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!
I still think “Baby Blue Turbans for Sexual Frankness!” might be one of the best titles for a post ever.
I wonder how much of the lowered rate of HIV is because us desi men got no game? 😀
bada-badump-bump
Been there, done that 🙂
Given the economic boom that India has been having for the past few years, could it be that people do not find as much time to have multiple partners?
And I doubt that it is just the high-tech field that is seeing the effects of this. To run a large company you have to rely on an army of unskilled (uneducated?) workers too.
This could not be THE only reason, but I am sure it contributed to the numbers.
There is more economic activity in the south and west than in the north. So there are more truckers and more mobility for labor. Could that be the reason for higher rates?
I am not sure for the north east though.
Drugs is part of it, as is trucking. Much construction of oil pipelines, etc.
Ennis- I hope you are not insinuating that morality has a part to play in this phenomenon. For some reason, I find your Southie/Northie distinction a bit offensive/judgmental, though I can’t exactly put my finger on the reason why! 😉
While it’s good news that the numbers are lower than previously thought, I would find it sad if people, here and in India, were relieved that AIDs was mainly a ‘high risk group’ problem. Is the epidemic really ‘managed’ just because certain marginalized groups are the main victims? I find the term ‘managed’ here very disheartening. From the point of view of a prostitute, it’s not ‘managed’ at all. It’s like it only becomes a serious epidemic if socialites in Mumbai start getting it.
And what makes it a good news
BB, I don’t see what morality has to do with a discussion on HIV at all.Wasn’t this the reason that AIDS research even in the West initially suffered because of a stigma wrongfully attached to the disease?
Also isn’t it possible that contaminated blood transfusions could also contribute to HIV prevalence? I am not suggesting that all blood banls are lax in India but the first AIDS victim I personally knew in India was a young 16 yearold who contracted it after major open heart surgery due to infected blood( This was way back in the late eighties)
:: I don’t see what morality has to do with a discussion on HIV at all
Are you kidding me, Runa? Maybe in an ideal world, but not so in this imperfect one.
@8, amit:
it is good news for one very important reason: in epidemic propogation there is some sort of thresholding effect. roughly speaking, as the probability of transmission increases, the level of infection in the population increases, but marginally, and remains controlled till a point. once the probability of transmission hits a critical level, suddenly the infection levels go out of control and you get very high levels of infection in the population. people study this as “percolation”, in physics, epidemics, and in some areas of wireless communication.
the lower infection numbers is in part an evidence that in today’s setting the probability of transmission is low across the population.
@DQ,
i believe when statisticians use “managed”, what they mean is roughly the above. by the time it reaches the news/ngo’s/people with money, the meaning is lost in translation.
Agreed that we don’t want to forget about those who have it, or that we want to treat it just as a disease that affects “those people”, but this post and every other post I’ve written about this subject should demonstrate that I care about the issue. I’ve spilled a lot of ink on this topic, my position should be pretty clear.
Yes, I too am concerned that this good news will be used as a reason to ignore the infected which would be a bad thing.
Suck it, Salil. Us boys from the south got better game than you.
BB, No I kid not .
My point is that when you bring something as emotionally charged as morality into the AIDS debate then its likely that the debate will end up with simplistic alleviations like: – If psrostitution contributes to AIDs spreading then ban prostituiton
The funny thing about that is that it’s 180 degrees wrong. If you’re concerned with AIDS you want the cooperation of sex workers since they’re an important part of the equation, and you can’t do that if they’re working underground.
The Gates Foundation is working with Indian sex workers right now, gathering data.
Ennis,
I agree with you .Let me clarify I don’t support the idea of banning prostitution .I was trying to say that morality or lack thereof needs to be kept out of a discussion on AIDS
Understood. I was trying to point out how the “common sense” / “moral” position has consequences which are quite harmful.
So, are you supporting the idea of banning any consideration of morality?
