Physical barriers affect India's fight against HIV

Vast distances are a major hurdle to India's efforts to curb its soaring HIV rate.

India, which has the world's third largest HIV-positive caseload, gives drugs for free to HIV/AIDS patients. But doctors say this is not enough to stop the spread of HIV which is making inroads in rural India, especially among women infected by itinerant husbands, and also children.

For three days a month, Sambit squeezes into a crowded and often filthy train for a three hour journey to Delhi to receive HIV treatment.

"There's no seat and I am very weak," said the 30-year-old former tailor, who asked that his full name not be revealed. He can't afford lodging in Delhi and can barely afford the train tickets.

"I need to borrow money from my family for all these trips," he said.

Many patients in the same position simply give up treatment, an anathema in HIV therapy as it gives rise to drug resistance. These patients may then need more powerful second line treatment, which is not freely available in India.

"Travel can affect drug compliance. Patients who don't get family support, women who may not like to travel alone will just give up," said a doctor at a New Delhi hospital, who spoke on condition of anonymity because he did not have permission to speak to reporters.

There are 147 "antiretroviral therapy" or ART centers in the country, part of a government drive that has been encouraged by the World Health Organization in a bid to prevent HIV from becoming a major health problem.

Delhi has nine such centers and is far better served than many other states. Up to 6,000 patients receive treatment in Delhi, nearly half of these live outside the capital.

The government now plans to build "link centers", small facilities that are closer to where patients live so people like Sambit can obtain their medications more easily.

"They just come to pick up the drugs if they have no side effects and they go home ... that saves transport and other costs," Rao said, adding that the plan was to have as many as 500 such centers all over India.

INFECTION FIGURES AREN'T GOING DOWN

India has 2.47 million HIV cases, according to the latest figures, but health workers say the number is rising rapidly and spreading to new population groups.

"Our numbers are going up," said Loon Gangte, South Asia coordinator of the Collaborative Fund for HIV Treatment Preparedness.

"It's not confined to high risk groups, it's going into the general population. It's not a problem of sex workers, drug users or truck drivers. These people have wives and children at home and the disease is making its way into the general population."

Sujatha Rao, director-general of the government's National AIDS Control Organization, says doctors are increasingly seeing women infected by their husbands.

In some clinics, 1 out of 100 women who come for ante-natal care checkups are HIV positive, she said.

"It is a generalized epidemic," she said. "We have pockets where the prevalence is more than 1 percent among ante-natal care mothers, so we need to intensify our work."

Out of India's 611 districts, HIV prevalence is more than 1 percent of the population in 156 districts.

"The epidemic is getting deeper into (certain) rural, general areas of the country ... it is migrant-related. They go to work and then they take back the infection to their homes," she said.

Even though HIV drugs are free, only about 155,000 people have access to retroviral drugs, up from 20,000 just two years ago.

Health expert say there are many people who do not know they are infected or who do not know that treatment is available.

Some health professionals believe India's HIV problem is closely intertwined with poverty and that the government must tackle poverty if it seeks to curb the spread of HIV.

"Many of these people are very poor, they worry about food, shelter. So they may not think their HIV status is a problem because they don't even know where their next meal is coming from," said Errol Arnette of the help group Sahara.

"A lot of AIDS patients die of TB because it's hard for hospitals to keep them (in hospital). HIV patients are just thrown in a corner because of heavy stigma."

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Study shows few HIV patients tested for tuberculosis

A new report suggests that only 1 percent of HIV-positive patients worldwide have been screened for tuberculosis, a curable infection that frequently kills those living with the AIDS virus.

The low TB screening rate is "unacceptable," researchers from the Advocacy to Control TB Internationally (ACTION) coalition said during a press conference at the International AIDS Conference underway here.

"A mere one percent of people living with HIV/AIDS are reported to have been screened for TB," said Dr. Jim Yong Kim, chief of the division of social medicine and health inequalities at Harvard Medical School. "One of the great tragedies of this epidemic is that people who are living with HIV, after hard-fought battles for access to antiretroviral treatment, go on to die needlessly from TB."

