India's AIDS crisis
When Silence Kills
India's AIDS crisis is huge and growing, but both its government and wider society have yet to acknowledge the scale of the problem. The first step: get honest about sex
By Alex Perry
When the richest man in the world announced 21/2 years ago that he would give away $100 million to fight AIDS in India, he might have expected thanks. Instead, Microsoft chairman Bill Gates was criticized by the government then in power in India for "spreading panic" and "completely inaccurate data" after he quoted much-cited predictions by the U.S.'s Central Intelligence Agency that the number of Indians infected with HIV and AIDS would top 20 million to 25 million by 2010. That trajectory would double today's global HIV/AIDS population and shift the epidemic's center from Africa to India. The Indian reaction to his pledge back in December 2002 was decidedly "mixed," Gates told TIME earlier this year. "The Prime Minister met me [but] there were other people trying to downplay the whole size of the problem. They didn't like the figures."
They still don't. India announced last week that it had cut the rate of new HIV infections by 95% in one year. The reaction was one of widespread disbelief. Granted, India's AIDS crisis is being taken more seriously than it once was. Dr. Seth Berkley, head of the International AIDS Vaccine Initiative (IAVI), says that when Sonia Gandhi won India's general election last May, "real, accelerated leadership on AIDS" arrived. In her only foreign trip as chairperson of India's ruling coalition, to the U.N. World AIDS Conference in Bangkok last year, Gandhi acknowledged that India had been ineffective in an increasingly "daunting" fight, and she has pledged to turn that record around. On a visit last week to India, Bill Clinton praised the government of Manmohan Singh, Gandhi's ally, for its commitment to "doing the right thing" on AIDS. But that would imply releasing accurate statistics, and the ones just out are startling. Whereas 2003 had seen 520,000 new infections in India, the Health Ministry said there were just 28,000 in 2004. Some states that had previously said they were home to hundreds of thousands of people with HIV and AIDS declared they were AIDS-free. Even government ministers had their doubts. "Our numbers may not be exactly accurate," said Science and Technology Minister Kapil Sibal. According to the official count, India has 5.13 million HIV/AIDS sufferers, while the U.N.'s estimate is up to 8.5 million. The Naz Foundation, a New Delhi-based AIDS charity, says the real figure may be closer to 15 million.
A problem that size demands resources to match. That's where Gates comes in. In 2000 he set up the Bill & Melinda Gates Foundation with his wife and father, William Gates Sr., who is co-chair. With an endowment of $28.8 billion, it is the largest foundation in the world. In visits to India, Gates saw that the nation's AIDS crisis could reach a tipping point where it might turn into a pandemic. Yet this also struck him as a war that could still be won, given enough money and direct involvement. "We're much more on the ground [in India] than in any other country," said Gates. From $67.5 million set aside for a campaign targeting the districts where AIDS is prevalent and the highways by which it is carried, to $5 million for an Australian project to fight HIV among heroin addicts who live on the edge of the Golden Triangle area bordering Burma in northeastern India, Gates has so far pledged a total of $200 million to AIDS projects in India. "There was a need, a vacuum, an urgency." Says S.Y. Quraishi, director general of the country's National AIDS Control Organization (NACO): "The world's battle against HIV and AIDS is going to be won or lost in India."
Yet in many ways the work of the Gates Foundation and its partners has revealed just how tough that battle will be. India has still not confronted its AIDS epidemic with the honesty that is essential to success. Denial is still rife, and so is an uneasiness toward outsiders. Ever since the Gates Foundation made its first grant five years ago, its India campaign (called Avahan after the Sanskrit word for "clarion call") has functioned under a cloud of suspicion. The American's munificence is often dismissed as a cynical cover for his corporate ambitions in the country. Says Purushothaman Mulloli, head of the Joint Action Council Kannur, an Indian charity involved in AIDS-related work: "Gates' interest in HIV projects in India is not meant for charity but to protect his billions of dollars of investments in pharmaceutical companies interested in conducting field trials in India." "Doing good in India, and getting away with it, can be very, very difficult," says Avahan's New Delhi-based head Ashok Alexander. "Indians don't like to be in a begging-bowl position. And everyone suspects ulterior motives. The question is always: 'Why are you really here?'"
