A history of two epidemics – AIDS and Covid-19 – analysis
The global turmoil created by the new coronavirus strain (Covid-19) reminds us that communicable diseases are always a threat to public health. I look at the coronavirus pandemic with a sense of déjà vu, with memories of the deadly spread of HIV / AIDS just two decades ago that came to mind. It consumed more lives and left many more infected than Covid-19 is likely to be before it was tamed and eliminated.
I see similarities in how countries responded to AIDS at that time and to Covid-19 now. Although, in the case of AIDS, it was Africa and third world countries that denied and suffered the worst part of the epidemic, this time, it is the developed world that has spoiled the response to the Covid-19 crisis, despite possessing the scientific and technological skills to challenge him. During the AIDS epidemic in the 1990s, African and Asian countries underestimated the spread of HIV, thanks to a lack of sophisticated epidemiological tools and responsive health systems. But there can be no excuses for the complacency of the developed world and the lack of preparation to face the coronavirus crisis; after all, they have the best epidemiological surveillance systems with information technology to track pandemics.
A common challenge that we faced then, and that we face even now, is to come up with a credible number of infections. In the case of Covid-19, most countries are adapting their responses to symptomatic cases or those quarantined on suspicion of infection. Infectious diseases always have a large number of unreported cases, with people unaware or afraid of being tested. But there are still no organized efforts to extract a credible number of estimated infections in countries that report large numbers of cases.
During the HIV crisis, the process of reaching an estimated number took place fairly early with the help of the United Nations system. India reported less than a lakh of HIV infections 20 years after the first case was reported in 1986. But sentinel surveillance nationwide in 1998 gave an estimate of three million infections. This was further refined with new data, but the number was still as high as 2.4 million, 20 times more than the reported cases. This forced the government to acknowledge the severity of the epidemic and invest resources in a widely expanded and decentralized national AIDS response in 1999. In the next 10 years, the level of infection was reduced by 56% and mortality was reduced through of an expanding treatment program covering almost 1.2 million people.
It should be epidemiologically possible to initiate nationwide sentinel surveillance for Covid-19 in India, to locate if there are latent epidemics in rural and remote areas outside of the hot zones identified by the states. The Integrated Disease Surveillance Program (IDSP) should be mandated to carry out such periodic surveillance with technical input from the Indian Council for Medical Research (ICMR).
Testing is another important component of epidemic control. In the AIDS program, the quick kits introduced in 2,000 had allowed the government to rapidly expand testing facilities across the country, allowing people to get tested and, if necessary, enroll in the treatment program.
Similarly, in the case of Covid19, India could easily overcome its initial reluctance to test large numbers. States could gradually expand test facilities; the numbers, if they are higher, can be partially explained by expanding the tests. The availability of rapid test kits for rapid diagnosis could have greatly helped the program, but China’s lower-quality kits slowed the effort. We need to rapidly increase indigenous production of standard quality quick kits to assess asymptomatic cases. The availability of voluntary test kits at a very low price will help people access health care services during the early stages of infection.
In the 1990s, the stigma and discrimination associated with HIV positives greatly hindered the response. Health care providers were reluctant to treat them due to fear of infection and the lack of universal infection control precautions in government hospitals that endured the brunt of the epidemic. The big difference this time around is that healthcare providers at the forefront of the response are hailed as heroes.
But stigma is emerging from society due to an inadequate understanding of the dynamics of the Covid-19 epidemic. The disturbing cases of locals resisting the latest rites of people dying of Covid-19-related infections point to the need to normalize the disease. Mass awareness campaigns in the late 1990s, with community participation, contributed to increased levels of HIV and AIDS awareness among the population. Similar efforts are needed now, with strong participation from Covid-19 communities and healed individuals.
Unlike HIV, which still infects approximately 1.5 million people each year, the immediate threat from Covid-19 cannot last for more than a year or two. But its impact on health systems and economies will be more profound than HIV, which was more of a silent tsunami that caused the inadvertent destruction of vulnerable communities. But even if Covid-19 is controlled, it may not necessarily go away. Until mass immunization of populations is possible with a preventive vaccine, we must be prepared for their periodic attacks, even in a less virulent form.
JVR Prasada Rao is a former secretary of health and director of the Government of India’s National AIDS Control Program.
The opinions expressed are personal.