As India stumbles on the threshold of the 21 st century – even as it is yet to come to terms with the basic needs of its billion people – the human immunodeficiency virus continues its spread causing as many as 16,000 new infections a day worldwide. Most of these new infections occur in the developing world; eighty-nine per cent of people with HIV live in SubSaharan Africa and the developing countries of Asia (1).

In India, the HIV/AIDS epidemic has reached frightening proportions since the first case of AIDS was identified in 1986. Even those who once dismissed it as a fashionable topic of conversation, or a ‘fund-raiser’ have had to sit up and take notice. Current projections estimate that by the year 2000, annual HIV-related deaths in India will be between 100,000 and 300,000 annually ( l0-15 % of all deaths in the age group of 15-45 years. (2)

Testing Patients

The epidemic has led to stigmatisation of’ HIV-positive persons, in their workplace, and even more shockingly, by the health services. Instances are reported every day, of doctors denying medical treatment to people testing HIV positive, of testing incoming patients for the virus — often even without their knowledge. Small efforts have been made to counter such practices. Recently, at a medical staff’ meeting in a major hospital in Mumbai, a proposal for universal testing of incoming patients was abandoned when a doctor insisted that all doctors be tested as well.

On the other hand, the acknowledgement of HIV and AIDS has had several consequences in the fields of health and development — both positive and negative. Long neglected subjects such as hospital waste management, standard of blood banks, implementation of universal safety precautions, sex and sexuality education, and terminal care have come into focus.

The first cases of HIV/AIDS in India were reported amongst commercial sex workers in Mumbai and Chennai and injecting drug users in Manipur, more than a decade ago. Such economically deprived groups remain most vulnerable to acquiring HIV, likely to fall ill earlier, and die earlier. For this reason, such populations are generally the focus of preventive health interventions.

Last month, some members of the Forum for Medical Ethics Society were invited by a voluntary organisation which is active in the red light area of Mumbai, to address doctors who have been practising in the area for several years. The meeting’s revelations were shocking.

Too many celebrity rallies

According to the doctors, as many as 30-40 per cent of the patients who seek their treatment are HIV positive. It therefore came as a great surprise that not a single organisation governmental or non-governmental -had till date made any organised effort to educate this group of doctors in matters concerning HIV and AIDS, or to involve them in their activities in this field. Some organisations have been in this area for many years, organising well publicised celebrity rallies but they seem to have kept the local doctors out of the picture. How can any HIV/AIDS control programme be effective without educating and involving the local general practitioner, especially in such sensitive and vulnerable localities?

HIV and AIDS have raised these and many other ethical issues: the maternal-foetal conflict, the need for patient confidentiality versus the rights of the spouse, the question of whether HIV-positive mothers should breastfeed, the AIDS vaccine and its trials – especially in third world countries, antiviral drugs, discrimination by employers etc. Some of these have been discussed in earlier issues of IME but with each passing day as HIV-AIDS insinuates itself into the community, more and more questions demand our attention.

Finally, for those who might believe that, with all the billions of dollars that are being spent on AIDS research, a cure for the scourge of this century is just around the corner, a note of caution. Professor Michio Kaku, a renowned theoretical physicist also known internationally for his futuristic vision, recently said in an interview published in The Times of India, “HIV in just two years mutates as much as humanity in two million years. Unlike cancers, which are mutated human cells, HIV mutates at such an incredible rate that a cure may or may not be on the cards .” (3) There is certainly no ground for apathy. The medical profession must accept the challenge. Let HIV/AIDS not be the last straw on the Indian health system’s feeble back.