AIDS Has Arrived in India and China.

• Author: Hwang, Ann
• Position: Speculation on an AIDS pandemic - Statistical Data Included

How will the world's two most populous countries cope with the pandemic?

In 1348, the Black Death arrived in Europe from its probable home in Central Asia, and over the next couple of years it is believed to have killed 25 million people. Sometime soon, mortality from AIDS will exceed the death toll of that worst outbreak of bubonic plague. Since the start of the AIDS pandemic roughly 20 years ago, 20 million people have died and over 50 million have been infected. Every 11 seconds, someone dies from AIDS. According to statistics compiled by the World Health Organization, AIDS is now killing more people each year than any other infectious disease. AIDS has become one of the greatest epidemics in the history of our species.

The AIDS epidemic took much longer to build momentum than did the Black Death, but AIDS has far more staying power. For all their intensity, the bubonic plague epidemics were relatively short: Yersinia pestis, the plague bacterium, tends to burn itself out quickly. And in any case, Y pestis and Homo sapiens are no longer caught up in an intense epidemic cycle. Plague still kills people in various parts of the world, but it does not spark epidemics on a continental scale. Even if it did, antibiotics have made it far less deadly than it was 650 years ago. But HIV, the virus that causes AIDS, shows no sign of releasing us from its grip. Indeed, it has evolved into several new forms, even as it continues to burn through humanity. And although there are now drugs that can prolong the lives of its victims-or at least, those who can afford treatment-there is no cure for the disease and no vaccine for it. (See "An AIDS Vaccine?" page 16.)

Within the AIDS pandemic, sub-Saharan Africa has become the equivalent of mid-14th century Europe. Ignorance of the disease, poverty, war, and frequently, a rather relaxed attitude toward sexual activity (especially when it comes to men)--such factors have allowed HIV to explode through some African societies. In 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) predicted that by 2000, over 9 million Africans would be infected with HIV. The actual number turned out to be 25 million. Though Africa is home to less than 9 percent of the world's adults, it has more than two-thirds of adult HIV infections. In Botswana, the county with the world's highest infection rate, one in three adults is now infected. And as the infected continue to die, places like Botswana may become increasingly unstable for lack of farmers, teachers, community leaders, even parents.

But in large measure, the course of the pandemic will depend on what happens not in Africa but in Asia, the continent that is home to nearly 60 percent of the world's people. AIDS is already well established in Asia, although no one knows precisely when or where it first arrived. By the mid-1980s, however, infections were beginning to appear in several Asian counties, including Thailand and India. A few years later, it was obvious that HIV infection was increasing dramatically among two of the best known "high risk populations"-prostitutes and users of injection drugs. As its incidence increased, the disease began to travel the highways of Asia's drug trade, radiating outward from the opium-producing "Golden Triangle," where Myanmar (Burma), Laos, and Thailand converge. The infecting of the world's most populous continent had begun.

That process may now be reaching a kind of critical mass. AIDS has arrived in the two most heavily populated countries in the world: India and China. With populations of 1 billion and 1.3 billion respectively, these countries are home to over a third of the world's population and nearly 70 percent of Asians people. Thus far, neither has suffered the kind of explosive epidemic that has ravaged sub-Saharan Africa. Each still has important opportunities to stem the epidemic. What will the giant societies of Asia make of those opportunities? This is one of the greatest social and ethical issues of our era.

Four Million Infected in India

India is home to an estimated 4 million people with HIV--more than any other country in the world. Because of India's huge population, the level of infection as a national average is very low--just 0.4 percent, close to the U.S. national level of 0.3 percent. But this apparently comfortable average masks huge regional disparities: in some of India's states, particularly in the extreme northeast, near the Myanmar border, and in much of the south, the rate of infection among adults has reached 2 percent or more--five times the national rate and more than enough to kindle a widespread epidemic.

Among these more heavily infected regions, there is another kind of disparity as well, in the way the virus is spreading. In southern India, AIDS fits the standard profile of a sexually transmitted disease (STD), with particularly high infection rates among prostitutes. Sex is big business in India, generating revenues of $8.7 billion each year, according to the Centre of Concern for Child Labour, a Delhi-based non-profit. Mumbai (Bombay), the country's largest west coast city, has twice the population of New York yet almost 20 times the number of prostitutes. By 1997, over 70 percent of those prostitutes were HIV positive. The prostitutes' clients, in addition to risking infection themselves, put their wives or other sex partners in jeopardy, thereby creating a bridge that allows the virus to spread from a high-risk enclave to the general population.

In some segments of Indian society, that bridge is now very broad. Long-distance truck drivers, for example, are usually away from home for long periods and many visit prostitutes en route. For one study, published in the British Medical Journal in 1999, nearly 6,000 long-distance truckers were interviewed and nine out of ten married drivers described themselves as "sexually promiscuous," defined as having frequent and indiscriminate change of sexual partners. Not surprisingly, HIV incidence is now rising among married Indian women. A study from 1993 to 1996 found that over 10 percent of female patients at STD clinics in Pune, near Mumbai, were HIV positive; over 90 percent of these women were married and had had sexual contact only with their husbands. (See "Increasingly, A Women's Disease," page 19.)

In India's northeast, the epidemic has a very different character. This region has an extensive drug culture--which is hardly surprising, given its proximity to the Golden Triangle. Here, the epidemic has been driven by intravenous drug use, particularly among young unemployed men and students. By sharing contaminated needles, addicts are injecting the virus into their bloodstreams. Data are scarce, but according to government estimates, there are 1 million heroin users in India...