Ennis, I see your points about why the lower numbers are heartening and to not slip in our caution despite what the numbers say. We all know too well of how the epidemic got labeled as a “gay epidemic” in the early 1980s in this country. So in a culture quick to assign blame to society’s most disenfranchised, are we now going to label prostitutes, their partners and truckers as the “risk groups” in India and waste another decade of efforts? What of the many urban and rural housewives who are supposedly infected by their husbands who are truckers or migrants workers? Which category would they fall in…being in situations of minimal power to negotiate safe sex. What of the homeless street children all over our Indian metros who are increasingly being infected by forced homosexual relationships to survive. By looking at geographic distribution or risk groups, we may blunt the efficacy of our prevention efforts. There are no risk groups but risky behaviors that we need to target. There are no geographical boundaries for HIV/AIDS. Today it is the South of India, tomorrow the boundaries will change. Yes prevention efforts can focus on regions to be culturally appropriate and effective but the message has to go out to everyone. We are all at risk. It’s our problem
Rahul, I am going to treat your question seriously.
Depends on context- I was generally speaking of sexual morality in the context of AIDS
Okay, whether we like it or not, the “morality” factor does have a play in the spread of AIDS, albeit maybe less so than other factors. But to suggest that it needs to be kept out of the discussion is garbage. Plenty of men “hire” prostitutes (or more appropriately margnizalized women) that have been forced into undesirable occupations and infect them with the HIV virus. And you mean to say that morality has NO play in it?
Runa, don’t embarass me by doing such things 🙂
OK a tad late here. While I was furiously typing my bit, you guys are on a “morality and HIV” discussion. Here are my 2 paise worth:
HOW can one not talk of morality in the Indian context and HIV/AIDS??? The transmission of HIV has everything (ok not everything) to do with how our society shapes notions of sexuality and sexual behavior. For instance, some glimpses of morality and HIV: it is an accepted fact that young Indian teens in small rural towns often have their first sexual experience with a prostitute; many studies have documented how women in their sexual negotiation with their spouses/sexual partners are unable to protect themselves for fear of losing financial and social security; HIV has been linked with notions of punishment from God; promiscuous HIV related sexual behaviors among men have been linked to their notions of masculinity and just “what men do” and the list goes on and on and on. I feel a little charged up (only slightly) as you can see being a medical anthropologist who worked on the HIV situation pretty closely.
In seriousness, I believe that what Runa is saying is that exactly the kinds of moral judgments that you talk about should be avoided while making public policy. I don’t think she will disagree with you about the actual social stigma that there is.
So, a couple of years ago, there was this entire brouhaha about the down-low culture among black men, especially in Atlanta etc. causing risky behavior such as unprotected gay sex. I read later that this was massively overstated because it played into a variety of cultural perceptions. pp, do you know more details about this?
I agree with much of your sentiment, but I don’t agree with that. Yes, there are risky behaviors but there are also higher and lower risk groups as well.
Broad education campaigns are fairly expensive and have low to no efficacy. Once you’ve educated the population about the basics, there is evidence that you’re better off targeting the higher risk sub-populations with a campaign tailored to their circumstances.
This is a good start:
By contrast, this is what happens when you just hand out free condoms to everybody.
Sadly, there are opportunity costs here. You want to not only do something with good intention, you want to examine the result and make sure money is being spent with high efficacy. If not, money spent on low / no effectiveness projects is money being taken away from better things that could have been done.
pp, Excellent points. My hesitation is in bringing a “This ( behavior) is moral/This ( behavior) is immoral”flavor into a discussion on AIDS. Because then the focus get shifted from working towards tenable solutions.As a parallel, see what happened in Bombay when there was a spate of rapes of bar girls – the government ended up banning dance bars .I suspect because of some notions of morality instead of focusing on the real issue of sexual violence against women.
