In an interview with Rashme Sehgal, Denis Broun, country representative of UNAIDS, defends a recently-published report by his organisation that states that over 4 lakh AIDS-related deaths occurred in India in 2005 -- the highest in the world

Denis Broun, country representative of UNAIDS, finds himself in the eye of a storm. The recently-released UNAIDS Report on the Global AIDS Epidemic highlights the fact that over 4 lakh AIDS-related deaths occurred in India in 2005. This is the highest in the world. South Africa, where almost 20% of the population lives with HIV, reported 3.2 lakh deaths for the same period.

Broun stoutly defends his position, insisting that India is facing a major AIDS epidemic and must take strong steps in order to avert a catastrophe.

Broun has served as director at the World Health Organisation (WHO) and has worked with the Geneva-based Management Sciences for Health.

UNAIDS has put the number of AIDS-related deaths in India at over 4 lakh a year. How did you arrive at this figure?

The whole life of HIV/AIDS, from infection to death, takes nine to 10 years. On average, people who were infected nine years ago will die now. You take the course, the evolution of the number of people living with HIV, those who have just become patients to those who have been living with it for some time, and you arrive at this figure. It is pure 'modelisation'; one deduces how many are likely to have died. The figure we arrived at was between 2.8 and 6.3 lakh, and so we took the average of 4 lakh. It is pure mathematics.

There has been no body count, no death certificates given out for so many AIDS patients. The diagnosis for AIDS is not easy. There is a huge amount of stigma attached to it; there is no insurance being given out to the families of patients who have died from it.

Death certificates in India rarely specify death from AIDS-related causes.
Less than 2,000 death certificates in India carry this label. It is very widely underreported.

What methodology did your organisation use to arrive at this 4 lakh figure, and what are the methodologies being used by other India-based organisations?
The Institute of Medical Statistics and the National Institute of Health and Family Welfare are using a method called Kink Regression, whereby they try and determine, through excess mortality figures, the number of deaths that can be attributed to AIDS.

UNAIDS is following the Global Reference of Estimation and Models approach. More than 110 top scientists around the world, including India's top statisticians, are involved in this method. We use Indian government figures which state that 5.2 million people in the 15-49 age-group are positive. When we take the whole population, we find 1 lakh people living below the age of 15 are likely to have AIDS. We try and arrive at a similar figure for those above the age of 50. What we know about AIDS is then distributed among these two groups. We have done this by looking at the statistics put together by the huge baseline behaviour survey conducted by the National AIDS Control Organisation (NACO) in 2001.

NACO is presently conducting a second baseline behaviour survey whose results will be out this year. The questions asked in this survey include whether an individual has had sex with multiple partners, condom usage, and so on. Sujata Rao (director general of NACO) has agreed to change the figures and go by (UNAIDS') 5.7 million figure.

Three major changes have taken place recently. In Tamil Nadu, the number of AIDS cases has declined by one-third. This has happened because the number of (sexual) contacts (of the HIV-positive) has gone down. There has also been an increase in condom usage. The state of Maharashtra is also witnessing a decline in AIDS cases, but in Orissa, Goa and Rajasthan the numbers are going up.

Arriving at these figures is a difficult task. The state of Uttar Pradesh has 0.2% of AIDS cases, which means we need to test over 500 cases in order to get to one case.

I need to specify that 99% of Indians are free of the virus. Looking for an AIDS case is like looking for a needle in a haystack. To find one case, one has to test 100 cases.

NACO has set up 400 sentinel sites at antenatal clinics where blood samples are taken from patients visiting here between the months of August to October. NACO is, in fact, planning to set up around 400 additional sentinel sites all over the country.

Is the Indian government minimising the figures? Is it doing enough to eradicate this disease?
The Indian government receives the figures. There is no game being played out there. The sentinel sites conduct their tests very regularly so I do not want to get into a statistical grinder. The NACO model is very solid; we don't have anything more solid. We have accepted the government's 5.2 million figure but have added the figures of the young and the old who are also suffering from this disease.

I would like to add that the government is committed to eradicating AIDS. The prime minister himself is chairing the National AIDS Commission. AIDS-prevention is becoming increasingly important for Indian legislators across the country.

What do you think about the way the AIDS campaign has been conducted in India?
It has helped generate very high levels of awareness, though how much of this has been translated into condom usage is difficult to say. There is always a gap between knowledge and behaviour. Some problems remain. The setting up of a distribution supply chain up to the last mile has not been effective.

Although present condom consumption in India is to the tune of 1.8 billion per year, we should be using 5 billion condoms per year to cover the present male population. This gap needs to be met.

Are you optimistic about the way AIDS is being tackled in India?
There are reasons to be both optimistic and pessimistic. What worries me is that the prevalence of this disease is not going down. This is because injectible drug use is on the rise. Also, as long as the government does not remove Section 377 of the IPC, which criminalises homosexuality, more than 1 million men will be at risk.

At present, the bulk of the epidemic is restricted to states like the northeast, which have high levels of literacy. If it spreads to the northern states, this will become a major problem.

I am, however, optimistic at the slow growth of the epidemic in the 15-49 age-group. It's barely growing; in fact it's flattening out.

But you have been quoted as saying that the 4 lakh figure is a catastrophe for a nation with less than 1% of adults HIV-positive...
There is a major problem but this is not to decry the government's initiatives. The government is committed to controlling the disease. Other Asian countries such as Thailand and Cambodia are also showing a decline in the number of cases. AIDS is on the rise in Eastern Europe because of an increase in the number of injectible drug users.

Has the cost of treatment come down considerably?
Anti-retrovirals are free of cost and are being paid for by the government. Anti-retrovirals cost around $ 140 per year. If a country has 10,000 HIV/AIDS patients, the cost is $ 1.5 million, but with 100,000 patients the cost works out to $ 25 million. It is the second line of treatment that is more expensive.

AIDS has a direct effect on the poor. Households affected by AIDS fall back into poverty. If two people are working in a family, the woman will stop work to take care of her husband. The family also has to pay additional transportation costs and the cost of antibiotics.

Is there any insurance package being prepared for AIDS patients in India?
The problem with this disease is the stigma attached to it. Insurance companies will enter if there are enough people to take this up. I have heard that the state of Jharkhand is planning a state insurance scheme for AIDS patients. Unfortunately, I do not know enough about this scheme to elaborate further on it.

InfoChange News & Features, June 2006