AIDS - The numbers controversy
In 2003, Mr. Bill Gates, the CEO of Microsoft, representing the Bill and Melinda Gates Foundation announced a gift of US $100 million (approximately Rs. 480,00,00,000) for the control of HIV/AIDS in India. He spoke about the magnitude of the problem in the world and the potential major impact that was predicted for India. Perhaps quoting a US National Intelligence Council report, he mentioned that by the year 2010 there would be 25 million infected persons in India. This statement provoked an immediate response and rebuttal from the government and remarks were made about the inappropriateness of "creating panic in the population".
Dr. L.M. Nath Consultant, Community Medicine WHO Delhi
All this was widely reported and commented on by the media. Instead of leaving the matter be, many activists and NGOs also contributed to the controversy by accusing the National AIDS Control Organisation (NACO) of willfully under reporting the prevalence of the infection in India. Nobody, of course, supported the official NACO estimate of 3.97 million.
All of us need to understand what the official NACO figure represents. It is estimated that there were, at the end of 2001, 3.97 million HIV infected persons in the 15 to 49 year old population in India. HIV estimates are exactly what the name says. They are estimates and should never be confused with actual numbers. No one knows, or can possibly calculate, how many HIV positive persons there are in India, or for that matter in any country, at any time. What NACO does is exactly what the majority of countries in the world do. They measure the prevalence of HIV infection in a small group that is representative of a particular life style or risk group and apply that figure to the estimated population size of that particular risk group. Attempts are made to ensure that different geographic parts of the country are represented in this measurement process. For example, if 40% of injecting drug users in a particular state are found to be infected in the "Sentinel Surveillance" sample of 200 people, and it is estimated that there are 25,000 persons who inject themselves with drugs in that state, then it is calculated that there would be 40% of them, or 10,000 infected persons in that risk group in that state. Currently, HIV prevalence is measured in groups representing the general population, those that are at special risk because they inject drugs into their own veins, sex workers, patients who have sexually transmitted diseases, men who have sex with men and long distance road transport workers. Adding up all these various figures gives an estimate of the number of infected persons in each part of the country and, thus, taken together in the entire state and country. It will be clear that the HIV prevalence estimate does not purport to actually measure every infected person, and in any case the denominator is the census estimate of the population in a selected sexually active age group. People below fifteen and those fifty years and above are not included in the sample.
In 2003, Mr. Bill Gates, the CEO of Microsoft, representing the Bill and Melinda Gates Foundation announced a gift of US $100 million (approximately Rs. 480,00,00,000) for the control of HIV/AIDS in India. He spoke about the magnitude of the problem in the world and the potential major impact that was predicted for India. Perhaps quoting a US National Intelligence Council report, he mentioned that by the year 2010 there would be 25 million infected persons in India. This statement provoked an immediate response and rebuttal from the government and remarks were made about the inappropriateness of "creating panic in the population".
You might well ask what benefit such a rough and obviously inaccurate estimate can give the country. If it is remembered that the estimate does not represent the actual number of those infected, but is the number obtained by following a process that is rigidly defined, then it will be realised that following exactly the same process in consecutive years will demonstrate changes in the pattern and trends of the disease. Estimates are designed to highlight changes in pattern and magnitude of the disease and do not represent actual numbers. The very process both over-estimates certain prevalence and may well under- represent other groups.
It will be very clear that given what the estimate represents and how it is calculated, no one should argue about the correctness or otherwise of the annual figure. It could be correct, could overstate the case or just as easily be well below the actual number. Other than by testing the entire population there is no way of getting a precise number - and that number will be wrong on the next day! All that can be done is to make sure that the estimation process is as accurate as possible and that the method used is both completely transparent and reproducible every year. This will give us trends and the ability to comment on what is happening to the epidemic in our country. The absolute number is not important but the trend gives us valuable information.
Arguments, claims and counterclaims about the number of HIV infected persons in India are not only futile and unproductive but they hinder the serious work of helping prevent HIV infection in the community. Let us all stop wasting time and energy in arguing about the exact number of infections in the country. Everyone will agree that there are many infected persons in India. Certainly the figure is more likely to be counted in millions rather than in thousands or hundreds. HIV/AIDS is a serious public health problem with the potential of causing untold misery, economic loss and an undermining of the social and economic fabric of the country.
An associated comment was that the $100 million was disproportionately large given the nature and extent of the problem in India. It is worth keeping in mind that the only country in the region that successfully tackled the problem of HIV/AIDS is Thailand. This demonstrated that the number of new cases could be slowed or even halted with an intensive education programme reaching out to the whole community. Thailand, a country the size of Maharashtra was spending $100 million a year on its programme!
Time alone will tell whether by the year 2010 there are indeed 25 million infected persons in India. If we mount an effective programme and are lucky, we will have far fewer numbers. If the programme is not pursued with vigour and determination at every level we will have to contend with an increasingly serious public health problem which will impinge on every part of our life. HIV/AIDS can only be stopped if everyone - government, NGOs, scientists and most importantly the people themselves, act together. If Bill Gates' prediction was not correct, let us prove him wrong. This is a very appropriate time to reflect on these issues. December 1 is World AIDS Day and the theme this year is "Live and let Live". Stigma and discrimination are perhaps the worst spin-offs of the epidemic. HIV kills the host slowly and without pain or visible disease for the major portion of its course. Stigma and discrimination are worse; they kill the spirit and the will to live. Stigma causes pain and suffering from the first day! We, the entire community including the media and even the doctors, are the cause of this needless pain and suffering. Stigma and discrimination must stop.