them," says Dr. Julia Walsh, UC Berkeley adjunct professor of maternal and child health, co-author of the paper, and a co-director of BIG. "In India, the government spends a total of $12 per year per person on health care. Per capita, you're lucky if get you get $1 per year spent on AIDS."
"Investment in AIDS prevention has been a story of too little, too late," says Potts. "The U.S. earmarked a mere $35 million globally for AIDS prevention in the mid-1980s. If we had had $200 million dedicated to AIDS prevention in Africa in the 1980s, the region would not be in the shape it is in now."
With limited resources, it becomes even more important to use AIDS funds wisely, the researchers said. Yet, scarce funds are being wasted on a large number of small AIDS prevention pilot projects that cannot be scaled to the larger population and on large scientific meetings that have become "platforms for non-evidence based lobbying" rather than a forum for an exchange of ideas and collaborations, the authors say.
Moreover, funding for prevention efforts is in direct competition with funding for anti-retroviral (ARV) drugs. The researchers found that 60 percent of $378 million in grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria went towards HIV projects, and that 21 of 28 countries receiving those grants will use the money to purchase ARV drugs.
"With the exception of preventing mother-to-child transmission during birth, ARVs are difficult to use and are expensive in developing nations, even when drug companies greatly reduce the price," says Walsh. "The most compelling lobbyists for extending ARV treatment to poor countries are infected individuals in rich countries. But evidence shows that focusing efforts on prevention rather than drug treatment can avert more infections and deaths from AIDS in developing nations."
Another mistake made in the early years of the AIDS epidemic in Africa was the failure to act quickly on scientific evidence that sexually transmitted diseases (STDs) contribute to the spread of HIV by widely distributing condoms and subsidizing the use of antibiotics.
"We know these work, we just have to do it," says Walsh. "Developing programs that helped those at highest risk for HIV transmission means dealing with groups that are marginalized in society: the prostitutes, IV drug users and men who have sex with men. There is still a traditional culture in India, but political leaders must be willing to acknowledge the need to commit more resources to these core groups if they are to slow the spread of HIV."
Evidence also has led the authors to recommend programs run by faith-based organizations, such as those in the Islamic, Christian and Hindu religions, that encourage sexual abstinence and a reduction in the number of sexual partners.
Another avenue of prevention advocated by the researchers is for HIV prevention programs to offer circumcision to Hindu men, who are generally not circumcised. This is based upon increasingly strong evidence that uncircumcised men are at significantly higher risk of becoming infected from an HIV-positive partner compared with circumcised men.
"We have a moral obligation to use the lessons learned from Africa to prevent a similarly catastrophic spread of HIV in India," says Walsh. "This involves coordinated efforts from national governments, large agencies and donor groups. To do anything less is unethical."
The Fred H. Bixby Endowment, the Bill and Melinda Gates Foundation and the William and Flora Hewlett Foundation provided funding for this research.
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