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HIV, short for Human Immunodeficiency Virus, is a retrovirus that attacks and destroys a vital component of the human immune system: its host cells are the CD4 T-lymphocytes, a type of white blood cells. Once the immune system is effectively destroyed, all sorts of infections normally kept at bay (called opportunistic infections) take hold and kill the individual. This final stage, when the immune system is highly compromised, is called AIDS (Acquired Immune Deficiency Syndrome). HIV's only known host is the human, and it survives in the bodily fluids -- blood, semen, vaginal secretions, breast milk. It is, therefore, transmitted by sex with an infected person, from mother to child at birth or via breast milk, or by contact with infected blood. The latter can occur by transfusion of contaminated blood, use of contaminated needles or surgical instruments, or when sharing needles as by IV drug users. Thus, an inadequate/corrupt/uncaring medical-dental establishment poses a significant risk of infection to all the population irrespective of whether an individual has risky sexual behavior and/or IV drug usage or not. HIV is very fragile outside the human body and is easily destroyed by contact with air, water, soap, etc.. Nevertheless there is a tiny risk of infection through use of (i) infected razor blades when visiting barbers, (ii) infected needles when getting tattoo's, (iii) puncturing of skin with infected needles during ear, nose piercing.

So far as we know, almost all people infected with HIV have progressed to AIDS if they are not being treated with anti-retroviral drugs. Certain groups of people, called long term non-progressors, offered a hope for cure and vaccine as their immune system was somehow resisting the advance to AIDS. Unfortunately, after 15-17 years, they too have started to suffer from diseases indicative of AIDS. So at present there is no evidence of remission or escape. We do not have a cure either -- the very costly treatments using anti-retroviral (ARV) drugs only keep the disease under control and it is not yet clear if, in time, even these will fail to protect. Worse still, these drugs are completely beyond the reach of over 99 percent of the Indian population. Even if the drugs were cheaply available, their prescription requires very careful monitoring of effectiveness and toxicity by a specialist, and a very strict schedule of ingestion. These requirements do not exist in India. Lastly, the consensus amongst researchers trying to find a vaccine is that there is very little hope for a low cost, high efficacy vaccine in the next 5-10 years and perhaps for much longer. So prevention is, at present, our only hope. Having said that current ARV therapy is not a solution to the long term goal of stopping the spread of HIV/AIDS in developing countries, it is also equally essential to understand that we absolutely need these drugs to be available cheaply. There are a number of reasons for this. As more and more HIV+ patients come into hospitals with serious opportunistic infections that are not immediately life threatening, the doctors need the ARV therapy to control HIV so as to speed up the recovery from the other infections. Otherwise the hospital stay of the patient can become indefinite, leading to frustration amongst the doctors and misery for the family. Second, in cases where the HIV infection is diagnosed very early, ARV therapy can keep the patient healthy and functional for a much longer period of time so that they can remain productive and take care of their family. Lastly, the human race survives best when there is hope, and ARV provides the best we have to offer at the moment for anyone who does get infected. Removing hope can lead to severe emotional trauma and I fear will result in a very high social cost.

Fortunately, the way to stop the spread is completely in our hands if we have the will. If people abstain from risky sex (unprotected sex with casual partners whose HIV status is not known) and the medical-dental community implements very strict control over blood transfusions and sterilization of instruments, the spread of HIV/AIDS can be stopped overnight. In reality both these are proving very hard to carry out. For example, cheap anonymous sex is one of the very few pleasures available to the poor, and over time they have gotten used to the prevalence of sexually transmitted diseases like syphilis and gonorrhea and know that these can be treated easily. So the morbidity of a new disease, HIV/AIDS, that is incurable and kills after a long infectious, but largely asymptomatic, period of years has not sunk in. Furthermore, risky sex abounds in all socio-political segments of society. The elaborate call-girl rackets and schemes for willing/unwilling induction and seduction are so many that one could fill many evenings narrating them. The tragedy is that while these are considered fun topics for conversation at social gatherings and the elite are in general very familiar with these practices, the disastrous consequences of such risky behavior has not sunk into even this elite. Changing people's life styles regarding sex is hard in India since sex is a taboo subject and people don't like to discuss it. Many of the politicians, policy makers, administrators, senior doctors, industrialists are over 50 years old. They are not willing to accept that sexual freedom and experimentation is common amongst today's youth. (Indian youth are, today, going through their version of the sexual revolution that the US went through in the 60's. Needless to say, the timing could not have been worse. ) This elite believes that by denying it, they will somehow curb the explosion. They would like to believe in the existence of a high moral force that is generated spontaneously and is independent of the reality -- deep rooted and pervasive corrupt practices, get what you can as soon as you can attitude, complete lack of care for anyone outside a small group of relatives and friends, and the lack of role-models amongst their generation. Since the generation in control is in denial, it is no surprise that effective dissemination of information and awareness is proceeding very slowly. Next, the lack of proper handling of blood and sterilization of instruments reflects the wide spread conditions of poverty and corruption endemic in India. One cannot expect the medical community alone to be honest and free of corruption when the rest of the society is not. Therefore, to curb the spread of HIV/AIDS and many other diseases like tuberculosis and hepatitis, we will have to also address issues of poverty, marginalization of large segments of society, and corruption. Even issues like social conditions for women, for example eliminating sexual and physical abuse and providing them with the ability to negotiate better conditions at home and at work, play a crucial role. The more one reflects on the issue, the more it becomes clear that in the absence of a cheap and highly effective vaccine the solution requires re-inventing society. Given this Herculean task one should rightly ask why suddenly focus on this latest killer HIV/AIDS when the need to improve the economic, political, and social conditions in India has been apparent for decades and people are proceeding at some convenient pace. The reason is that the very rapid spread of HIV/AIDS we are seeing in India has dramatically reduced the time allowed unless we are prepared to lose a very significant fraction of the most productive segment of society. In addition, there will be millions of victims of contaminated blood and surgical instruments who will get infected in spite of the best of their precautions. Socio-economic status is not sufficient to eliminate all the risks for HIV infection. To bring about the required change in a very short period of time needs a massive grass-roots movement as we have to educate one billion people and make them aware of the disease and its tremendous consequences for the individual and the family. This requires the status of a top national priority which can only be achieved by if there is political stability and there is the direct and personal involvement of the prime-minister.