VISIT 1: MARCH 1 - MARCH 8, 1999 (DELHI AND LUDHIANA)

A summary of my activities during this visit to India is given below. After an overall summary, I present (A) a discussion of the status of Indian situation, (B) Prevention and awareness message, (C) Costs, and (D) details on specific points, (E) Details of my activities, and (F) Acknowledgements.

SUMMARY

India is facing 4 major pandemics -- TB, Sexually transmitted diseases, Hepatitis, and HIV. Together they will wreak havoc on the entire nation in the next decade. Current efforts are vastly inadequate. We all have to contribute to stopping their spread as we all stand to lose our dear ones.

Given the current conservative numbers of HIV positive individuals (UNAIDS estimates 5 million HIV positive people in India at end of 1998) and doubling every 2-3 years means that there will be 50 million by 2007 and 100 million by 2010. This is one in 10 people, i.e. on average one in every family. Also, it is important to realize that all socio-economic levels are already affected. Thus life as we know of will cease to exist by year 2010 if not sooner. We already have concrete examples of 9 countries of Sub-Saharan Africa devastated by HIV.

It is therefore essential that every individual that understands the situation starts to educate those around them with a sense of urgency. We do not have the luxury of waiting for someone else (government, NGO's, ...) to do it. Even if we start today the cost (social, medical, industrial, and cultural) will be enormous. There is no future for our children in India unless we act now with cohesion and co-operation.

This message is not supposed to create panic as these diseases are transmitted only by risky sex, bad blood supply, and infected needles and surgical instruments. Their spread can be stopped tomorrow if we as a nation act together to change our life style, in particular our sexual behavior. I believe that this can be done, provided we act together and now.

THE MAIN COMMON MESSAGE:

1. IT HAS TO BE EMPHASIZED THAT TODAY INDIA IS FACING 4 DEADLY PANDEMICS

   1. Tuberculosis (TB) and especially multi-drug resistant variants. (2 million Indians died of TB in 1998)
   2. Sexually Transmitted Diseases (STD) like syphilis and gonorrhea (70-80 million new occurrences per year)
   3. Hepatitis B and Hepatitis C (Hep B can be fatal. Hep C has no vaccine or cure and is fatal)
   4. HIV leading to AIDS, is the unforgiving killer. (5 million infections by end 1998, and doubling every 2-3 years)

   Each of these diseases are by themselves affecting millions of Indians and spreading very fast. Their combination is particularly disastrous as they each reinforce the spread of all others. For example, someone with TB is far more likely (roughly a factor of 10 more) to get HIV infection through sex; and of those with HIV, 63% in India have died of TB.

2. UNAIDS estimates 5 million HIV positive people in India at end of 1998. The rate of increase is alarming -- 5000 new infections a day (2 million a year). Doubling every 2-3 years means 50 million by 2007 and 100 million by 2010. (Most people suspect the above numbers are underestimates). Thus, in 10 years, one in every 10 Indians will be HIV+. They will be living with a 6-10 year death sentence. One in 10 means, on average, one HIV infection within a nuclear family of just brothers, sisters, kids, and parents. The disastrous parallel of the socio-economic situation in Sub-Saharan Africa to Indian conditions makes clear why India may loose hundreds of millions of people if an immediate mass campaign to prevent spread is not started.

3. The only viable approach to fighting the spread is a massive education and awareness campaign. Prevention is our only hope. This campaign should be given the priority of a national emergency -- a state of war.

4. There are certain groups of people at very high risk, for example commercial sex workers, hijras, and truckers. The rates of seropositivity in these is already very high (over 50-60%). These people need to be educated immediately and counseled to using condoms and ALWAYS practicing protected sex.

5. The next most vulnerable group is the industrial labor force of 200 million and their spouses, which makes it a total of roughly 400 million at risk. This is mainly a migrant labor force, living away from their roots/homes, in highly over-crowded and unhygienic conditions. A lonely depressed migrant worker who has sex outside marriage is typically having 30-100 risky encounters a year. Once the HIV+ rates in this community become large, the entire urban/rural population is at risk. Spread in this community will lead to economic collapse as numbers of absenteeism and death of these industrial workers grow.

6. The pattern of sexuality amongst well to do school and college kids in cities is beginning to resemble the sexual revolution of the 60's in the US. These kids are experimenting with vaginal, oral, anal and group sex and are not very conscious of the risks involved -- that there is no second chance with HIV. They need to be counseled on abstinence and delayed sexual activity. Failing that, on practicing protected sex ALWAYS.

7. There are two blood supplies in India -- through official blood banks and unofficial. Even amongst the official, screening is not 100%.

8. Use of unclean needles and instruments, and unethical practices by qualified, semi-qualified and quacks are common.

9. Full blown AIDS cases are being seen in all parts of India. Maharastra, Karnataka, Tamil Naidu, and Andra Pradesh are the hot spots. In these four states the rates are already alarmingly high. It is clear that HIV infections are present in all socio-economic sections of Indian society.

10. Unlike the US and western Europe where gay men and IVD users were the most vulnerable, sexual patterns and medical care in India put all socio-economic sections at high risk. NO ONE CAN ASSUME TO BE SAFE!

