In a vicious circle

Despite the efforts of several NGOs, Manipur continues to be in the grip of an AIDS epidemic, whose spread is aided by widespread poverty and a thriving business in the smuggling of heroin.

STATISTICS released by UNAIDS, the Joint United Nations Programme on the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome, on the eve of the 14th International Conference on HIV/AIDS in Barcelona estimate that by mid-2002 only "a fraction of those in need were receiving antiretroviral treatment (also known as triple therapy)". Of the 730,000 people who are on this therapy worldwide, 500,000 live in the developed world.

In Imphal, the capital of Manipur, when a question is posed to S. Raghumani, secretary of Lifeline Foundation, a non-governmental organisation that works in the area of HIV/AIDS, about the number of HIV infected in the State who are on this therapy, he says, "It is very expensive. You need Rs.1,800 a month for a combination of three antiretroviral drugs and only the rich can afford that kind of money. This is the cheapest combination. The cost can go up to Rs.15,000 a month. I know three people who are on these drugs."

About 70 km from Imphal, at the little town of Churachandpur, at another NGO, Sahara, when asked about the treatment available for full-blown AIDS cases, its administrator Ryan Fernandes says wryly, "You are asking us about full-blown AIDS. Forget it. There is so much poverty here that not too many HIV-positive people live long enough to reach that stage. That stage is reached in big cities where money and medical facilities are available. Over here, people die of a common cold. We have seen the HIV-infected dying within two years. For them, full-blown AIDS is just a story."

Manipur is a tiny northeastern State with a population of 2.38 million and as a perceptive housewife points out, "it is a small State with big problems." Insurgency is one of them; and HIV/AIDS, which is acquired mainly through injecting drug use (IDU), is another. But the biggest problem, and the root cause of drug abuse, which is widely prevalent among the population, is poverty and the near-total absence of industrial development.

Dr. Khomdon Singh Lisam, project director of the Manipur AIDS Control Society (MACS), points out that though Manipur's population constitutes only 0.23 per cent of India's it has over 8 per cent of HIV-infected persons in the country. But there is a distinct difference in the pattern of infection. While in 86 per cent of the cases of HIV infection in other regions of India the transmission route is sexual, in Manipur, about 72 per cent of the cases originate from the sharing of needles and syringes by injecting drug users (IDUs). "This is the distinctive feature of the HIV/AIDS story here, which compels us to have a different strategy and intervention policy," Lisam says.

The first cluster of cases in Manipur - involving six heroin-injecting men - were detected in February 1990 among IDUs. "This information galvanised the entire society; what was believed to be a disease of the Americans and the white people had come to their doorstep. People were taken by surprise and they thought they had to do something," Lisam said.

The police sprang into action by arresting drug addicts. In the early 1990s, at any point of time, there would be more than 500 drug addicts locked up in Manipur's jails, and compulsory testing of drug addicts began without any counselling. Women activists would go to homes at midnight and demand that the son or daughter who was on drugs should be turned over to the police. Next, chemists and pharmacists announced that since HIV spread through the injecting of drugs and the sharing of needles, they would not sell these to young people.

"On the roads, the police would check people for needle marks on the body, and those found with pock-marks in the arms or legs would be promptly arrested. Next came the insurgents, who handed over a bullet to each family, threatening to come back in a week and shoot youngsters who continued to use drugs. All these people were afraid that HIV/AIDS would spread through IDUs. The only people who were not active were the medical people, who did not know what to do," says Lisam.

All this hectic activity sent the IDUs underground, and the drug addicts refused to come for counselling or de-addiction programmes. Worse, the non-availability of needles and syringes made them concoct a crude device to inject drugs - a rubber dropper fitted with a needle, which was shared by groups. "And the HIV seropositve rate among heroin-injecting people shot up from 1 to 2 per cent to 50 per cent in just six months. It was a world record," according to Lisam.

The reason for the high addiction rate, according to Lisam, was the spill-over of heroin and other drugs entering India from Myanmar through the Manipur town of Moreh on the India-Myanmar border. The State shares a good part of its border with Myanmar, and the purest form of heroin - known locally as No. 4 - comes into India from Vietnam and Laos through Manipur, he says.

The administrators and policy-makers thought that drug addiction could be checked best through total abstinence from drugs. But the problem with this policy was the high relapse rate; 80 to 90 per cent of the "de-addicted" persons returned to the same environment with the same set of friends and followed the same risky behaviour pattern using shared needles.

The fallout of all this was an even faster spread of the virus through IDUs. The HIV sero-prevalence rate among IDUs increased from 50 per cent in 1994 to 80.7 per cent in 1997. From September 1986 to May 2002, 85,298 blood samples were tested and 13,448 people, including 1,831 women, were found to be HIV-positive. HIV/AIDS-related deaths have been tabulated at 217. But the NGO representatives, as well as the project director himself, say that the actual numbers could be far higher. And HIV/AIDS is no longer a problem of IDUs; it has spread from HIV-positive drug-injecting people to their sexual partners as also children.