I see your point of being effective with educational campaigns that are more focused, but seriously my argument is in the “perception of risk” and sexual behaviors based on that. So even a level above the educational campaign is the campaign to understand risk and what behaviors are at risk rather than “who” is at risk in the Indian context. IF you launch an HIV education campaign that only targets prostitutes and say truckers, what of the other overlapping “risk groups” say the wives, sexual partners other than prostitutes etc. Since now HIV is being explicitly linked with the above mentioned risk groups, then of course what do I, a middle class housewife who’s trucker husband travels, have to do with HIV infection? All I am saying, is education has to be more encompassing and the prevention messages can target effectively through socially relevant strategies.
27 was by the way addressed to Ennis’s #25.
Slow up guys…what’s with the superspeed typing…let me catch a breath….and arm myself with a glass of wine.
Well, you guys should know there is a NGO industry (mainly in the religious conversion business) which was hoping to capitalize on this tragegy. By inflating the figures they can extract more funds from the government, corporations and individuals.
Agreed that we need a good basic level of education. This is still a problem:
And yes, you need to make it clear that AIDS is about behaviors, not group membership.
Beyond that, I hate to be cold hearted, but it is about what is more efficacious. It may well be more effective to target the truck drivers and change their behavior and reduce their infection rate than it is to try to launch an education campaign for middle class housewives. [It may be hard to reach truckers’ wives as a subgroup].
To me these aren’t ideological questions, they are pragmatic ones. I don’t value the life or a prostitute or a truck driver any less than that of his “innocent wife”. It’s all about making sure as few people die total as possible. Health policies should be informed by results.
From what I’ve seen, narrow works better than broad, and targeting the higher risk populations generally works better than targeting larger groups. While ideally we would do both, dollar for dollar it might work better to try to reduce the 10-20% prevalence amongst CWS before tackling the less than 1% prevalence rate of the population as a whole. The most effective way to protect the trucker’s wife might be to change behavior at the brothel rather than in the bedroom.
I am speaking in broad generalities however, so we may agree when it comes to concrete policy but still frame our approaches very differently.
I don’t think that the conservative Christian organizations in the conversion business go around handing out condoms. It’s two different types of NGOs.
Seems it Aids is more prevalent in the South b/c the South is economically stronger —-
From the Time article – The study, which leans heavily on the national health survey — itself is based upon face-to-face interviews with some 200,000 people between the ages of 15 and 54, more than half of them women — found that infection rates in southern India are significantly higher than in the north of the country. This could be because the disease has spread more quickly in more affluent areas, just as it has in Africa.
I wonder why in Kerala there seems to be less HIV infection.
Ok where were we Runa?
I totally see the cliff we could all fall off in India if we look at HIV infection through the morality lens, the way you put it. But HIV is about sex and morality, who defines it, what is appropriate, what is inappropriate and how those perceptions put men and women at risk through cultural constructions of shame, secrecy, virginity etc.
But we need to question Indian society’s moralistic pronouncements of moral and immoral behavior….look how far the U.S got in terms of slowing the spread of infection and reinfection, by research/education/intervention that moved away from the moralistic connections between gay sex and HIV to all the behaviors that puts one at risk. Maybe in a utopian Indian context in the time of AIDS (this is my non-anthropological self speaking), my hope is to not waste more time assigning blame, counterblame, stereotypes, moralistic pronouncements but to change how Indians view sexuality and sexual behavior. What a simple and modest exercise, right you all?
So to take your example, Runa, the bar girls that work in those bars that closed: to fund social science research, editorials, newspaper reports, that gets published in not just dusty journals, but in more mainstream media that makes the connections between the political, social and economic constraints in the lives of these women that may put them in these vulnerable situations rather than their moral values. It should be the discussions that become “normal” for my parents to have, or the auntie in the neighborhood or a bunch of college kids etc.
We did the blaming, the pointing fingers, the stereotyping here in the U.S and wasted an incredible number of years and lives in the process. We do not have the luxury of time or money in India…we’re have to get it right the first time.
And Goa as well.
