by Rupa Chinai
- India -
Monday, December 1st marked World AIDS Day. As experts continue to search for a cure, we are honored to present Rupa's informative 3-part series on AIDS in India, a compelling look at the gaps in the system and possible solutions for the future. - Ed.
In the course of my work as Special Health Correspondent for a leading English language newspaper based in Mumbai, HIV/AIDS patients from across the country often came to my office to share their story. Those were the years when the hysteria around this disease was reaching its most fevered pitch. Mass HIV testing within the general population was being encouraged or enforced. The patients however reported that their experiences did not conform to the tutoring of the AIDS lobby.
Mushtaq’s (name changed) experience is consistent with that of many who I met. While seeking a work permit for the Gulf, he tested HIV-positive during a mandatory test. Although subsequent tests conducted by a reputed private hospital laboratory showed a negative result, the Gulf Board rejected the “HIV-positive” candidate. Sadly, stigma from the flip-flop testing still sticks to him wherever he goes.
Those interacting with HIV/AIDS patients are well aware of the innumerable cases of men and women who seek repeated testing at leading laboratories and still come up with conflicting results. Nobody is yet able to explain cases where a pregnant woman tests positive during her pregnancy but then negative after giving birth. There is no explanation for “discordant couples” - why one partner is HIV-positive while the other remains negative despite the practice of unprotected sex.
Mumbai’s State government-run J. J. Hospital, which has documented such cases, also points to patients who are showing other symptoms of immune suppression, such as lymphatic cancer or skin lesions.
Such cases of false HIV-positive results or unusual symptoms are only the tip of the iceberg. Nobody really knows the extent of such incidents because the AIDS lobby and the health authorities have no system for monitoring its incidence across the country or desire to know why they occur. These cases however reveal how an HIV test conducted on those with no clinical symptoms of AIDS can cause havoc in their lives. In fact, many patients accept their first “HIV-positive” result as a death sentence.
The poor cannot afford to do a second confirmatory HIV test as per subsequent WHO guidelines. These stipulate a requirement of at least three confirmatory tests, to eliminate the possibility of picking up other infection markers. They clarify that a single HIV test is not enough to label a person as “HIV-positive.” For the poor however, a single HIV test continues to remain the norm across India and in most developing countries.
The health authorities in Mumbai acknowledge there is a problem. A senior official at the Mumbai AIDS Society attributes it to the many private laboratories in the city that lack accreditation and technical expertise to assure standardized testing. Beyond the urban metros, the situation is worse, particularly in the rural districts. Most developing countries have not built up a cadre of trained microbiologists or laboratory infrastructure to ensure accurate diagnoses. The absence of professionals and technology further has an adverse impact in monitoring patients on ARV (anti-retroviral drugs) treatment.
Unable to bear the high costs of HIV testing, public hospitals in Mumbai no longer insist on an HIV test on admission. They instead rely on clinical symptoms such as repeated bouts of diarrhea, fever, rapid weight loss or TB – the common symptoms of AIDS-associated illness – that warrant suspicion and the need for a confirmatory test.
Private hospitals in Mumbai however, insist on a routine HIV test for all admissions. At various times “fly by night” AIDS NGOs in Mumbai have called for mass HIV testing. Such insistence of HIV testing serves the interest of test kit manufacturers but is fraught with consequences for those subjected to it.
Manufacturers of testing kits also admit that the HIV test is unreliable. Abbott Laboratories’ printed literature states that their product is not specific to the detection of HIV antibodies. Thus in developing countries, the poor and malnourished who regulary suffer from infection and disease, are likely to test HIV-positive because the antigen cross-reacts with the host of infections already present in their bodies. Scientists have pointed out that false-positive HIV test results may show up in 70 different conditions, which include malaria, TB or influenza and even in pregnancy.Thus the ground reality in most developing countries is that a death sentence is passed on the basis of a single test conducted by ill-equipped laboratories and poorly trained technicians who are, more likely than not, to have erred. The test, conducted on a poor class of patients who are malnourished and in poor health, is therefore likely to produce misleading results.
Meanwhile, even if a test is clearly HIV-positive, it only means that a person suffers from a severely compromised immune system. Many eminent Western scientists are now questioning the sexual transmission theory as the sole cause of AIDS, raising the possibility that the presence of the virus merely represents the marker of a suppressed immune system. The presence of the virus is like the witness at the site of an accident, it did not cause the accident, they hold.
The real cause of AIDS, these scientists say, is the assault of toxins and deficiencies on the body’s immune system. These factors include antibiotic abuse, recreational drug abuse and nutritional stress, all of which are major public health problems in India. Evidence, both within India and outside, suggests that the damage caused to the immune system is reversible, even without drugs.
The experience of developing country diseases show that the presence of microbes in the body does not necessarily indicate progression into disease, for much depends on the status of the immune system. In Asia and Africa, where TB is rampant, even healthy people are carriers of the TB germs and may have a positive report if they undergo a diagnostic test. Their ability to live with the microbes and prevent the downslide into disease depends on their nutrition and immune status. The same analogy works for AIDS.
Africa is a continent in the throes of AIDS. Health historians say that AIDS in Africa is a consequence of the depletion of the body’s nutrition pool down though the generations and the destruction of the immune system. As sub-Saharan Africa plunged deeper into the cycle of poverty, malnutrition and civil war, it also suffered epidemics of Ebola and Marburg or Lhassa fever, which stayed within the population for decades. AIDS could be the result of this depletion of the nutrition pool.
Until now, India, despite its poverty and malnutrition, like many other Asian countries, has not seen an impact of AIDS similar to that of sub-Saharan Africa. Barring pockets of malnutrition in tribal areas of India, the last major Indian famine took place in Bengal during British rule. In both cases malnutrition and famine was, and remains, a consequence of poor public food distribution services, corruption, maladministration and lack of purchasing power.
The African experience of the Structural Adjustment Programme (SAP) led to the loss of local food security when international donor agencies compelled these countries to convert their agriculture to cash crop cultivation of coffee. The subsequent crash in international coffee prices plunged these countries into economic, political and social chaos. It led to the health consequence of AIDS.
India took up the SAP in the early 1990s and these consequences are beginning to manifest here as the country plunges along its path of unequal economic development, throwing vast segments of the population into deep poverty. At stake are the issues of local food self-sufficiency and national sovereignty in determining agriculture and development policies. It is this wider picture that must now gain attention.
This is the second in a three-part series on the Indian experience with AIDS. Part 1 addressed the issues of inflated infection projections and poverty. Next week, Part III tackles the new directions necessary for proper treatment.
About the Author
Rupa Chinai is an independent journalist based in Mumbai, India. She has been writing on health and development issues for the past 25 years and her work has appeared in some of India's leading English language daily newspapers and websites as well as foreign publications. Her basic education was obtained in Mumbai and opportunities for further studies and exposure came through prestigious awards such as a journalism fellowship from the Harvard School of Public Health in the US, amongst others. She is co-author of a book on rural women's health issues and is currently engaged in writing a book on northeast India, based on 20 years of travel and work in that region.