If it wasn't asked so often, that query would sound crazy. Says another Gates Foundation executive: "If it were a p.r. thing, we'd do something warm and fuzzy with kids. Can you think of anything you'd less like associated with your brand than sex work, anal sex, drug use and sexually transmitted diseases?" Yet it is precisely such matters that India now needs to discuss. And the nation finds it incredibly hard to do so. In India, people simply don't talk about sex. From the West the subcontinent can seem like a land of sensual exoticism, home to an erotic history stretching from the Kama Sutra to the epic Tantric orgasms celebrated by today's more ostentatiously profound pop stars. But India is more inclined to see itself as just the oppositea bastion of decency under attack by Western forces of lust and pornography. While there are signs that India is loosening upBollywood couples now kiss onscreen, India has its own sex-obsessed edition of Cosmopolitan, and a lesbian couple recently married in New Delhithere are many more indications that conservative morals still dominate. The Supreme Court effectively reaffirmed a ban on homosexuality last year, and "respectable" Indian women still wouldn't dream of owning a miniskirt or a bikini.
AIDS experts regard India's social constraints as a key reason the country hasn't yet seen infections reach the rates witnessed in Africa. But prudishness is also a liability. Two years ago, for example, India's then Health Minister pulled condom ads from state TV for indecency. While AIDS campaigners receive public money (albeit tiny sums), they have also been attacked by mobs and arrested by police. Half of India's parents marry off their daughters before they are 18, but almost none will tell them the facts of life. Suniti Solomon, a doctor who documented India's first case of HIV in Madras in 1986, describes how, at sex-education talks in schools, "parents have got up and screamed, 'Why are you spoiling our children? Our children are angels!'" Even her cardiac-surgeon husband avoids the subject. "If even I can't talk about it at home," she says, "imagine the distance the country still has to travel." Gates said he is more and more aware how big a task he has taken on: "AIDS relates to sexuality, drug use, men having sex with men, and it's very much [about] first owning up to the problem."
India has a lot of owning up to do, as health workers at the Gates Foundation know. As they fan out across India to study and quantify the country's sex industry, they are discovering a sexuality far more active and diverse than anyone suspected. A foundation executive in southern India describes as a "total revelation" the large communities of homosexuals, gay sex workers and transsexuals found in every major town. In India's cities, millions of men have long secretly visited brothels, and researchers in New Delhi have also discovered wife-swapping rings and networks of high-class prostitutes who double as executives and doctors by day, while in Bombay they found middle-class housewivesor "aunties"who entertain teenage boys. "HIV brings your secrets out of the cupboard," says Sanghamitra Iyengar, director of Samuha Samraksha, which is a Bangalore AIDS NGO and a Gates Foundation partner. "And what always comes through is a much more colorful rainbow of sexuality than anyone expected." Far from exposing India to tawdry Western mores, says Arundhati Char, general manager of DKT India, a charity that promotes and provides contraceptives, those campaigning against AIDS are forcing the country to confront its own sexuality: "It's coming out into the openboom!and people are amazed. 'Is that right? Do these things happen?' We've even had to hold history classes for our sales staff to tell them about the Kama Sutra and show them it comes from our own culture."
Lifting the Covers
Neelu, 26, is an example of a culture many Indians would prefer to forget. He is a eunuch, or hijra. Like witches in medieval Europe, hijras make money blessing clients and cursing their enemies. But they are also the dirty little secret of some rail commuters. Neelu speaks of servicing 20 men a day for as little as 50¢ each while wandering the platforms of Madras' rail stations. On the lowest rung of India's social order, hijras have existed almost entirely outside mainstream society. "No ration cards, no identity cards, no vote," says Neelu. "Not even clients talked to us." Now, paradoxically, "AIDS has given us respect and recognition. Health workers and government people come to us, accept us, treat us as human beings."
