UNITED NATIONS—Reports prepared for the International AIDS Conference now taking place in Bangkok confirm what many have been predicting: that India, with 5.1 million people living with HIV/AIDS, is poised to overtake South Africa as the nation with the most cases in the world. South Africa has 5.3 million infected people.
The story is not just about numbers, however. It is about attitudes, and the willingness to admit that catastrophe looms and that national responses have to equal the scale of the problem. South Africa, it is now accepted by AIDS activists and many government officials alike, wasted precious years in denial, followed by arid debate about whether HIV really causes full-blown AIDS. Is the bungling of South Africa about to be replayed in India?
In Asia, India is not alone in being slow to rise to the potential damage ahead. China, with at least a million AIDS cases, tried to cover up not only the epidemic but also a scandal about tainted blood transfusions that contributed to the toll. In countries such as Thailand and Cambodia, where early and effective measures were taken to stem the spread of the disease, experts fear that a dangerous complacency has set in.
But India is by far the most powerful and influential country in South Asia—that broad expanse that stretches eastward from Afghanistan to Bangladesh, north to the Himalayas and south into the Indian Ocean. The brothels of India are peopled by women from Nepal and Bangladesh, among others. AIDS knows no borders.
There are paradoxes aplenty. India has a large pharmaceutical industry making antiretroviral drugs for AIDS patients around the world. But that industry has not flooded the Indian market on a sufficient scale to bring relief to fellow Indians as Brazil's drug industry has concentrated on making these medicines available to every needy Brazilian.
Furthermore, Indian drug firms, whose quality control standards have long been suspect among Indian consumer organizations, are beginning to attract more scrutiny abroad. Substandard drugs or the careless control of their use, AIDS experts are saying this week in Bangkok, can fuel hazardous variant strains of the virus, possibly unresponsive to current medications.
More than that, the World Bank said recently, other social and economic factors point to a very high risk setting for South Asia. More than 35 percent of the region's people live below local poverty lines, often equivalent to earnings of about $1 a day. Illiteracy is high. Sex is not considered a fit topic of conversation in polite society. Men resist the use of condoms and the status of women is generally abysmally low, so they have no power to insist.
In research done for the East-West Center in Honolulu, Tim Brown, a senior fellow focusing on the Asia-Pacific region, wrote recently that there are huge gaps in available data—a perennial problem in too many Asian nations where not knowing is preferable to facing unpleasant statistics that require tough action. Model "boutique" programs are not enough when the numbers are climbing at this rate. In January, Brown wrote in Asia-Pacific Population and Policy, a publication of the East-West Center, that "political leaders find it difficult to acknowledge the level of HIV risk in their own societies."
He added, "They may find it even more difficult to work with the stigmatized population groups who can help halt the epidemic—clients and sex workers, drug users, men who have sex with men and people living with HIV."
Throughout much of Asia—with the exception of Thailand—newspapers and television largely lack serious reporting on issues of human behavior and sexuality. Gay life is rarely covered in the media. Most people, especially women, remain woefully ignorant of the way AIDS spreads into the general population. In India, as in southern Africa earlier, the disease is now affecting women in large numbers—most of them, sex workers aside, are innocent wives who are not aware of (or are in denial about) the husbands' premarital or extramarital sexual activity, homosexual or heterosexual.
While Western campaigners who push for more help from rich countries for AIDS sufferers in the developing world focus on cheaper drugs and prefer not to talk about behavior change in the name of cultural sensitivity, people in the hardest-hit nations think otherwise. But changing attitudes and behavior can involve cultural awareness.
At the East-West Center, Brown says, for example, that in Asia, where intravenous drug usage and the commercial sex industry are major factors, "Mounting an effective response means placing a strong emphasis on CNN (condoms and new needles) as opposed to the ABC (abstinence, be faithful, use condoms) strategy that some are advocating for Africa."
"Teaching people how to protect themselves and providing them with the means to do so will be more effective than trying to change culturally embedded behavior overnight," he wrote.
The World Bank recently took a look at another vulnerable region, the Caribbean, and found that almost any local proclivity to engage in risky behavior, whatever the social, cultural or economic reason, can be countered by strong political will—something that many find missing in large areas of Asia.
The bank, which promised the Caribbean region $155 million to put a regional AIDS-control plan into practice, singles out two very different countries for their early success.
In the Dominican Republic, half a dozen ministries—labor, youth, science and technology, women's affairs, tourism and education—were brought together to work on the problem.
In Barbados, the first country to qualify for part of the World Bank grant, AIDS deaths have been reduced by 50 percent through the free and universal provision of antiretroviral drugs and better health care for the infected population. But along with that came extensive education programs and an abstinence campaign in schools aided by UNICEF funding. Condoms are marketed widely at low cost under government direction.
Barbados may be small, but it was badly threatened by AIDS before political leaders committed the country to comprehensive measures, then followed through on them.
"Barbados is a model for enhanced HIV/AIDS treatment and care in developing counties," the bank said. Asian nations, big and small, would do well to look at this winning formula.