Published: January 2004
AIDS Tragedy Highlighted at World Social Forum
By Richard Stern*
Stern is an AIDS activist based in Latin America who attended the
World Social Forum in India. He does not pretend to be an expert on
the AIDS crisis in India after spending just 10 days in Mumbai, but
feels compelled to at least place certain issues into a public forum
with the hopes of stimulating further discussion and debate)
As a country overwhelmed by poverty as well as a myriad of other social
problems, India's AIDS tragedy is hard to focus on, and the magnitude
of the situation is only just becoming visible. The World Social Forum
and the International Health Forum for Defense of People's Health,
held in Mumbai from January 14th-21st helped to place AIDS in the
national spotlight, albeit briefly.
Among India's many other overwhelming problems there are an estimated
4 million People Living with HIV/AIDS. In a country that has over
1 billion people, the "incidence" of AIDS is still relatively
low, less than one half of one percent, but the numbers are still
staggering. Care and treatment are virtually non-existent. According
to Sanjay, a Person Living with HIV/AIDS (PLWA) "more than five
years ago, the government promised to begin providing medications
for opportunistic infections, but they still haven´t done so.
There is no Bactrim, no Fluconazole."
Ironically, India is home to CIPLA, Ranbaxy, and Aurobindo, all of
whom export generic anti-retroviral medications to other countries,
but even at the price of less than $1 per day, these medications are
unavailable to Indians who need treatment now, an estimated 300,000.
An average salary for a working class Indian in Mumbai is $30-40/month
and most people with AIDS are unemployed, and have to rely on charity
just for food.
Government Promises Scale-Up
The government has recently announced that it will begin providing
treatment for 50,000 people beginning in April of 2004, but activists
I spoke to were skeptical of the government's commitment to follow
through According to Vivek "they have not allocated any budget
for the purchase of these medications, so how are they going to buy
them? We have not heard of any concrete plan to implement this promise."
The NGO "Communication for Health India Network" (CHIN)
raised similar questions in their Newsletter distributed at the World
Social Forum. CHIN voiced several concerns including "What are
the plans for making available low cost second line drugs?, and "Would
health personnel be trained adequately enough to handle problems related
to drug distribution such as laboratory, and the delivery system itself
and handling side effects?" They also referred to issues related
to ARV availability for women and children, gender issues, confidentiality,
and criteria for selection of clients to receive free drugs.
The biggest concern that this writer has, after witnessing innumerable
announcements by governments about scaling up plans that were never
followed through on, is "will this really happen in India or
is it a placating strategy, designed to silence activists and create
a false impression that something meaningful will occur?"
The NGO Coalition SAATHI (Solidarity and Action Against HIV infection
in India) presents a rather pessimistic overview of the AIDS panorama
in India. According to the SAATHI website:
to PLHA is refused even in governmental hospitals giving excuses
such as lack of "adequate infrastructure" and lack of
'expertise' in treating PLWA.
hospitals almost always deny treating PLWAs.
of the patient's HIV status is not maintained in government and
for opportunistic infections are not always available in government
treatment is not provided to PLWA even if there is an absolute necessity
in centers which are treating PLWA, the basic facilities are inadequate.
care for people living with HIV/AIDS is non-existent.
widely publicized speech delivered at the Indian National AIDS Conference
in Chennai in late last year, activist Dr. Subha Ragahavan demanded
that the Indian government respond to the crisis in care and treatment.
"Treatment is a basic human right...in the past 3-4 years I have
lost seven of those young men who went to school with me. How can
they not be my family, they work and serve my village and take care
of my family." She added that "we are the manufacturer of
cheap drugs for the whole world...it is unacceptable that the very
same drugs we export to the whole world are not available at affordable
prices in India."
Raghavan finished by demanding that treatment access be made available
by July of 2004 in India, and asked for support from UNAIDS and the
WHO "3 x 5" team in implementing a plan: "We demand
that...WHO, UN agencies, Bi-lateral partners, and Foundations work
together in equal partnership with civil society and People Living
with HIV in developing a comprehensive plan for immediate scale-up
of ARV treatment in India."
as many as a thousand people in India do receive anti-retroviral medications
that are provided by NGO's, including the Freedom Foundation in Bangalore,
and the Naz Foundation in New Delhi.