Quoting WHO statistics, the report says that of the 33 million HIV-positive people worldwide, only 314,394 individuals had been tested for tuberculosis. Of those who had been screened, over one in four were found to have active tuberculosis, according to a press release issued by ACTION.

"Persons living with HIV/AIDS are 50 times more likely to develop tuberculosis, than those who are HIV negative," the release cautions. "Without treatment, approximately 90% of persons living with HIV/AIDS die within a few months of developing TB."

"We are facing a preventable plague inside a devastating epidemic," said Michel Sidibe, assistant secretary general and deputy executive director of UNAIDS.

Screening for tuberculosis is not mandatory in the programs being funded by the three major international donors -- Global Fund, PREPFAR and the World Bank, the release states.

The ACTION group recommends universal TB screening of all people living with HIV/AIDS and access to the 3 "I"s -- Intensified case finding, Infection control, and Isoniazid preventive therapy.

Screening tests for tuberculosis are inexpensive compared to the cost of the drug cocktails used to treat HIV/AIDS, Kim said in response to a question at the press conference.

An integrated HIV/TB approach is needed, Kim told Reuters Health.

"TB is a curable disease," he said. "It is a crime not to test for tuberculosis."

For more information visit http://www.jigfo.com, the no.1 source of information.

Malaysia fights HIV

Strict laws and conservative attitudes are making the fight against HIV/AIDS harder in predominately Muslim Malaysia as they drive high-risk groups deeper underground.

Soliciting and sodomy are outlawed and there are heavy penalties for illegal drug use.

While lobbying from activists has won government support for HIV/AIDS prevention programs, distributing condoms and clean needles, implementation is far from easy.

Celine Ng, who runs a program distributing clean needles to drug addicts, knows that only too well.

Each day, her colleagues, many of them former drug addicts, lie in wait in abandoned buildings, on the fringes of jungles and dumpsites, where they give out clean needles to addicts in exchange for used ones.

Asked what her biggest challenge was, Ng answered instantly: "The police. They wait outside and (then conduct raids) and they say we are informers.

"Even my staff encounter problems with them. We have the endorsement of the narcotics (authorities) and we give needles, not drugs. So if they catch our clients with drugs, we can't stop them, but you can't catch those with just needles."

For homosexuals and sex workers, laws make it difficult to distribute condoms in gay venues because they are often used as evidence of the offence in court.

Anal and oral sex, even between consenting adults, is regarded as a "heinous crime" and is punishable by up to 20 years in prison. While prostitution is not illegal, soliciting is punishable by up to 10 years in prison.

Drug trafficking carries a mandatory death sentence.

DRIVEN UNDERGROUND

"They (people in high risk groups) are driven underground, so you can't reach them," said Adeeba Kamarulzaman, president of the government-backed Malaysian AIDS Council.

"We have (our) outreach workers getting arrested. They (authorities) raid and catch everyone, we are forever trying to bail out our outreach workers from the lockup, which is a major headache on a day-to-day basis," she said.

Injecting drug users in Malaysia make up the largest risk group for HIV/AIDS, or 65 percent of the 4,549 new infections in 2007. The country had 80,938 people living with HIV/AIDS at the end of 2007, with 13,635 of them suffering full-blown AIDS.

But sources familiar with the HIV/AIDS situation in this country of 26 million people say the problem may be graver than the figures suggest.

"Infections are going up but surveillance is very poor in Malaysia," said Raymond Tai of the Pink Triangle (PT) Foundation, which runs drop-in centers for major risk groups like sex workers, drug addicts and transsexuals in Kuala Lumpur.

"Many young gay men only know of their illness for the first time when they are warded with AIDS. How long have they been positive, how long have they been infectious? It is critical."

He said one in four men who have sex with men is HIV positive in Bangkok and there was a rising trend in Hong Kong.

"Those who came in for HIV testing and identified themselves as men who have sex with men, 10 percent tested positive. This is very high and consistent with what is happening in the region," he said.

The 10 percent figure came from tests conducted by PT Foundation between mid 2006 and end 2007.