Across town, the Gates Foundation is funding Dr. R. Lakshmibai of the Tamil Nadu AIDS Initiative to take the first comprehensive head count of male sex workers in India. While the hijras were impossible to miss, she says she was shocked at the far larger number of conventionally dressed gay prostitutes; by her estimate, there may be thousands of them in Madras alone. "I thought it would be a minority thing," she says. "I could hardly even conceive of a male sex worker." Partly that's because in India, "even homosexuals don't accept homosexuals," adds Lakshmibai. "[Male] clients who pay for sex with a man don't consider it sex at all." As a result, many homosexuals would not even recognize their own relevance in condom or AIDS campaigns; and Lakshmibai says a persistent Indian myth is that AIDS is a "straight plague."
Delusion is hardly limited to the gay world. In India's business capital, Bombay, a surging economy has produced millions of young men with money to burn and an industry of 80,000 women in thousands of "dancing bars" keen to take it. Some clubs are simply brothels with a bar. But in high-end establishments, patrons and managers join in an elaborate pretense to mask the sex on sale. A typical bar will feature 30 or so girls in saris dancing coquettishly to Bollywood numbers as customers look on from sofas like modern Mughal Emperors. There is no touching or nudity, and devoted customers shower their favorite dancers with hundreds of dollars in small notes. After hours, it's a different story. "Definitely, some girls have sex with customers," says Manjit Singh, owner of the Karisma, a dance bar in downtown Bombay, and head of the city's dance-bar association. "We keep it decent in here, but how can we control that?" DKT India general manager Char says even the women buy into the illusion. "Many of these girls are married," she says, "but they haven't told their husbands, their friends or their neighbors. And they'd certainly never use a term like 'sex worker.'" Char considers the dance bars an improvement in Bombay's red-light areas. There is less sexual slavery, and bar owners like Singh who preach safe sex have helped keep HIV prevalence relatively low at 10%, according to surveys by various NGOs, compared with 50% in the city's brothels. But she warns that Singh is an exception and his competitors' pretense that they are not in the sex industry means "this is an epidemic in waiting." On April 12, R.R. Patil, Deputy Chief Minister of the state of Maharashtra, which includes Bombay, announced his intention to shut all 1,300 of the city's dance bars, saying: "These bars are corrupting the moral fiber of our youth and culture." There was no announcement, however, about the less visible, more infected red-light ghettos, where thousands of former dance-bar girls may end up if Patil goes ahead with his plan.
A day's drive south of Bombay, in the district of Koppal amid the rocky barrens of the northern Karnataka state, there's no pretending anymore. Brought in by truckers and migrant workers returning from the cities, AIDS is referred to in Karnataka as "Bombay Disease." HIV was first detected in the district 12 years ago, and health surveys show the prevalence of AIDS in Koppal's million-plus population may already have reached 5-8%. Dr. Satish Bhuthaieh of Samuha Samraksha holds a weekly clinic in the village of Kustigi in a shack with two attached dormitoriesone for women, one for menthat are reserved for the dying. That the disease has long crossed over into the general population is apparent from the 300 peopletruckers, migrants, prostitutes, grandmothers, child brides and toddlersoutside his door. Samuha director Iyengar says HIV was spread by more than the mere mobility of truckers and migrants. "Most married men have multiple partners," she says. "And women quite often have a steady stand-in partner, or more than one, for when their husband goes away." Koppal is a testament to the dangers of denial. "When the first cases started appearing, the government said: 'AIDS is not an issue in India. This is a foreign thing. Condoms only promote promiscuity.' Today, every single village in Koppal knows it's an issue. There's not one untouched by HIV. And that's because none of those cherished ideas about sex and fidelity apply." Asked how far ahead Koppal is of the rest of India, Iyengar replies: "Five years."
