San Francisco Chronicle - Sunday, November 17, 2002
Sabin Russell, Chronicle Medical Writer

Two decades after the AIDS epidemic began its relentless march through sub- Saharan Africa, the disease has gained a strong foothold in Asia, menacing tens of millions who live in the most populous nations on Earth.

Health experts say a catastrophe can be averted only with far-reaching action.

In India and China alone, at least 5 million people are believed to be infected with HIV, the virus that causes AIDS, and epidemiologists forecast that the numbers will climb rapidly.

By the end of this decade, HIV infections may reach 25 million in India and 15 million in China, according to the National Intelligence Council, an adviser to the CIA.

"The numbers going up in India and China are keeping us all awake at night, " said Dr. Chris Beyrer, an epidemiologist at Johns Hopkins University's Bloomberg School of Public Health.

The United States has 900,000 people infected with HIV, including 17,800 in San Francisco, according to public health officials. For the Bay Area, already inextricably linked to the AIDS epidemic from its early appearance in San Francisco, the prospect of an Asian AIDS epidemic is particularly sobering.

There are 1.4 million Bay Area residents of Asian heritage -- roughly 1 in 5 of the population of the nine-county region. As AIDS spreads throughout Asia, the disease could touch on the extended families of thousands of Californians.

China, with 1.3 billion people, experienced a 67 percent increase in reported HIV infections during the first half of 2001 alone. International AIDS organizations have been goading the Chinese government to face up to the peril.

In June, the United Nations issued a report warning China that "a potential HIV-AIDS disaster of unimaginable proportions now lies in wait to rattle the country."

Yet in both India and China, home to almost 40 percent of the world's population, government neglect and hostility toward the HIV-infected have been the rule. China recently jailed -- then released under international pressure -- activist Dr. Wan Yanhai, who has uncovered local government complicity in blood-selling schemes that have spread the virus.

In India, HIV-prevention workers have been harassed, and impoverished AIDS patients have been shunned, while the disease spreads unchecked into the general population.

"There is enormous stigma associated with AIDS in China, India, Malaysia and Indonesia," lamented Dr. Peter Piot, executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS), an arm of the World Health Organization.

In Southeast Asia, the highest rates of HIV infection may be in Burma, where a secretive and repressive regime, grinding poverty and flourishing criminal trade in drugs and sex make fertile ground for the virus. In rural areas, 5 percent of pregnant women are testing positive for HIV. In Rangoon and Mandalay, infection rates at drug-treatment clinics are as high as 85 percent.

THE ROLE OF THE NEEDLE

The paths to an outbreak of AIDS in Asia are varied, long and complex, but a common feature is the early role of the hypodermic needle -- whether shared by heroin users in a Ho Chi Minh City alleyway or by paid blood donors in rural Henan province in China.

In China, the practice of paying impoverished farmers for blood plasma -- and returning pooled blood products to their veins so they can donate again after little more than a week -- may have infected 1 million residents in Henan province.

The practice has created "AIDS villages" where as many as 80 percent of the residents test positive for HIV.

Johns Hopkins' Beyrer has mapped the spread of HIV along the heroin- trafficking routes that pour out from the "Golden Triangle" poppy fields of Thailand, Burma and Laos, and extend into eastern India, southern China and the far reaches of Southeast Asia.

HIV is spreading among prostitutes who frequent those heroin-trafficking regions, as well as trucking routes and commercial sex districts of large cities.

"In Southeast Asia, you've got a lot of sex and a lot of drugs. In Cambodia, it's more sex than drugs. In Vietnam, it's more drugs than sex. In Thailand, it's both," said UCSF epidemiologist Dr. Andrew Moss.

Bangkok became an early epicenter of the AIDS epidemic. The disease took hold among prostitutes, but doctors credit an aggressive program promoting condom use "100 percent of the time" for reducing the spread of the virus. Annual infections fell to 29,000 in 2001, compared with 143,000 a decade earlier.

There has been less success in keeping HIV under control among users of injection drugs.

SEX AND THE PRICE OF PROSPERITY

China's drive to transform itself into a modern, industrialized nation carries with it increased vulnerability to AIDS. Prosperity has created a vast "floating population" of 120 million rural migrants who work in cities, become infected and return to their communities -- a practice that accelerated the spread of HIV in Africa.

"The fastest-growing infections are among those who contracted the virus through heterosexual sex," said Bates Gill, a China expert with the Center for Strategic and International Studies in Washington.

The liudong renkou, or floating population, are young, "in the most sexually active period of their lives," and take on the least desirable jobs, Gill said. Among the youngest are women who engage in commercial sex at "restaurants, teahouses and karaoke bars," he said in recent congressional testimony.

As infection rates grow, the virus can piggyback on a variety of unsanitary practices to spread even faster. Gill noted that the illegal reuse of disposable syringes is "commonplace" in some hospitals, particularly in the interior of China.

It remains unclear what factor or combination of factors causes a smoldering epidemic to spread dramatically, as it has done repeatedly in African nations. In Botswana, for example, 39 percent of the adult population is believed to be infected.

Epidemiologists shudder at the thought of similar rates in densely packed Asian cities. Because the populations are so large in Asia, even low percentages of infection presage a ghastly human toll.

"Once you get over 2 to 3 percent, you get into a really dangerous zone," said Piot of UNAIDS. "Once you get to 5 percent, usually it accelerates quite dramatically."

In India, the 4 million HIV cases represent less than 1 percent of a population of 1 billion. But epidemiologists worry that the sheer size of India masks the seriousness of concentrated epidemics within that country. In Bombay and nearby Pune, rates are inching up to 4 percent, according to the National Intelligence Council.

CRITICAL NEED TO SPREAD WORD

Despite the ominous forecasts, AIDS experts believe that an Asian AIDS catastrophe can be averted if the leaders of these threatened nations seize the initiative.

"The level of awareness in Asia is shockingly low, but compared to a year ago, it has gone up," Piot said.

Unlike many African nations that are mired in poverty, corruption and indebtedness, many of the threatened nations of Asia have the wherewithal to mount effective HIV prevention and treatment programs. What is lacking, with few exceptions thus far, is the political will to mobilize against the virus.

Better late than never, the Chinese government has at least begun to acknowledge the extent of its problem, admitting that more than 1 million of its citizens are HIV-positive.

"But if business as usual continues," Piot warned, "we are going to see a catastrophe that is unprecedented in human history."

E-mail Sabin Russell at srussell@sfchronicle.com.

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