This is the second in a multipart series of articles by United Press International on the status of the global AIDS epidemic.
WEST PALM BEACH, Fla. (UPI) -- As bad as the AIDS epidemic is in Africa, it could easily become worse in Asia, where grim statistics quietly continue to gain momentum.
AIDS researchers and government officials are, of course, aware of the spreading epidemic in India and China -- the home of more than 2 billion people. But in the vulnerable, under-educated, poverty-stricken areas of those two countries, those warnings are muted or not even heard.
Take India. Officially there are just under 4 million people living in the world's most populous democracy with the human immunodeficiency virus, which causes AIDS. But many doctors and epidemiologists suggest the figure is underestimated.
In a country of a billion people, even 4 million carrying a disease amounts to an infection rate of 0.4 percent -- similar to that of the United States. But India's infection rate is rising. When it reaches 1 percent, it will mean 10 million people have become HIV-positive.
What frightens health experts is if India's level of infection reaches that of sub-Saharan nations -- as some are predicting. Then, as many as 100 million will be infected with HIV. Looking at the situation right now, with attempts to curb the infection rate spotty and unmeasured, there is little evidence for hopefulness that such a monstrous scenario will not unfold -- particularly among the rural populations.
The epicenter of the Indian epidemic lies within Mumbai, the city of 19 million people formerly known as Bombay.
"This is Grant Road," announced Dr. Mohit Bhatt, a neurologist in Mumbai, as he drove through the city's red light district, where thousands of female sex workers offer tens of thousands of men services that are negotiated in 5-rupee increments. A rupee is worth about 2 cents.
Grant Road is a mile-long stretch of tenements on a street so well traveled the pavement is crumbling into dust.
"There are estimates that as many as 70 percent of the women here have HIV," Bhatt told United Press International as he crept along the five-lane, one-way (except for buses) artery. Bhatt treats a number of HIV patients, many of whom develop brain infections or suffer from HIV-associated dementia.
Alarming to Bhatt and others on the epidemic's front lines is most of the men visiting the commercial sex workers are not residents of Mumbai, but are among the teeming masses of men who spend a few weeks or months living on the streets of the city, eking out a few rupees in order to take some money back to their home villages.
"They are also taking back with them something else," Bhatt said. In many cases, the wives of these men have no idea they have been infected with the slow-acting but deadly virus -- until newborns fail to thrive, because the babies, too, have become infected.
A recent report from the Joint United Nations Programme on HIV/AIDS, also known as UNAIDS, suggests some progress.
"New behavioral studies in India suggest that prevention efforts directed at specific populations such as female sex workers and injecting drug users are paying dividends in some states, in the form of higher HIV/AIDS knowledge and condom use," the report states.
However, the report, written by UNAIDS epidemiologists, also notes: "HIV prevalence among those key groups continues to increase in some states, underlining the need for well-planned and sustained interventions on a large scale."
Education about AIDS, especially in the rural areas, is spotty. Studies indicate only 8 percent of rural women harbor no misconceptions about how AIDS is spread -- though this knowledge probably will not protect them from becoming infected by their husbands, who have engaged in extra-marital sex away from home on grimy Grant Road.
In neighboring Bangladesh -- a nation the size of Wisconsin but with a population of 140 million -- reports, officially, only a few hundred people are infected with HIV, said Dr. A.Q.M. Serajul Islam, professor of dermatology and sexually transmitted diseases at Chittagong Medical College and Hospital.
"We screened 400 men at our clinic," he told UPI, "and two of those men were positive for HIV." The clinic is but one of several in Chittagong, the second largest city in Bangladesh, with a population of more than 4 million.
Though that would suggest the infection rate is 0.5 percent, Islam said he was more disturbed by the reactions of the patients. "Both men are married," he said, "but neither of them wanted to have their wives tested. Neither of them even wanted their wives to know that they had HIV."
Islam said women in Bangladesh seldom receive even standard health care or testing for any sexually transmitted disease, let alone testing for AIDS. He said he suspects HIV infections in Bangladesh could total as many as 20,000 -- still relatively low and barely enough to raise alarm in the impoverished nation.
Because HIV does not receive top-level government attention, however, and because the cultural attitudes of the country result in the under-treatment of women, the explosive spread of HIV is more probability than possibility in Bangladesh.
China, the largest nation in Asia and the most populous in the world, also is in the midst of an HIV/AIDS crisis.
"The epidemic in China shows no signs of abating," a UNAIDS report published in December 2002 stated. "Official estimates put the number of people living with HIV in China at 1 million in mid-2002. Unless effective responses rapidly take hold, a total of 10 million Chinese will have acquired HIV by the end of the decade." Put another way, 10 million people is equivalent to the entire population of Belgium.
Though the epidemics in India and most of the other developing nations -- including Africa -- generally are caused by heterosexual activity, injected drug use fuels China's epidemic.
Drug use also worries doctors in Indonesia, where HIV infection rates among injecting drug users is rising dramatically. "Virtually unknown in Indonesia just a decade ago, drug injection is now a growing phenomenon in urban areas," UNAIDS researchers reported.
In one drug treatment clinic in Jakarta, nearly 50 percent of the patients are infected with HIV, compared to 1998, when the infection rate was near zero.
There are about 200,000 injecting drug users in Indonesia, a nation whose population is approaching 250 million. UNAIDS officials said an estimated 9,000 women in Indonesia have been infected with HIV by sexually active men who inject drugs. About two-thirds of the men who inject drugs are sexually active.
The worldwide focus on the AIDS epidemic remains on Africa, but the numbers from Asia and the Pacific are daunting: 1 million people in the area acquired HIV infection in 2002; nearly half a million people died of the disease last year and 2.1-million young, sexual active men and women ages 15-24 are living with HIV infection.
Proven programs that can slow spread of the disease, but researchers fear the window of opportunity to control the epidemic in Asia is closing -- and closing with deadly rapidity.
Next: Though outbreaks in the underdeveloped African continent and the huge population masses of central and southern Asia might seem far from the United States, the AIDS epidemic also rages nearby, in Latin America and the Caribbean.
(Ed Susman, a medical writer for UPI, has been covering the AIDS epidemic for more than 20 years)
(Editors: UPI photos WAX2003091501 and WAX2003091502 are available)