Streets of Mumbai
As an outsider who came to find out about AIDS in India, it was impossible
for me to ignore other problems that are much more visible. During
my daily 75 minute taxi ride from my Hotel to the site of the World
Social Forum in Mumbai, it was absolutely overwhelming to see the
number of homeless families who simply camp out by the side of the
Western Express highway and on the sidewalks of the major thoroughfares
that wind their way through Mumbai. Returning along the same route
at night, it is as if the homeless turn to corpses as they lie fully
wrapped in blankets along the sidewalks and roadsides. And aside from
those who are homeless are thousands of others who seem to have put
together several pieces of tin and some wood and plastic to create
a makeshift shelter. Peering into some of these shelters at traffic
lights I could see five or six children and their mother, cooking
something in a pot over an open fire fueled by sticks gathered from
At the World Social Forum, and the International People's Health Forum
which preceded it, AIDS was a topic of concern in many presentations.
The Indian "Lawyer's Collective" of Mumbai sponsored programs
focusing on intellectual property issues which threaten the future
ability of companies such as CIPLA to continue to
export their medications on the world market. According to Anand Grover
of the Lawyer's Collective, India must enact TRIPS compliant patent
legislation by the end of 2004, and this may mean that CIPLA will
have to respect local patents that have been filed on anti-retroviral
medications, meaning that they could not export their products. Up
until now, Indian law did not recognize any patents on medications,
only on "processes" for producing the medications. Thus,
any company that could develop a new process for producing a medication
could do so. But the World Trade organization is requiring India to
enact a law that will fulfill the requirements of the TRIPS agreement.
Even as the World Social Forum was concluding, local English newspapers
carried a story about an apparently precedent setting case won by
Anand Grover in the High Courts of India, in which a woman who had
been fired from her job in an insurance company for being HIV+ was
ordered to be reinstated within one month. But discrimination even
among medical personnel is described as being rampant. Indira from
Chennai in South India described how an AIDS support program in that
city fired all of its HIV+ employees. Many PLWA stated that most physicians
will refuse to treat a person if they know the person is HIV+.
WHO "3 x 5" actions unclear for India
The World Health Organization sent several members of its Core "3
x 5" (3 million people on treatment in developing countries by
the year 2005) to Mumbai for the two Conferences, but it was clear
that the 3 x 5 plan, does not address India's country specific realities,
and that at the moment it is a "theoretical prescription"
for India. Craig McClure and Ian Grubb from the WHO Geneva Core Team
gave presentations at a Plenary Session attended by 800 people held
January 14th, at the International Health Forum in Defense of People's
Health. However, there was no participation in this event from India
based staff of the UN Agencies who are focused on scaling up ARV access.
So the local situation remained very unclear, and there is no evidence
that any of Subha Raghavan demands listed above have been addressed
In other developing countries during the history of the AIDS epidemic,
WHO/UNAIDS staff have, with notable exceptions, clearly failed to
take a pro-active role in supporting goverments in implementing treatment,
and have tended to identify more with elite government decision makers
than to push these leaders to help poor people. Given the fact that
India has by far the lowest priced ARV's in the world, it is indeed
shocking that, seven years after ARV access became virtually universal
in Europe and the United States, the government of India still does
not provide treatment.
Delays in Global Fund Implementation
However, perhaps the biggest tragedy in India is the failure to even
begin to make use of extensive resources that have already been allocated
by the Global Fund for AIDS, Tuberculosis and Malaria for India.
The Global Fund contract for the proposal relating to HIV/AIDS, approved
in Round Two (January of 2003) still has yet to be signed. Although
the proposal itself is for about two hundred million dollars, including
all components, it only provides treatment access for about 19,000
people over the five year period (roughly 7 million dollars based
on current costs of ARV access in India) According to current estimates
as many as 300,000 people in India need treatment access now, and
over a million will be in need with five years. As such, the proposal
does not reflect the Global Fund policy of funding proposals that
will significantly scale up treatment availability for people living
with HIV/AIDS. Most Indians with AIDS will not benefit from the proposal.
