Until recently, the best estimates for the number of HIV+ Indians was 5.7 million, although estimates ranged from 3.4 million to 9.4 million. However, a new study puts the number of Indians with HIV/AIDS at roughly half of the previous estimate:

Early analysis of the figures suggests that India really has between two and three million victims, according to several sources, including American epidemiologists who know the data and the Health Ministry here.

The lower figure for India would imply that India has managed to keep its epidemic more like that of the United States, 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, on the borders with Myanmar. [Link]

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The big improvement in the quality of the numbers comes from the third National Family Health Survey:

The third National Family Health Survey was a gigantic exercise in logistics. Research organizations had to interview 124,385 women and 74,369 men in 3,849 villages and urban centers across India…. NFHS-3 was the first large scale nationwide survey to collect dried blood samples for HIV testing. Nearly 110,000 women and men were tested for HIV and more than 200,000 adults and young children were tested for anemia. [Link]

One surprise result of the new numbers- infection rates are much higher in the South than in the North:

But Ashok Alexander, director of Avahan, the Indian AIDS program of the Gates Foundation, says that while “it’s good news that overall the numbers are down, the real danger of this is it masks the real prevalence in one third of India: the south.” The study … found that infection rates in southern India are significantly higher than in the north of the country. [Link]

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Two side points. First, HIV/AIDS advocacy groups are accused of having previously overstated the numbers in order to increase their own clout. I can see how they might have erred on the side of over-estimation, but the Gates Foundation was one of the groups that previously argued that the numbers were high and that the Indian government wasn’t doing enough, and which underwrote the comprehensive survey. That makes me think that the previous numbers were not just the result of projection by activists.

Second, I worry that people will make too much of Indian sexual fidelity and assume away the possibility that AIDS might still pose a serious threat:

Indians do not have the same kind of sexual networks that are common in southern and eastern Africa, in which both men and women often have two or more occasional but regular sexual partners over long periods of time. Also, outside of prostitution, “transactional sex” between teenage girls and older men in return for money, food or clothes is much less common in Asia than in Africa. [Link]

This is in fact true – Indians stress female virginity and there is little privacy, so it is harder for most people to have sex before or outside of marriage. Men do stray somewhat, but according to a friend who is an AIDS researcher, sexual double standards serve to limit spread of diseases in the population.

Over-stressing sexual behavior ignores other more important factors such as women’s sexual health. Emily Oster‘s research argues that women’s poor sexual health is at the root of the epidemic in Africa:

… Africa has very high HIV transmission rates, likely due to high rates of other untreated sexually transmitted infections, while transmission rates in the United States are low. The difference in transmission rates is large enough to explain the observed difference in prevalence between the United States and Sub-Saharan Africa. [Link]

Oster argues strongly that differences between the US and Africa are caused by the fact that transmission rates are far higher in Africa and the epidemic started sooner. It’s really not about the number of sexual partners that Africans have. To make this point, she demonstrates that if Africa had transmission rates as low as the US, it would take superhuman levels of sexual activity to explain the epidemic. Basically, everybody would have to have far tremendously more sex than they do:

The results demonstrate that extremely large increases in sexual behavior would be necessary to produce the rate seen in Africa with the transmission rates from the developed world. One possible mechanism includes everyone having nonmarital sex (everyone has both premarital sex and extramarital sex in all periods), all women having an average of four nonmarital partners, and all men having an average of five nonmarital partners per year. Such a scenario involves sexual behavior that would have to be many times higher than in the reported DHS data. [Link]

If correct, then India should invest in female sexual health to keep rates of transmission low, rather than just relying on continued social pressures, especially since sexual mores are gradually changing. [If you’re interested, see Emily Oster’s webpage, she’s one of the top young economists today, and the author of the study I cited. Here’s a shorter less technical version of the paper cited above.]

Here are just a few of the many posts we’ve written on the past on this subject: NEJM on AIDS in India today, India in Focus on World AIDS Day, World AIDS Day on Indian Standard Time, Fight AIDS in your Computer’s Spare Time!, AIDS ’06, India Leads in … AIDS cases?, Treating AIDS patients like animals, Bachchan joins Mandelas anti-AIDS campaign, 25, Baby Blue Turbans for Sexual Frankness!