So you have the virus slowly, but surely, eating away at the young in the community. Deepak Singh, secretary of the Manipur Network of Positive People (MNP+) and himself a former IDU, who along with a few of his friends "came out" a few years ago, with their HIV-positive status, says, "We have lost so many friends from HIV/AIDS. In our society there are so many people dying of unknown causes which might well be HIV/AIDS." Banta Singh, his colleague in the MNP+, adds: "These days we find so many elderly men bringing out of their homes the bodies of their young sons. Earlier, the young used to cremate or bury their older relatives, but these days in Manipur, it is the other way round."

MNP+ was born in September 1997, when "two of my friends came up to me, started crying and said they were HIV-positive. So I said I am positive too," says Deepak. According to him, all of them felt that there must be others like them who required care and support - mental, psychological and physical - and that this group could help them. Deepak himself started taking drugs in the mid-1980s, stopped that in 1993 after going through a de-addiction course, and worked with the Lifeline Foundation until he founded MNP+ with his friends. Today MNP+ has over 100 members and runs seven centres to provide care and support to persons who are HIV-positive.

As for Banta, his addiction to drugs began "while studying in a boarding school in Imphal. Having booze after exams was common. Next came marijuana and then the pills in the early 1980s. I was 16 when I came out of school in 1983, and then heroin came in." He and four of his friends would share a needle during the 1980s, when disposable needles and syringes were not widely marketed in India. To make the injections affordable, they chose a rubber dropper into which a needle would be stuck. In 1992, Banta discovered that he was HIV-positive. By then he had graduated in architecture and found a job with the government, which he still holds.

Surprisingly enough, the discovery of their HIV-positive status did not shatter them, says Deepak. "We knew we were indulging in risky behaviour and surely something dangerous would happen to us but we would say that at least we would be together in that too."

Today Deepak is married to a nurse, "who is a very understanding person and married me knowing that I was a former drug addict and could be HIV-positive. We have a lovely five-year-old daughter. Banta has two daughters too. But Bobby (another colleague at MNP+) is lucky because he is not married. Sometimes I look at my lovely daughter and wonder about her future if anything were to happen to me," adds Deepak, his voice barely a whisper. But the next instant he finds his voice and his smile. "One day I'll die, but I'm sure I'll die of something else and not AIDS".

It is this kind of spirit, courage and resolve that help the NGOs in Manipur that work for the prevention and control of HIV/AIDS and the provision of care and support for the already infected to keep going. Funded by UNAIDS and ActionAid, MNP+ leaves the distribution of needles and syringes to other NGOs - there are about 20 of them. In Churachandpur it was an NGO called Shalom which pioneered the needle exchange programme.

But MNP+ feels that there is a dearth of good rehabilitation centres for the drug addicts and HIV/AIDS-afflicted. "You can count the good rehabilitation centres in Manipur on your fingers and they are there only in urban pockets," says Banta Singh. MNP+ concentrates on helping HIV-infected persons with medicines and hospitalisation when they fall sick. This has become easier over the last five years as "we have developed a good rapport with the doctors," he adds.

But the root cause of the high rate of HIV infection in Manipur remains IDU and as long as the smuggling in of heroin continues the problem will remain. There are allegations from almost anybody you talk to about the involvement of politicians, top police officers and security personnel, and other bureaucrats in the smuggling business.

UNAIDS estimates that the global drug trade is a multi-billon-dollar industry, with 10 million IDUs worldwide. "By the end of 1999, injecting drug use was being reported in 136 countries," and HIV cases among IDUs were found in 114 of them, says its "Report on the Global HIV/AIDS Epidemic".

"Some people say that 'Moreh' stands for 'Millions Of Rupees Enter Here'," says Lisam. With Manipur situated along a thriving heroin route, there is enough spillover of the drug for a large number of educated and unemployed youngsters in the State to be hooked. There are hardly any employment avenues open to them other than government jobs. The thriving insurgency 'industry' of Manipur - one estimate puts the number of groups at 15, and each one has its own "tax structure" - has kept corporate India away from the State. There is no local industry worth the name and the lack of economic progress and industrial development has left the majority of Manipur's people in the grip of poverty and frustration.

Lisam estimates that there are about 40,000 drug addicts in Manipur, of whom 20,000 are IDUs. However, the UNAIDS report puts the number of IDUs in Manipur around 40,000. Drug addicts cannot be de-addicted in a short time, and NGOs like Sahara face a funding problem because they cannot satisfy the "rigid norm" of funding agencies."

Sahara's project director Charles Cardoz says that the approach towards tackling drug addiction and HIV/AIDS in Manipur needs to be revamped. For one, there needs to be better coordination among government agencies such as the Narcotics Bureau, the Police Department and the Health Department. "Also, we find that the accent is still on IDUs for HIV/AIDS prevention and control, while the truth is that HIV/AIDS has gone beyond the IDU community into the general population. And there are many, many more HIV-positive people than the official figures suggest. In Churachan-dpur town, which has a population of 5,000, official figures put the number of HIV-positive people at 300, but we know from our experience that there are about 1,500 HIV-positive people here," Cardoz says.

The NGO has been running vocational training services for carpentry and handicrafts. But at the moment these are closed for lack of funds. Total rehabilitation takes time, but then, he says, funding agencies look at success stories and insist on a time-frame of six months.

At the moment, as their counsellor Larry Pereira puts it, Sahara exists without any formal funding: "We exist on the crumbs that are falling out of people's tables and live in the hope that one day we will get a full loaf of bread."