PREVENTION AND AWARENESS

Since there is no cure or vaccine at present, our only tool against further spread of HIV in India is PREVENTION VIA MASS AWARENESS. In all cases HIV leads to AIDS and death in 6-10 years. Throughout this period, as the immune system degrades, the individual is infective independent of whether there are any symptoms of HIV infection like fevers, persistent diarrhea, rashes, headaches, .... We therefore need to repeatedly emphasize and promote the need for

1. Delayed sexual activity in school and college children.
2. Safe sex. Sex with only one partner. Both partners maintaining fidelity of the relationship.
3. Protected sex. 100% and proper use of condoms, vaginal barriers and spermicide creams like nonoxynol-9. Anonymous availability of condoms in workplace, schools and colleges, and instructions on their proper use are essential.
4. Immediate and proper treatment of STD's. Counseling of these individuals to change their risky behavior before they contact HIV.
5. Counseling of individuals with HIV to not have risky sex and spread the disease.
6. Vaccination against Hepatitis A and B
7. Safe blood supply
8. Proper sterilization of instruments by doctors.
9. Emphasis on the fact that HIV is not spread by casual contact. We have to avoid fear and panic in society leading to victimization of those afflicted and at highest risk.

Achieving these objectives requires a major change in our behavior and assuming social responsibility. This will need the message to be delivered repeatedly.

COSTS

Industrial cost:

• Absenteeism. For example a worker with HIV gets a common cold that progresses to bronchial infection to pneumonia. Thus a worker who would be say 60% effective for 3 days is now out for a month.
• Eventual loss of skilled labour. As the disease progresses, the worker will be no longer able to work and die at some point.
• Spread of TB, which is the most common opportunistic disease, in the crowded and poorly ventilated work conditions in India.

It is estimated that it takes 1-4 years to train a skilled worker. The cost to industry of a skilled laborer with HIV even prior to disappearance with AIDS is Rs. 1-2 laks per year. In addition, this laborer will have to spend increasing amount of his/her salary on medical bills leading to significant decrease in buying power.

Medical Costs:

• The medical costs, even at pre AIDS stage will soak major portions of a family's discretionary income, leaving little buying power.
• Hospitalization will deplete all family savings. People, especially the labor force will take loans at very high interest rates to pay medical bills. When not able to pay back loans they will resort to selling their children to either the sex industry or for child labor.
• My estimate is that by year 2002-2003 we will see the start of the flood of HIV positive and AIDS cases in hospitals across the country. They will either be refused care or the hospital will buckle under treating just these people and doctors will panic. This pattern is already emerging in the highest hit states -- Maharastra, Karnataka, Tamil Naidu and Andra Pradesh.

Social Cost:

• HIV infection in one parent can be passed to other if she/he does not get tested and changes behavior. With both parents gone children will be left as orphans and easy victims to street violence and contracting HIV. Thus entire families will be wiped out.
• Fear and suspicion will grow in workplace even though HIV cannot be transmitted by casual contact. Also, people will question visiting dentists and barbers. These fears will lead to isolation and victimization of those afflicted or at high risk of getting HIV like commercial sex workers, hijras, truckers.

MISCELLANEOUS DETAILS

1. Reports by psychologists, gynecologists, health care workers on the widespread sexual and physical abuse of children by servants, nannies and relatives.
2. High incidence of sex between men and men (not aware of situation between women and women). Also, there is significant behavior of bisexuality which causes the disease to move between homosexual and hetrosexual communities. Rather than getting bogged down by discussion of sexuality, we have to emphasize that HIV and Hepatitis can be spread by anal, oral and vaginal sex.
3. Children in private schools are experimenting with sexual activities and drugs very early. Again reports by psychologists, gynecologists show the increase in the number of kids coming in with trauma related to sex or drug use.
4. Lack of supervision of children in well to do families. This is leading to rebellion, and early experimentation with risky behavior.
5. Parents are so caught up with their lives and junkets that they are not being proper role models for social awareness and responsibility.

FREQUENTLY ASKED QUESTIONS

1. If dirty needles can transmit HIV, then why not mosquito bites.
2. What procedures to follow in case of needle-sticks or contact with infectious blood. (this was mainly from the medical workers).
3. What is the window period during which ELISA tests can be negative while the person is actually HIV positive?
4. Was it safe to visit barbers? Was their use of straight edge risky? Was it OK if one took their own blades?
5. What are the risks of visiting dentists for cleaning and other procedures?

DETAILS OF MY ACTIVITIES:

ACKNOWLEDGEMENTS:

I am very grateful to Arun Kapur and the staff of Vasant Valley School for organizing the talks at Vasant valley school, Delhi and for making all the arrangements.

Shri Prem Nath Gupta, Secretary of DMCH, and the senior staff of DMCH (Drs S. C. Ahuja, G. S. Wander, Rajoo Singh, Sanjeev Uppal, Mrs V. Malhotra, Rajiv Gupta, and Col. K.S. Kanwar) by their personal and daily involvement. This commitment of time and reinforcement of the urgency opened up the entire Ludhiana community to this AIDS campaign.

Shri Sunil Munjal arranged my visit to Hero-Honda industries. His personal interest in pushing this message in industries throughout India is very welcome and needed.

Lavleen Singal and Rekha Singal contributed by their constant encouragement and support.

Ashok Row Kavi educated me on many aspects of the crisis, in particular sexuality and risky behavior amongst mem having sex with men.

I thank T. Bhattacharya, S. Colgate, A. Hayes A. Chapman, E. Jens, D. Sharp, S. Sharpe, L. Weaver, G. West, G. Zweig, and the Los Alamos Medical Center for their generous support.

The above talks and the frankness of the discussions would not have been possible without the direct involvement of the above mentioned people. I feel that this model of gaining the confidence and support of pillars of society first and then reaching the public through and with them is very efficient in India.

I am very grateful to all the participants and hope that each one of them will carry the word forward with the urgency of a national emergency.