Overestimating the HIV burden in India

March 5, 2007 at 10:04 pm (Sarah's Posts)

Overestimating the HIV burden

I’m once again stealing someone else’s story to tell here because I think it is a fascinating one with a good reminder in it for all of us. Here’s the short version with the corresponding paper attached. For those of you who are geeks like me, take a look at how sexy their methods are. For the non-nerdy, the study itself has some interesting applications.

The folks who wrote this paper are convinced that the burden of HIV in India is highly overestimated. We’re talking a difference of 3-3.5 million people instead of the current estimates of 5.2 million. They are basing this on an intensive study taken on in Guntur District of India. The estimated surveillance in the area was about 4.38%, using data collected by the generally accepted sentinel surveillance method from public antenatal and STI clinics. Doing a very intense population-based survey, the folks writing this paper found that the rate was 1.79%. So, why the difference?

It turns out that the public hospitals where the current country-wide data is collected from contains a higher representation of people from lower standards of living who represent a greater part of the HIV burden. In addition, the second that a private doctor suspects HIV, he refers the patient to the public hospitals so that he doesn’t have to deal with it. So, the public hospitals are (in their view) representing a much larger portion of HIV cases than private hospitals, which wasn’t taken into account in the earlier data.

When I asked Dr. Dandona about the policy implications of this study, his one big comment was that HIV funding represents a disproportionably large part of healthcare funding in India and in the world already, even without these overestimates. I’m loathe to just step up and say that HIV funding needs to be cut because it is clearly a huge problem in India that is mostly being ignored and swept under the carpet. But, it is important to really look at the study methods that are being used when we’re looking at data like this that is used to prioritize health budgets.

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4 Comments

  1. Alex said,

    I’d like to make two points, from a global policy perspective:

    1) I don’t think anyone should be making the argument that HIV funding is disproportionately high (without getting into the complexities of what “HIV funding” actually means – service delivery? Basic research? Epi? Crossover TB treatment?), but rather that funding for other diseases is disproportionately low. I’ll just leave that one at that.

    2) I’ve been thinking a lot lately about why HIV gets the amound of attention that it does, outside of the fact that it is a scary and incurable disease. The fact is, HIV/AIDS advocates are really damn effective, and have been from the get-go in the 80s. They’re loud, they’re creative, they’re organized, and they’re smart, both scientifically and politically. So rather than lamenting that HIV rates are overestimated and HIV is over-funded (which I am extremely loathe to do, from a moral standpoint), perhaps we should be thinking about how to boost the profile of other, relatively unknown and under-funded diseases.

  2. misarita said,

    I agree with you–the HIV advocates have done an ace job in a lot of cases. And while I agree that it is a simplification that isn’t very comfortable to say that HIV funding might be too high, it is an idea that is worth considering. I’m feeling the same thing about polio right now… it is the highest funded health program in India right now, with 670 cases last year. But, because the WHO is pushing for eradication, money is being dumped into the polio program haphazardly.

    On a large scale, I’d love to see us all think more creatively about garnering funding for less publicized diseases. But, I do think that it is a real choice that gov’ts are forced to contend with when then make their healthcare budgets. What do you do when it comes down to ARVs or strengthening routine immunization?

  3. msoule said,

    I think another reason HIV gets so much attention is because it is the new Holy Grail for researchers. It’s the Moby Dick of the ID world. The virus made such an impression on me the first time I heard its mechanism because it seems to know exactly how we’re built and it does exactly the thing that kills us the best. Whoever solves this virus gets all the marbles.

    Now that’s a reason for why it gets a lot of research attention, but I think that that enthusiasm spills over to the rest of the healthcare community (because at heart, many if not most of us are scientists and we long to take down the biggest game). Also, when we talk about AIDS, it gives us as health workers a great “in” to talk about a lot of taboo stuff. Like the health of IV drug users and the health of sex workers. It makes the margins part of the discussion and that’s really important.

    Sarah, when you put it frankly, as you did in your last paragraph, ARVs come second and routine immunizations come first. Period.

    And Alex, I’d contend the assertion that AIDS advocates have been vocal and outspoken and visible as a group. In the US? Yes. In Europe? Yes. In India? Not as much. At least in South Asia, there have yet to be the major public discussions about AIDS that we had in the states in the 80s when Keith Haring came out publicly and in the 90s when Magic Johnson revealed his positive status. Just because there may be an overestimation of the disease’s prevalence in India doesn’t mean that AIDS activists have gotten through to where they need to.

    The paper’s assertion is one that I’m not yet ready to swallow. Last time I checked, there wasn’t really data for the North of the country and that means to me that there’s still an underestimate. Unless I missed it, Sarah’s post’s paper didn’t address this but rather continues to focus on the South where much of the original epidemiology was done. There may be an overestimate down there but there’s no estimate for the North so overall, I’d say that the UN is still right. Unless I missed something big in my reading. Who funded that study? The Government?

  4. Alex said,

    Quick response to you Michael, to clarify. Yes, it’s true that in many places in the world, there isn’t the huge, effective activist commnunity that’s brought attention to the problem of HIV in the West, but remember that today’s American and European AIDS activists and advocates work just as much through international political channels as through domestic ones. They’re a huge international presence, and have affected HIV policy and funding throughout the world, not just in their home countries. Sarah’s WHO polio situation is an excellent example of the way international institutions (and therefore internationally active advocates) have a say over domestic policy.

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