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HIV Epidemic in India: Personal Experience From Silicon Valley
By Carol A. Kemper, MD, FACP
Dr. Kemper reports no financial relationship relevant to this field of study. This article originally appeared in the April 2007 issue of Infectious Disease Alert. It was edited by Stan Deresinski, MD, FACP, and peer reviewed by Connie Price, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, and Dr. Price is Assistant Professor, University of Colorado School of Medicine. Dr. Deresinski serves on the speaker's bureau for Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Dr. Price reports no financial relationship relevant to this field of study.
Source: R. Steinbrook. HIV in India — A complex epidemic. N Engl J Med. 2007;356 (11):1089-1093.
The San Francisco Bay area is now home to one of the largest Asian Indian populations in the United States, especially in Silicon Valley, where it is estimated that 40% of the computer programmers are Asian Indian. As a result, I see more endemic disease (eg, typhoid, salmonella sepsis, malaria and tuberculosis) in a community-based private practice than I ever did at the county hospital. There has been, however, one unique addition to my practice over the past 2 years: 6 Asian Indian patients with HIV, who represent ~5% of my total HIV/AIDS practice. Two are female and 4 are male. One young woman, aged 24 years, has a hidden history of abuse. The other woman is in her early 40s and was a practicing surgeon in India before moving to the United States, where she is a housewife. She presented with a CD4 count of 90 cells/mm3 but was virtually asymptomatic. The 4 men are bisexual or have had sex with men, though were reluctant to disclose this information. Homosexuality is illegal in India and punishable by the same Penal Code as sex offenders, pedophiles, and people who have sex with animals.
With the exception of the housewife, all work in high tech and were unaware of their HIV status. Infections in all 5 were detected when HIV tested for immigration purposes. While it is possible that the men may have acquired their HIV in the United States, the timing and CD4 cell count results suggest earlier infection.
It is interesting that this experience parallels the emerging epidemic in India, as outlined by Dr. Steinbrook. It is estimated that somewhere between 3.4 and 9.4 million persons in India are infected with HIV, although less than 10% are aware of their status. The estimated prevalence of infection among persons aged 15 to 49 years old is 0.5 to 1.5%. However, prevalence data for much of India is lacking. Of India's 35 states, 6 are considered high prevalence based on observations of HIV seropositive rates > 1% in woman getting prenatal testing and rates > 5% at STD clinics. But many states don't offer prenatal screening, and treatment during pregnancy or peripartum is limited.
HIV prevalence studies in Indian sex workers typically find rates of 10% to 20%, with an estimated number of 2 million female sex workers and 235,000 male sex workers. In addition, India has an estimated 2.35 million men who have sex with men — although many would not identify themselves as such. According to Dr. Steinbrook, sex between men is often considered "mischief."
An important part of the emerging epidemic is the 5 million truckers in India. Similar to the experience in Africa, sex work along the main truck routes is common, bringing the epidemic home to housewives in rural areas. In Chennai (formerly Madras) in southern India, one fourth of HIV+ clients at one treatment center were housewives. Spousal violence against women astoundingly ranges from 16% to 44% , depending on the city. It is no wonder that the Joint United Nations HIV Program in India found "it is not possible to control the overall HIV epidemic if it is out of control in India."
Physicians in the United States should be aware that Asian Indians without readily identifiable risk factors may have HIV. Public health experts advocate stepping up HIV screening in all persons with tuberculosis. Just because someone from India is at increased risk for reactivation TB doesn't mean they don't have HIV. Similar logic should apply to any Asian Indian with salmonella bacteremia, pneumonia, or hospitalization for infection.