Other elements of the AIDS infrastructure that would be funded by
the proposal such as voluntary testing and counseling cannot be put
into place until the proposal is signed and funds are disbursed, further
delaying any treatment access scaling up that would come as a result
of the proposal. A representative from PNUD in India, who attended
the session sponsored by the Lawyer's Collective told me that there
is virtually no infrastructure related to scaling up ARV access in
India, and that the infrastructure would need to be in place for treatment
access to begin. He defended that fact that only about 5 percent of
the Global Fund proposal will actually go for purchase of anti-retrovirals,
claiming that the government is simply incapable of providing treatment
to a large number of people. When I reminded him about Paul Farmer's
work in rural Haiti and its success, he insisted that Haiti has a
more developed health care infrastructure than India.
Other activists present in the Forum were angry about the lack of
emphasis on ARV access in the GF proposal, and claimed that they were
never consulted about possible input into the proposals presented
by the CCM to the Global Fund.
The Global Fund CCM seems to be very much dominated by the government,
in the sense that few HIV+ Indians I spoke to were even aware of its
existence, or the resources it potentially may have provided or could
at least begin to provide. The 4th round of proposals for the Global
Fund will close in April, and there is a movement among activists
in India to submit a proposal focusing on ARV access. But one has
to wonder what
will be the Fund's reaction, given that India has been unable to even
begin to make use of nearly $200,000,000 that has already been approved.
Activists from TAC in South Africa, Healthgap in the United States,
as well as from Brazilian NGO's, were present at activities during
the World Social Forum, and discussed implementation of collaborative
actions that would provide support from the International Community
to Indians living with HIV.
Compounding India's AIDS problem is that fact that homosexuality,
even among consenting adults, remains illegal, meaning that most gays,
lesbians and transgendered people remain hidden which compounds prevention
Paradoxically, the streets of Mumbai remind one, at least superficially,
of San Francisco's Castro street gay district, in the sense that it
is culturally acceptable for men to walk down the street hand in hand.
In a half hour walk through the crowded Colaba district, I counted
at least 30 male couples, generally in their teens and 20's, walking
hand in hand, but in Indian culture this is completely acceptable
behavior for heterosexuals.
The extermination of Men who have Sex with Men in India
More overt homosexuality is not visible in bars or other socially
tolerated venues, but is dramatically visible at the urinals in the
huge restrooms in the commuter railroad stations that wind their way
through Mumbai. There seems to be a section reserved for "cruising"
among gay men, and there were dozens of men presumably "seeking
sex with men" present at the Churchgate station men's room during
rush hour one evening. Equally visible were many men who were obviously
cruising a darkened section along the beach just to the South of the
famous Taj Mahal Hotel in Colaba. So if Indian authorities, who tend
not to visit such places, try to deny the existence of a substantial
community of men who have sex with men, they are sorely mistaken.
According to "Fridae" an Asian Gay and lesbian network,
there is a whole gay culture associated with the railroad system.
"Tuesdays is for Dadar railway station...Wednesday is for Bandra
station, platform one booking counter...the crowd here tends to be
what the snobbish upper crust of Mumbai would refer to as the lower
classes...on the express trains, the second to last compartment is
often the cruising section of the train."
Mumbai, a city of 14 million, has only one gay bar that is only open
one night a week, but there is an underground network of contacts
and parties and there are several gay associations as well. But the
law against "unnatural acts," enacted by the British in
1871, carries stiff penalties, and, even if rarely enforced, casts
a deep shadow over India's gay community which is highly repressed
by culture as well as law.
According to Indian gay activist Ashok Row Kavi, Director of the Humsafer
Foundation in Bombay, (quoted in an interview written by Perry Brass
in Gay Today) "Indian gays are a product of Indian civilization.
We will be reflecting all the contradictions of Indian Society....Gay
men in huge numbers are infected. I estimate over 60 percent HIV prevalence
in the 520,000 Men-Having-Sex with Men sector in Bombay. But they
are dying futile, unsung deaths."
According to Row, the Indian term for gay sex "is 'musti,' or
mischief. and young Indian boys who engage in gay sex are often joked
about....Musti is considered something that takes place along with
marriage but never in place of it. Musti, then is something to be
joked about, it is never serious, and the deeper romantic feelings
that Western gay men often have about their relationships are alien
to Indian culture."
Rainbow Planet, a Coalition of NGO's that supports sex workers as
well as sexual minorities in India, held a well attended plenary session
at the World Social Forum in which various sex workers, as well as
transgendered, lesbian and gay people gave testimonies as to the abuses
and discrimination they are constantly subjected to.
Agua Buena Human Rights Association
San Jose Costa Rica