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Sunday, April 11, 2004 - Page updated at 12:57 A.M.

Guest columnist
AIDS and India

By Melinda French Gates
Special to The Times

GATES FOUNDATION
Melinda French Gates, sits with commercial sex workers who are involved in an HIV-prevention project in Calcutta, India. The garland around her neck and dot on her forehead are from the traditional Tika greeting.
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India's emergence as one of the world's fastest-growing economies, with a highly skilled workforce and climbing literacy rates, has fueled optimism that the country could one day overcome its crippling poverty.

But as I recently saw firsthand, India is on the brink of an AIDS catastrophe that could undermine the country's potential for progress.

There are already over 4 million people infected with HIV in India, and the epidemic is on the verge of crossing over from those at highest risk into the general population.

If this happens, experts project that as many as 20 million Indians could be infected by the end of the decade — that's more than twice the population of New York City.

What I heard during my trip to Calcutta — from AIDS experts, community workers and people affected by the disease — confirmed that a tremendous amount of work must be done to fight AIDS in India. But I am hopeful that the nation can avoid disaster. A range of HIV-prevention measures are working in India — if expanded to reach all those at risk, these efforts can stem the country's surging AIDS epidemic while there's still time.

During my trip, I learned about three urgent priorities for preventing the spread of AIDS in India: the need to empower women; to reach mobile populations, such as truck drivers, with HIV prevention services; and to fight the powerful stigma attached to the disease.

I'll never forget a sex worker named Gita, who brought home to me the role that women's empowerment can play in stopping AIDS. Gita has joined with other sex workers in one of Calcutta's poorest districts to educate other women about AIDS. Shockingly, 70 percent of Indian women have never even heard of AIDS.

Working together, Gita and her peers have helped to increase condom use from near zero to 70 percent in their district, and to reduce HIV infection rates to 7 percent — compared with rates as high as 66 percent among sex workers elsewhere.

I was particularly moved when, during my visit, several sex workers spontaneously started singing "We Shall Overcome." As I listened to their Bengali-accented English, it became clear that the familiar lyrics were not just a dream for them. By taking an active role in educating other sex workers and distributing condoms, these women are playing a vital role in making prevention work.

More women must be empowered in the face of AIDS. That means ensuring women a place at the table in planning and implementing HIV-prevention programs, replicating successful programs for sex workers around the country, and accelerating research into new technologies like anti-HIV microbicides that women could use to protect themselves from infection, even if their partners refuse to use condoms.

GATES FOUNDATION
Melinda French Gates discusses HIV prevention with Indian commercial sex workers who serve as peer educators in Calcutta.

Of course, the best long-term solution is to provide greater economic and educational opportunities so that fewer women enter the sex trade.

HIV-prevention services must also be provided to mobile populations in India, such as truck drivers, soldiers and migrant workers, who can be highly vulnerable to HIV and play a key role in the spread of the disease.

For example, Indian truck drivers typically spend 80 percent of their time on the road, a majority report having sex with commercial sex workers, and they are 10 times more likely to have HIV than the general population. If infected while on the road, they can easily pass on the virus to their wives or girlfriends when they return home.

To learn about prevention efforts targeting mobile populations, I visited a truck stop in Calcutta where, I was told, "lots of sex happens" between truck drivers and sex workers. But I also saw a sign of progress, in the form of a bamboo hut — a clinic where truck drivers and sex workers receive HIV counseling and testing.

Inside the tiny clinic, I had an eye-opening dialogue with six of the truck drivers. They said they had never heard of AIDS before outreach workers talked to them, and they've shared what they have learned about the disease with their friends and teenage sons. The truckers admitted they never use condoms with their wives — it would expose their infidelities — but they do use condoms now with sex workers. Obviously, this is not ideal, but it is an important step in the right direction.

Finally, it is critical to end the stigma surrounding AIDS, which often prevents any discussion of sex and keeps people from getting tested for the virus. I was told by the leader of a support group for HIV-positive people that the stigma of AIDS — and the inferior status of women — is so strong that a woman whose husband dies of AIDS is often blamed for his death, and thrown out of the home with her children.

AIDS has always raised thorny issues. Many of us are simply not comfortable talking about the behavior that can lead to HIV infection, such as unsafe sex and injection drug use. But every nation that has successfully reduced infection rates has recognized the need to promote open discussion about the disease and reach those populations most at risk.

Many of India's leaders see the urgent need for aggressive efforts to stop AIDS — both through prevention programs and recently announced efforts to expand access to treatment — and are taking many of the steps needed to keep the disease from crippling a great nation.

Bill and I started our foundation based on the firm belief that every child in our world deserves a chance at good health. But the reality is that more than 10 million children die every year, and two-thirds of them are dying from diseases that could be prevented with low-cost interventions, such as vaccines. Diseases like tuberculosis and malaria are resurging due to neglect, and if nothing is done to change the course of the AIDS epidemic, 100 million people could be infected by the next decade. That is why it is so important that nations with emerging epidemics, like India, act now.

Our foundation has committed $200 million to support HIV prevention in India, with a focus on sex workers, truckers and other vulnerable groups. We're hopeful that this initiative will have a major impact, but far more will be needed for the country to turn back its epidemic. India urgently needs more clinics, more condoms, more testing, more information and more treatment — efforts that require additional resources from rich countries and international agencies.

Individuals can make a difference, too — there are things that each of us can do to help stop AIDS around the world. For example, you can educate your friends and family about the disease, volunteer for a local AIDS organization, or ask your lawmakers to increase funding for global AIDS programs. You can also donate to organizations such as the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org), which supports AIDS programs in the hardest-hit countries throughout the world.

With the strong support of the international community, I'm confident that India can prevail in its fight against AIDS. If it succeeds, the public health won't be the only benefit — children will thrive, economies will boom, democracies will flourish and women like Gita really shall overcome.

The Bill & Melinda Gates Foundation's Web site is www.gatesfoundation.org

Copyright © 2004 The Seattle Times Company

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