India, which has been repeatedly accused of denying the size of its AIDS epidemic, probably has millions fewer victims than has been widely believed, according to a new but unreleased survey.
The survey was carried out under international supervision with American financing. If it is correct, India is no longer the world’s supposed leader—with 5.7 million people infected with the virus, according to the official UN 2006 estimate—but is again behind South Africa, which is believed to have more accurate survey results and has an estimated 5.5 million cases, and possibly other countries as well.
Early analysis suggests that India really has between 2-3 million victims, according to several sources, including American epidemiologists and the health ministry here.
How the rates are calculated has been a subject of debate, with some experts contending that the rates in many places may be exaggerated.
“Everyone transiting through here says, ‘This is a pandemic’,” Dr Anbumani Ramadoss, India’s health minister, said. “But I am very confident that we will not turn into a generalized epidemic.”
The lower figure would imply that India has managed to keep its epidemic more like that of the US, in that the virus circulates mostly within high-risk groups.
In India’s case, these are prostitutes and their clients—especially truckers; men who have sex with men; and people who inject drugs, especially in the Northeast.
That is what some experts on AIDS surveillance techniques have been arguing for years, saying that Indians do not have the same sexual networks common in southern and eastern Africa, in which both men and women often have two or more occasional , regular sexual partners over long periods.
Also, “transactional sex” between teenage 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, Berkeley, has made the case 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.
Chin has been vindicated by recent surveys, paid for by the US, that take blood samples in randomly chosen households in rural and urban areas.
One of those, called the National Family Health Survey and finished last year, produced India’s new figures.
Such surveys, country by country, have led the UN AIDS program, UNAIDS, to slowly scale back its world estimates.
“This is a replay of what happened in Kenya,” said Daniel Halperin, an expert on AIDS infection rates at the Harvard School of Public Health.
When Kenya was more carefully surveyed in 2004, he said, its prevalence rate was halved, to 6.7% from the 15% UNAIDS estimated in 2001.
But Halperin said that AIDS-fighting agencies had such a stake in portraying the epidemic as an approaching Armageddon that they were hesitant to make revisions.
Avahan, an AIDS group here financed by the Gates Foundation, said it was still reviewing the data but that it planned “no change in strategy.”
In a telephone interview with Mint from London, Avahan executive director Ashok Alexander said, “We can expect to see a drop, or perhaps even a significant drop, overall but that masks the fact that we have sub-epidemics that are nowhere under control.”
An official statement from India’s National AIDS Control Organization (NACO) says that there has been some drop in HIV prevalence among pregnant women surveyed in southern states. However, Alexander calls the southern states with the highest prevalence the key battleground going forward and says the epidemic is still very much a problem there.
“If the total number of cases in the world is half of what you’ve been saying, that’s a bitter pill to swallow,” 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%.
In recent years, several prominent figures have accused India of denying the scope of its AIDS problem, but Indian health officials dispute their conclusions.
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: “The official statistics are wrong. India is in first place.”
S.Y. Quraishi, then director of India’s NACO, took offense, calling projections “technically incorrect and misleading”.
Current NACO director-general Sujatha Rao declined to say whether any drop in the patient population would affect the government’s five-year, Rs11,000 crore plan to fight the epidemic.
In 2002, when Bill Gates visited India to donate $100 million (Rs410 crore) to fighting its epidemic, Shatrughan Sinha, then the health minister, accused him of “spreading panic among the general public” by suggesting that cases could reach 25 million by 2010.
Asked if he felt India was owed any apologies, Ramadoss said he wanted only “that the world acknowledge the efforts India is making”. NYT
(Alison Granito and Bhuma Srivastava of Mint contributed to this story.)