Response to Drs Potts and Walsh article, "Tackling India's HIV epidemic: lessons from Africa"

This passionate plea is in response to the recent article by Drs Potts and Walsh, "Tackling India's HIV epidemic: lessons from Africa" in BMJ 2003 volume 326, 1389-1392. While parts of their article present a reasonable point of view, there also are many issues and recommendations that I believe will lead to a very significant backlash. I feel strongly enough to request the authors to withdraw their article. The most significant reasons for my plea are the following:

  1. CIRCUMCISION: It takes someone completely unfamiliar with India and the Hindu culture to even consider, much less recommend, circumcision. Hindus do not generally circumcise their male children and most Hindus deny this practice as strongly as many Muslims and Jews adhere to it. A very significant way to distinguish between Hindus and Muslims males in India (as painfully brought out during Hindu Muslim riots) has been male circumcision. This distinction is very deeply ingrained in the minds of people of both religions. Thus, the beneficial role of circumcision in preventing HIV infection (possibly a factor of 2-3 reduction in transmission rates is similar to the factor of 2-5 reduction due to the control of other STDs, especially those causing genital ulcers. In my opinion the latter is a much better, less controversial, and more effective goal to aim for.) is not sufficient to convince the majority of Hindu mothers or fathers to have their male children circumcised, i.e., planning against the possibility that their newborn will have risky sexual behavior. The public outcry at such a recommendation by "Americans" will set back HIV/AIDS intervention very significantly, perhaps by years.

  2. CONFRONT LOBBYING FOR INCREASED USE OF ANTIRETROVIRAL DRUGS: The cost-effectiveness of prevention versus treatment and the need for both is very well known and documented. The issue a policy maker must consider is what fraction of a limited budget is spent on treatment and what fraction on prevention. This is especially relevant when one considers the large numbers - 4 million HIV+ people in India at end of 2001 and the US National Intelligence Council estimates of 20-25 million by 2010. Should we abandon the current 4 million infected? Or do we give them band aids in the form of some support for opportunistic infections? Or do we treat them as in Brazil or as in the US or any other part of the industrialized world? The lesson from San Francisco (which the authors should be very familiar with) is that PWHA are among the most effective change agents. Creating these change agents and removing the stigma associated with PWHA and HIV/AIDS requires access to treatment and social acceptance of HIV as another terminal but manageable disease.

    India is already paying a high price, and failing in its HIV control, because HIV+ people are considered immoral and are thus marginalized. The recommendations made by you will only help the government shrug its responsibility to provide treatment and justify their lack of action by quoting similar eminent scholars who doubt the efficacy of treatment. My question to you is -- Why does the medical establishment in the US not unite and demand that the large pharmaceutical companies bring down the cost of ART drugs and allow poor countries to produce generics rather than advocating that ART is not a good strategy for poor countries?

  3. RELIGIOUS LEADERS: All religious leaders in India - Hindu, Christian, Muslim, ... - have consistently been advocating abstinence and asking their congregations to uphold high moral standards. I certainly have not met any religious leader, outside of fringe groups, who do otherwise in public, even though many lead very interesting sex lives. It is not clear to me if religious leaders anywhere can give a message that is substantially different from abstinence and faithful relationships to their congregation. What we must ask them to do is promote compassion for those infected and through outreach convince the public that HIV cannot be spread by casual contact. They can and should play a vital role in reducing stigma.

  4. URBAN VERSUS RURAL: you seem to indicate that risk begins once people move to the anonymity of urban life. You say India remains a traditional society. But, can I ask you, what are the patterns of sex and sexuality in this "traditional" society? Rural India enjoys and suffers sex and the details of sexual behaviors outside marriage would fill volumes - much of which you would classify as very high risk sex. In short, the risk of HIV is very large once the infection enters any community in India!

  5. PRESCRIPTION REGULATIONS IN RURAL INDIA: India would benefit tremendously if an enforcement of prescription regulations (and the general issue of monitoring of delivery of health care) was carried out not only in rural India but everywhere, including cities!

