Thirty-five-year-old Rama Devi is not exactly an icon of good fortune. She and her five children live in a dusty, thatched-hut village called Kashiou, in the northern Indian state of Uttar Pradesh. She once had a husband, a man who spent most of the year selling fruit on the streets of Mumbai, but he contracted HIV during his travels and came home a few years ago to die. Devi is now HIV-positive herself. She works as a casual laborer in the wheat fields around her village, receiving her daily pay in grain. But Devi's luck could be worse. She happens to live within 20 kilometers of Allahabad, where the Uttar Pradesh Network of Positive People runs a drop-in center--and she has a brother who can spare a few precious rupees to get her there each month for a free checkup, followed by a five-hour bus ride to the nearest government treatment center. Nearly 800,000 of India's 5.1 million HIV-positive people are now sick enough to need the kind of medication that keeps Devi alive to feed her kids. She is among the 10 percent who are getting it.
Experts call India a "next wave" country--ripe for the kind of devastation that South Africa has experienced during the past decade, but also capable of the bold action that has helped countries like Thailand and Brazil contain their epidemics. As you travel through this vast land, those possible futures really do appear as a fork in the road. To the south, in hard-hit states like Tamil Nadu, vigorous public-health efforts now appear to be slowing the spread of the virus. But to the north, poorer states such as Bihar and Uttar Pradesh look more and more like disasters in the making. Though their HIV rates are still far lower than those in the south, their large migrant workforces provide a ready conduit for infection--and their crumbling health systems are woefully ill prepared for the onslaught. The lesson of the south is that intervention works. The question is whether the rest of India--indeed, the rest of Asia--will learn it in time.
Until recently, India's AIDS outlook has seemed uniformly grim. But that changed this spring, when Indian and Canadian researchers published findings from a four-year study involving 294,000 pregnant women from 18 states. The results showed that HIV prevalence had fallen by some 35 percent among young women throughout the "high-prevalence" states of the south and west (Tamil Nadu, Andhra Pradesh, Karnataka and Maharashtra). Sometimes, a drop in new infections means only that the most vulnerable people have died. But behavioral surveys suggest the decline in this region has more to do with public safety measures, including the increased use of condoms among sex workers and their clients. "AIDS was a great opportunity for Tamil Nadu to better its entire public health system," says Vijaya Kumar, former director of the state's official AIDS control society. "We cleaned up our blood banks and trained our health workers down to the village level to educate the community."
That kind of success is harder to find in Uttar Pradesh. With a population of 170 million, it is home to 25 percent of India's migrant workers. In villages like Tardeo, near Allahabad, almost a quarter of the men are working in the big cities, and many bring HIV home with them. The local women have seen enough AIDS to have their own name for it. They call it the Bombaywala-bimari (Bombay illness), yet Uttar Pradesh is only now launching the first few prevention programs for migrant workers, and the entire state has only three AIDS treatment centers. The neighboring state of Bihar has none at all. Patients who fall sick in Patna or Muzaffarpur often show up 1,100 kilometers away at Delhi's hulking All India Institute of Medical Sciences, desperately seeking the medicine they can't get back home. "Why don't they open ART [antiretroviral therapy] centers in Bihar?" asks Dr. S.K. Sharma of AIIMS. "Why are people traveling a thousand kilometers? If they can't return every 25 days, they will default on treatment and develop drug resistance."
India does have a national AIDS program, but it's designed to support state-level initiatives--and the states that most need those initiatives are often the least prepared to plan and implement them. In Muzaffarpur, a district of more than 3 million people, the main public hospital sits all but abandoned. Broken, rusted cots are scattered like old toys. Local officials would be hard pressed to revive it without outside support--but they're stretched too thin to document their needs, let alone address them. "We need to train people," says Dr. Ajay K. Khera, New Delhi's top officer in charge of rolling out AIDS drug therapy. "We need to provide the right equipment, the CD4 testing, the HIV testing, the counseling. It is not just dumping medicine."
When the Indian government first began opening free antiretroviral centers in 2004, it projected patient enrollment would top 100,000 by early 2006. The actual number is still less than 30,000, though officials say they expect to have 180,000 patients on treatment by the end of 2008. "The government is committed to provide free ART to all eligible people," says Sujata Rao, director of India's National AIDS Control Organization.
Meanwhile, countless thousands of HIV-positive Indians are turning to traditional healers who peddle herbal potions as cures for AIDS. In fact India's best-known AIDS doctor is not a doctor at all but a 68-year-old mining engineer named T. A. Majeed, who sells a product called ImmunoQR. He won't say what's in the 23-herb formulation (a 100-day supply goes for $232), but he claims to have cured some 100,000 patients since 1993. "Can I fool that many people?" he asks, amid the silk carpets and teakwood fixtures of his white marble palace in the southwestern state of Kerala. Barred in 2000 from advertising ImmunoQR as a cure for AIDS, his Web site now refers to "killer viral diseases," saying eight jars of pills are "all that is required for the patient to be completely cured."
If only the truth were so simple. India may yet escape South Africa's nightmare, but the threat is still real and the social obstacles are still as daunting as the practical ones. As Majeed counts his money, and dying patients trek from Bihar to Delhi for a shot at salvation, Rama Devi is preparing to marry off her 18-year-old daughter in Uttar Pradesh. The groom is a fruit vendor who will spend most of his time across the subcontinent in Gujarat. Has Devi spoken to her daughter about HIV? No, she says--that would be uncomfortable. Has her brother spoken to the groom? No idea, she says. It wouldn't be her place to ask.