TIMEasia Magazine: When Silence Kills
When Silence Kills
India's AIDS crisis is huge and growing, but both its government and wider society have yet to acknowledge the scale of the problem. The first step: get honest about sex
By Alex Perry
When the richest man in the world announced 21/2 years ago that he would give away $100 million to fight AIDS in India, he might have expected thanks. Instead, Microsoft chairman Bill Gates was criticized by the government then in power in India for "spreading panic" and "completely inaccurate data" after he quoted much-cited predictions by the U.S.'s Central Intelligence Agency that the number of Indians infected with HIV and AIDS would top 20 million to 25 million by 2010. That trajectory would double today's global HIV/AIDS population and shift the epidemic's center from Africa to India. The Indian reaction to his pledge back in December 2002 was decidedly "mixed," Gates told TIME earlier this year. "The Prime Minister met me [but] there were other people trying to downplay the whole size of the problem. They didn't like the figures."
They still don't. India announced last week that it had cut the rate of new HIV infections by 95% in one year. The reaction was one of widespread disbelief. Granted, India's AIDS crisis is being taken more seriously than it once was. Dr. Seth Berkley, head of the International AIDS Vaccine Initiative (IAVI), says that when Sonia Gandhi won India's general election last May, "real, accelerated leadership on AIDS" arrived. In her only foreign trip as chairperson of India's ruling coalition, to the U.N. World AIDS Conference in Bangkok last year, Gandhi acknowledged that India had been ineffective in an increasingly "daunting" fight, and she has pledged to turn that record around. On a visit last week to India, Bill Clinton praised the government of Manmohan Singh, Gandhi's ally, for its commitment to "doing the right thing" on AIDS. But that would imply releasing accurate statistics, and the ones just out are startling. Whereas 2003 had seen 520,000 new infections in India, the Health Ministry said there were just 28,000 in 2004. Some states that had previously said they were home to hundreds of thousands of people with HIV and AIDS declared they were AIDS-free. Even government ministers had their doubts. "Our numbers may not be exactly accurate," said Science and Technology Minister Kapil Sibal. According to the official count, India has 5.13 million HIV/AIDS sufferers, while the U.N.'s estimate is up to 8.5 million. The Naz Foundation, a New Delhi-based AIDS charity, says the real figure may be closer to 15 million.
A problem that size demands resources to match. That's where Gates comes in. In 2000 he set up the Bill & Melinda Gates Foundation with his wife and father, William Gates Sr., who is co-chair. With an endowment of $28.8 billion, it is the largest foundation in the world. In visits to India, Gates saw that the nation's AIDS crisis could reach a tipping point where it might turn into a pandemic. Yet this also struck him as a war that could still be won, given enough money and direct involvement. "We're much more on the ground [in India] than in any other country," said Gates. From $67.5 million set aside for a campaign targeting the districts where AIDS is prevalent and the highways by which it is carried, to $5 million for an Australian project to fight HIV among heroin addicts who live on the edge of the Golden Triangle area bordering Burma in northeastern India, Gates has so far pledged a total of $200 million to AIDS projects in India. "There was a need, a vacuum, an urgency." Says S.Y. Quraishi, director general of the country's National AIDS Control Organization (NACO): "The world's battle against HIV and AIDS is going to be won or lost in India."
Yet in many ways the work of the Gates Foundation and its partners has revealed just how tough that battle will be. India has still not confronted its AIDS epidemic with the honesty that is essential to success. Denial is still rife, and so is an uneasiness toward outsiders. Ever since the Gates Foundation made its first grant five years ago, its India campaign (called Avahan after the Sanskrit word for "clarion call") has functioned under a cloud of suspicion. The American's munificence is often dismissed as a cynical cover for his corporate ambitions in the country. Says Purushothaman Mulloli, head of the Joint Action Council Kannur, an Indian charity involved in AIDS-related work: "Gates' interest in HIV projects in India is not meant for charity but to protect his billions of dollars of investments in pharmaceutical companies interested in conducting field trials in India." "Doing good in India, and getting away with it, can be very, very difficult," says Avahan's New Delhi-based head Ashok Alexander. "Indians don't like to be in a begging-bowl position. And everyone suspects ulterior motives. The question is always: 'Why are you really here?'"