  6. THE ROLE OF WORKSHOPS AND CONFERENCES: Kindly allow me to present two sides to another one of your recommendations. Your comment that large international meetings waste resources has merit. Meetings can be of two kinds - educational or networking - and both serve a purpose and can be very beneficial. Unfortunately, the problem you bring up, and I agree with, is with the organization and focus. There is very significant scope for improvement there and I hope the funding agencies address these.

    At the same time there is need to address the flip side of the issue - the vast number of public health people and academics in the industrialized world who invest all their time in "scholarly" reports and meetings when they could be working on the ground where their need is the greatest. While not belittling the need for research and analysis, most us know all there is to know regarding prevention of HIV, the problem is implementation and the people resource needed to help implement prevention and treatment. For example, given the large numbers of college graduates in Sub-Saharan Africa that emigrate at the first chance, is it any surprise that there is so little infrastructure (developed or left) to stop the spread of HIV or any other infection?

    Just like the case of meetings, the amount of resources from donor governments and foundations that directly or indirectly find their way back into the hands of academics and organizations in the industrialized world, part of which then ends up being used to sponsor scholerly meetings, could be better utilized by people working on the ground. I can show you many excellent organizations in India that are doing an incredible job under the most unimaginable restrictions and lack of resources and support. The funding agencies, rather than seeking them out, have chosen to create a proposal based system that is alien to these organizations. Thus to get funded you have to be proficient in the western system of proposal writing and not necessarily in the ability to create a good organization that has the trust and welfare of the poor, the sick, and the marginalized. Why don't we, who know the issues, do the leg work and see that funds end up with dedicated and good organizations with good and caring people who need and can absorb additional resources? And then help them do better by working with them?

    Most of us who know how to stop the spread of HIV are choosing not to work on the ground. That would require us to give up our air conditioned comfort. That is where the greatest tragedy and shortcoming is. We claim to care but we cannot bring ourselves to do what we know really needs to be done!

  7. TARGETED INTERVENTION: Targeted intervention as a national policy has not been successful even in the US. The label of HIV as a gay disease set back the US response by years and even now a significant fraction of the public connects HIV with homosexuality and therefore denies risk to themselves or to their family. The rise of infections in the 15-24 year old heterosexuals in the US shows that as the pandemic matures the infections spread in so called "low risk" groups. The advocacy for a nationwide school education program, which targets all students in the US, is certainly a universal approach and not one based on immediate high risk behavior or group. Once the window of opportunity for targeted intervention has passed, the National policy should be aimed at the entire population.

    I would like to present general arguments on why the window of opportunity for TI as a National Policy has passed in India. Targeted intervention as a policy relies on four fundamental concepts:

    I propose that in view of the current level of spread of HIV/AIDS, these four conditions no longer apply in India.

    Based on these arguments my recommendion is that the national policy now has to be aimed at the full population. The perception of risk by the public, based on my interactions with thousands of people, is that HIV/AIDS is still a problem of the immoral -- the high risk groups. People have not come to understand and accept how large this population is nor come to terms with the reality that many people, at some time in their lives, have risky sex or come in contact with blood or needles or medical instruments that are infected.

    The concept of targeted intervention is important in the implementation. Working with high risk groups and reducing risk to them is essential and necessary strategy. This distinction between policy and strategy for implementation should be clarified otherwise stigma, denial, and ignorance of risk will continue and the infections will continue to spread.

    The most effective workers within these high risk groups are peer educators, peer counselors, and peer health workers. This requires that treatment be a very important and significant part of the policy. The next most successful are NGOs with a holistic portfolio who integrate HIV/AIDS prevention work into their activities. The funding of NGOs should reflect this.

    What is needed most to stem the tide of HIV/AIDS in India and Africa and elsewhere are

    I hope these arguments convince you to retract your paper.