I would tie this to literacy, educated females are much more likely to assert themselves in matters of birth control & contraception. The TN economy is certainly growing much faster than Kerala’s but it still lags wrto basic education
There is more sex than you think. If you go to debonairblog.com website, you will be amazed by the number of amateur sex videos by cameraphones or regular ole home camcorders in some random Indian place.
And as far as the south, I do not know why it is so. Maybe they just have more sex, and probably have more of the drive to cheat with others as premarital sex is still limited.
I wonder which findings are classified as Southern and how rural/urban they sampled. To my knowledge, the AIDS belt seems to be in the rural Maharashtra-Karnataka-Andhra Pradesh overlaps with serious connections to the Renuka-Yellamma devadasi system (this is also the antiseptic Haldi producing belt). Anybody know?
I think Kerala’s social development index would partly account for the lesser HIV infection rates. It might also be the coconut oil 🙂
I always thought it was strange whenever I read about this issue that in the Indian society with an endless stress on ‘sex and morality’ and lack of privacy making such relations even harder to have that rates could approach those of Africa so these new figures seem to make sense to me. Some PC person will probably come along soon to be shocked or outraged by that statement but societal behaviour is a factor whether anyone wants to mention it or not. What these NGOs need to keep doing is educating the high risk groups about the disease and how sexual practices can affect its spread. Of course we must keep in mind that 3 million people are infected and they need help but overall these new numbers are good news.
Honestly, a quick brake to this awful epidemic would happen if gay sexuality was treated less as a taboo or some “black mark” among Indian men. Honestly guys, if you like to stick it to another guy or have it stuck to you, then you are gay. It’s the same way HIV/AIDS spreads throughout poorer neighborhoods here in the US where it’s regarded as some kind of “weakness” or “social ill” or “abnormality” to be gay.
Honeys, if you have biological urges, go take care of them and use a condom for chrissakes. That’s it. This whole being macho and not using a condom bit or screwing with men behind your wife/girlfriend’s back — it’s all a bit lame.
Ajit – nobody ever said the rates were as high as those in Africa, the question was about the total numbers, i.e. about the small percentage of a much larger population.
You’re right of course, had a lapse of thinking there. Although this does reinforce that the socially accepted difference in behaviour is key to the difference in rates and why India’s is low in comparison.
RG, do you have statistics on how big a contributor gay sex is to the spread of AIDS in India and in the US? I had a similar question in #24. In India and Africa, my sense is straight extramarital sex is what often brings the virus home to wifey.
Really? And here I was under the impression that it was all parthenogenesis.
Check the bottom third of the post – India’s rate is like that of the USA, but the difference between the USA and Africa can be explained in terms of how more contagious AIDS is in Africa than America (due largely to the presence of untreated STDs) and how much longer the disease has been around in Africa than in America.
It’s not quite the same thing in India – Africans and Americans have roughly the same numbers of partners over their lifetimes, while I imagine that Indians have fewer, but the larger point stands, that sexual behavior need not be the biggest part of the story.
As for the spread of AIDS in Africa, Emily Oster has some interesting research that makes the point about untreated STDs, as well as a great observation about the lower value placed on one’s life in Africa.
BTW, Emily Oster is the one who “explained away” a significant fraction of Amartya Sen’s 100 million missing women.
Also, has there been any analysis on what impact this phenomenon has had on the spread of AIDS in India?
Also, has there been any analysis on what impact this phenomenon has had on the spread of AIDS in India?
Too funny!
One surprise result of the new numbers- infection rates are much higher in the South than in the North:
Ennis, how exactly is this result surprising?
At 43 and 24:
AIDS in India isn’t a majority gay issue as it is in the US. The spread of HIV/AIDS in India is primarily from heterosexual truckers sleeping with non-partners and then sleeping with their partners, etc; and from sharing needles. I have no data. Jasoos Vijay was a very popular tv detective serial meant to promote AIDS awareness and discuss general sexual health.
i just read this crazy story about how a husband knew he was HIV+, did not tell his wife, and ended up passing it on (and the story gets worse from there). no details on how he first contracted, though.