(This is a sidebar to The coming epidemic, an article about the AIDS epidemic in India, and part of a special package on Indian science called Nature Outlook: India.)

When you’re trying to manage an AIDS epidemic and you have limited resources, preventing infection is the logical priority. But where does that leave those who are already infected?

Treating people with AIDS is not easy. At the very least, it requires trained medical staff and the resources to make sure patients take the drugs on time. Nobody knows that better than the doctors at Tambaram Hospital.

Built in 1928 as a sanatorium for patients with tuberculosis, the government centre is 45 km outside Chennai and has more AIDS patients than any other Indian hospital. There are often more than 900 inpatients for its 776 beds, so some have to sleep on the floor. Every hallway is flooded with patients who look skeletal, with shrunken limbs and sallow skin. Outside the wards, hairy black pigs roam beneath drying laundry, accompanied by the rancid smell of sewage.

The hospital was one of eight government centres that together were meant to roll out antiretroviral drugs (ARVs) to 100,000 people over five years. In the first year, which began April 2004, it treated fewer than 1,000.

“From the outside, you may think it is a low number, but for people working here, there are a lot of problems,” says S. Rajasekar, the hospital’s deputy superintendent. Despite repeated requests, he says, the centre has the same resources it did in 1993, when it had just two HIV-positive patients. In 2004, it saw 14,991 new patients and had 140,000 hospital visits from HIV-positive patients. “With just 25 doctors,” says Rajasekar. “Amazing, right?”

By June 2005, government centres, including Tambaram Hospital, had doled out ARVs to 8,000 people. In the same time, since April 2004, small private and non-profit clinics reached an estimated 30,000 sufferers. But these clinics are in a constant struggle for survival.

One such centre is the Naz Foundation’s orphanage in New Delhi. Of the 24 children there — ranging in age from 19 months to 17 years — 10 are on ARVs. Despite one child dying two years ago, only the oldest one knows that she is HIV positive. To spare the children from stigma, their status has also been kept secret from their teachers and neighbours.

One child’s monthly supply of ARVs can cost about Rs900 (US$20). The home was funded by the Gere Foundation until March 2005, but since then money has come almost entirely from small, private donations. “Care is something no traditional donor wants to fund,” says the centre’s director, Anjali Gopalan. “They see it as a black hole, as one donor told me. There’s no return on the dollar.”

Scrambling to treat their patients, doctors at some clinics use medicines that are past their expiry date; others bring free drugs they are given in the United States or elsewhere. Staff at the YRG Care Clinic in Chennai last year began asking people to donate just $10 each. “It’s always beg, borrow, steal, donations, fundraise. That’s how we get funds for care,” says Suniti Solomon, who runs the
YRG. “We cannot save the millions out there. The government has to do that.”