If it wasn't asked so often, that query would sound crazy. Says another Gates Foundation executive: "If it were a p.r. thing, we'd do something warm and fuzzy with kids. Can you think of anything you'd less like associated with your brand than sex work, anal sex, drug use and sexually transmitted diseases?" Yet it is precisely such matters that India now needs to discuss. And the nation finds it incredibly hard to do so. In India, people simply don't talk about sex. From the West the subcontinent can seem like a land of sensual exoticism, home to an erotic history stretching from the Kama Sutra to the epic Tantric orgasms celebrated by today's more ostentatiously profound pop stars. But India is more inclined to see itself as just the oppositea bastion of decency under attack by Western forces of lust and pornography. While there are signs that India is loosening upBollywood couples now kiss onscreen, India has its own sex-obsessed edition of Cosmopolitan, and a lesbian couple recently married in New Delhithere are many more indications that conservative morals still dominate. The Supreme Court effectively reaffirmed a ban on homosexuality last year, and "respectable" Indian women still wouldn't dream of owning a miniskirt or a bikini.
AIDS experts regard India's social constraints as a key reason the country hasn't yet seen infections reach the rates witnessed in Africa. But prudishness is also a liability. Two years ago, for example, India's then Health Minister pulled condom ads from state TV for indecency. While AIDS campaigners receive public money (albeit tiny sums), they have also been attacked by mobs and arrested by police. Half of India's parents marry off their daughters before they are 18, but almost none will tell them the facts of life. Suniti Solomon, a doctor who documented India's first case of HIV in Madras in 1986, describes how, at sex-education talks in schools, "parents have got up and screamed, 'Why are you spoiling our children? Our children are angels!'" Even her cardiac-surgeon husband avoids the subject. "If even I can't talk about it at home," she says, "imagine the distance the country still has to travel." Gates said he is more and more aware how big a task he has taken on: "AIDS relates to sexuality, drug use, men having sex with men, and it's very much [about] first owning up to the problem."
India has a lot of owning up to do, as health workers at the Gates Foundation know. As they fan out across India to study and quantify the country's sex industry, they are discovering a sexuality far more active and diverse than anyone suspected. A foundation executive in southern India describes as a "total revelation" the large communities of homosexuals, gay sex workers and transsexuals found in every major town. In India's cities, millions of men have long secretly visited brothels, and researchers in New Delhi have also discovered wife-swapping rings and networks of high-class prostitutes who double as executives and doctors by day, while in Bombay they found middle-class housewivesor "aunties"who entertain teenage boys. "HIV brings your secrets out of the cupboard," says Sanghamitra Iyengar, director of Samuha Samraksha, which is a Bangalore AIDS NGO and a Gates Foundation partner. "And what always comes through is a much more colorful rainbow of sexuality than anyone expected." Far from exposing India to tawdry Western mores, says Arundhati Char, general manager of DKT India, a charity that promotes and provides contraceptives, those campaigning against AIDS are forcing the country to confront its own sexuality: "It's coming out into the openboom!and people are amazed. 'Is that right? Do these things happen?' We've even had to hold history classes for our sales staff to tell them about the Kama Sutra and show them it comes from our own culture."
Lifting the Covers
Neelu, 26, is an example of a culture many Indians would prefer to forget. He is a eunuch, or hijra. Like witches in medieval Europe, hijras make money blessing clients and cursing their enemies. But they are also the dirty little secret of some rail commuters. Neelu speaks of servicing 20 men a day for as little as 50¢ each while wandering the platforms of Madras' rail stations. On the lowest rung of India's social order, hijras have existed almost entirely outside mainstream society. "No ration cards, no identity cards, no vote," says Neelu. "Not even clients talked to us." Now, paradoxically, "AIDS has given us respect and recognition. Health workers and government people come to us, accept us, treat us as human beings."