MOVING INTO GENERAL POPULATION

What's worrying is the disease is moving away from high-risk groups to women in general.

"These (high risk) groups don't exist in isolation, drug users have wives, drug users patronize sex workers, they buy sex, they sell sex," said Kamarulzaman.

Concerned groups are trying to push out HIV/AIDS prevention messages, difficult in an environment where advertisements are under tight state control.

Condom ads are not allowed on national television, except in certain contexts such as promoting use between married couples.

"You can't use anything deemed pornographic," Tai said.

"When gay men are in a place picking up other men, (brochures) are competing (for attention). You have all the good looking men there and you are giving out boring information. Who is going to read it?"

Activists stress that more must be done, with the government first acknowledging the situation and cooperating with non-government organizations in spreading anti-HIV information.

"The number of sex workers has grown in Kuala Lumpur," said Rachel, a former sex worker who is now an outreach worker with PT trying to teach safe sex.

"Some university students, housewives and office workers do sex work part-time for money."

Her colleague, Jamie, agreed: "Some of them are so scared they won't even accept condoms from us because they think we are undercover police."

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Global AIDS deaths edged down

The number of people killed by AIDS worldwide edged down for a second straight year in 2007 after rising for more than two decades, amid intensified global efforts to fight the disease, a U.N. agency said on Tuesday.

The AIDS epidemic is far from over, but appears to have leveled off with more people getting life-extending drugs and the number of new HIV infections falling in many places, UNAIDS said in a report.

Officials with Geneva-based UNAIDS and outside activists said much more needed to be done to beat this modern scourge.

Dr. Paul Zeitz, executive director of the Washington-based activist group Global AIDS Alliance, said the report showed the big increase in spending on prevention and treatment programs in sub-Saharan Africa and elsewhere had produced results.

"Based on this evidence, it's time to ramp up funding from all sources -- not to slow down or go on to other things. We're on the path toward victory here. Let's invest more," he said.

Global AIDS deaths numbered about 2 million in 2007, down from 2.1 million in 2006, UNAIDS said. AIDS deaths peaked in 2005 at 2.2 million after a steady climb since the disease was first identified in the early 1980s, UNAIDS said.

"A six-fold increase in financing for HIV programs in low- and middle-income countries (from) 2001-2007 is beginning to bear fruit, as gains in lowering the number of AIDS deaths and preventing new infections are apparent in many countries," according to the report issued before an international AIDS conference in Mexico next week.

"Progress remains uneven, however, and the epidemic's future is still uncertain, underscoring the need for intensified action to move towards universal access to HIV prevention, treatment, care and support," the report read.

In 2007, about 33 million people were infected with human immunodeficiency virus, UNAIDS said. HIV is most often spread through sexual contact or injection drug use.

The total number of people living with HIV infections continues to inch higher as more people in hard-hit regions like sub-Saharan Africa, with two-thirds of all global cases, receive drugs that help them live longer, the report showed.

NEW INFECTIONS

New HIV infection rates were basically the same in 2007 as in 2006 -- about 2.7 million people, with a very small increase last year over the prior year, the agency said.

The report cited a big increase in the number of people receiving AIDS drugs in low- and middle-income countries, numbering about 3 million. But many more still lack access.

"There are still five new infections for every two people who are newly added on treatment. So clearly, we're not pushing back the epidemic enough," Dr. Paul De Lay of UNAIDS said.

Rates of new infections are rising in many countries, including China, Indonesia, Kenya, Mozambique, Papua New Guinea, Russia, Ukraine and Vietnam, and even rich nations such as Germany, Britain and Australia.

UNAIDS said its report used data from 147 countries, but De Lay said he was disappointed the United States did not provide its 2007 AIDS figures because U.S. officials continue to "refine" the numbers and will announce them soon.

Last week, the U.S. Congress passed a bill to triple spending on a program to fight AIDS, malaria and tuberculosis in Africa and other parts of the world, with President George W. Bush scheduled to sign it into law this week.

It calls for $48 billion over the next five years.

The Black AIDS Institute activist group issued a report saying the U.S. government had neglected the epidemic among black Americans even as it fights the disease overseas.