Across town, the Gates Foundation is funding Dr. R. Lakshmibai of the Tamil Nadu AIDS Initiative to take the first comprehensive head count of male sex workers in India. While the hijras were impossible to miss, she says she was shocked at the far larger number of conventionally dressed gay prostitutes; by her estimate, there may be thousands of them in Madras alone. "I thought it would be a minority thing," she says. "I could hardly even conceive of a male sex worker." Partly that's because in India, "even homosexuals don't accept homosexuals," adds Lakshmibai. "[Male] clients who pay for sex with a man don't consider it sex at all." As a result, many homosexuals would not even recognize their own relevance in condom or AIDS campaigns; and Lakshmibai says a persistent Indian myth is that AIDS is a "straight plague."
Delusion is hardly limited to the gay world. In India's business capital, Bombay, a surging economy has produced millions of young men with money to burn and an industry of 80,000 women in thousands of "dancing bars" keen to take it. Some clubs are simply brothels with a bar. But in high-end establishments, patrons and managers join in an elaborate pretense to mask the sex on sale. A typical bar will feature 30 or so girls in saris dancing coquettishly to Bollywood numbers as customers look on from sofas like modern Mughal Emperors. There is no touching or nudity, and devoted customers shower their favorite dancers with hundreds of dollars in small notes. After hours, it's a different story. "Definitely, some girls have sex with customers," says Manjit Singh, owner of the Karisma, a dance bar in downtown Bombay, and head of the city's dance-bar association. "We keep it decent in here, but how can we control that?" DKT India general manager Char says even the women buy into the illusion. "Many of these girls are married," she says, "but they haven't told their husbands, their friends or their neighbors. And they'd certainly never use a term like 'sex worker.'" Char considers the dance bars an improvement in Bombay's red-light areas. There is less sexual slavery, and bar owners like Singh who preach safe sex have helped keep HIV prevalence relatively low at 10%, according to surveys by various NGOs, compared with 50% in the city's brothels. But she warns that Singh is an exception and his competitors' pretense that they are not in the sex industry means "this is an epidemic in waiting." On April 12, R.R. Patil, Deputy Chief Minister of the state of Maharashtra, which includes Bombay, announced his intention to shut all 1,300 of the city's dance bars, saying: "These bars are corrupting the moral fiber of our youth and culture." There was no announcement, however, about the less visible, more infected red-light ghettos, where thousands of former dance-bar girls may end up if Patil goes ahead with his plan.
A day's drive south of Bombay, in the district of Koppal amid the rocky barrens of the northern Karnataka state, there's no pretending anymore. Brought in by truckers and migrant workers returning from the cities, AIDS is referred to in Karnataka as "Bombay Disease." HIV was first detected in the district 12 years ago, and health surveys show the prevalence of AIDS in Koppal's million-plus population may already have reached 5-8%. Dr. Satish Bhuthaieh of Samuha Samraksha holds a weekly clinic in the village of Kustigi in a shack with two attached dormitoriesone for women, one for menthat are reserved for the dying. That the disease has long crossed over into the general population is apparent from the 300 peopletruckers, migrants, prostitutes, grandmothers, child brides and toddlersoutside his door. Samuha director Iyengar says HIV was spread by more than the mere mobility of truckers and migrants. "Most married men have multiple partners," she says. "And women quite often have a steady stand-in partner, or more than one, for when their husband goes away." Koppal is a testament to the dangers of denial. "When the first cases started appearing, the government said: 'AIDS is not an issue in India. This is a foreign thing. Condoms only promote promiscuity.' Today, every single village in Koppal knows it's an issue. There's not one untouched by HIV. And that's because none of those cherished ideas about sex and fidelity apply." Asked how far ahead Koppal is of the rest of India, Iyengar replies: "Five years."
TIMEasia Magazine: When Silence Kills
