In late November, Sitadevi went for a routine check-up at a medical camp organised by the government health workers in her hamlet of Premganj in Uttar Pradesh’s Unnao district – only to learn she had HIV. The 60-year-old was not alone. Twelve other people from the village, mostly the elderly and young children, tested positive for HIV that day. A week later, routine blood tests for fever at a government hospital added four more residents to the list of the infected. A number of people were diagnosed with HIV in the neighbouring village of Chakmirapur as well.

What could have led to this outbreak? Most likely, the villagers and health workers suspect, a local medical practitioner spread the infection by using infected needles. In Premganj, the health workers found out that at least eight of the infected people had seen the doctor about minor ailments and received at least one injection each.

The Unnao health department has since started an investigation into whether the doctor’s injections spread the infection. He is said to be absconding.

The Human Immunodeficiency Virus weakens the body’s immune system, making it susceptible to various infections. Over time, an HIV infection can develop into AIDS – a progressive failure of the immune system that leaves the body open to life-threatening infections and cancers. The virus is transmitted through blood transfusion, use of infected needles and syringes, unprotected sex, or from mother to child.

There is hardly anyone in Premganj and Chakmirapur who has not visited the local doctor to treat common ailments such as fever and diarrhoea in the past 15 years. Mainly that is because his clinic in Bangarmau town was about a kilometre nearer than the nearest public healthcare facility. In addition, he offered an inexpensive remedy for most illnesses – an injection that cost Rs 10.

That the villagers did not know whether the doctor was qualified to practise medicine is not surprising. Unqualified medical practitioners – quacks, basically – who treat minor ailments with injections of antibiotics, painkillers or steroids are common across India, especially where public healthcare is poor.

The doctor ran his clinic out of this school in Bangarmau. Photo credit: Kanchan Srivastava

“The majority of Indians are dependent on unqualified doctors because of access and affordability issues,” said Dr Amit Sengupta, national convener of the Jan Swasthya Abhiyan, a network of health NGOs. “These practitioners pose a huge threat to public health. Unfortunately, we do not have data pertaining to such cases, barring the few anecdotes reported in the media. Lack of regulation allows them to flourish.”

Sitadevi said she first consulted the doctor about a backache some three years ago and went back to him 10 or so times. “He treated us for just Rs 10, including medicines and injection, which was affordable for all of us,” she said. “I saw him using the same needle and syringe on every patient who came to him but we did not know the consequences then. We did not know if he was qualified, but his injections were really effective as my backache would disappear for 10-15 days.”

Six to eight months into her treatment, Sitadevi started developing chronic fever, fatigue, weight loss, skin rashes, nausea, mouth sores, and swelling of joints – symptoms typical of HIV infection. But she continued to visit the doctor.

Likely source

In July, four months before the 13 HIV cases were detected in Premganj, the chief medical superintendent of the Uma Shankar Dikshit District Hospital in Unnao wrote to Rajendra Prasad, who was then the the district’s chief medical officer, asking for an investigation into the doctor’s practice. The letter cited a complaint by two residents of Premganj that he used the same needle on all his patients.

It was not until after the discovery in Premganj, though, that an investigation got rolling. “We constituted a committee to look into the high number of HIV cases in the area,” said Prasad. “The report has indicated the involvement of the quack in spreading the disease in many patients.”

Health officials in Unnao believe that since many of the infected people are either elderly or children, it is unlikely they contracted HIV through sexual contact. Although some villagers are migrant workers who go to cities looking for jobs and could have contracted HIV outside Unnao, the officials said that the sudden spurt of infection suggests it was spread locally through contaminated needles. Moreover, few people in the two villages have been treated at health facilities outside Bangarmau block.

“These cases suggest the infection has been transmitted through needle only,” said Dr Jairam Singh, deputy chief medical officer of Unnao. “The patients have blamed [the doctor] who they consulted for minor illnesses such as fever in the past three-four years.”

A letter from the district hospital medical superintendent to the chief medical officer referring to complaints about the doctor in Bangarmau.

Meanwhile, health workers serving the two villages are on alert. A social activist claimed every fifth home in Premganj and Chakmirapur has at least one HIV patient and some have two or more. The Accredited Social Health Activist for Chakmirapur, Usha Devi, claimed that six young men with HIV had died in the village in the last last two years.

According to data from the nodal government hospital, Bangarmau block accounts for a third of all recorded HIV cases in Unnao district, with the rest scattered across the other 15 blocks. In 2016, nine new HIV cases were detected in Bangarmau. In 2017, according to the Uttar Pradesh State AIDS Control Society, 99 HIV infections were recorded in Unnao and 27 of them were in Bangarmau. “The actual number of HIV patients in this area could be much higher as three-fourths of the population has not been tested,” a state health official pointed out.

Of all HIV infections in Unnao, a report prepared by the National Aids Control Organisation, based on government data from 2011, found, around 43% were transmitted through contaminated needles.

The organisation has now called for a thorough investigation. “The HIV cases in Unnao, like the boy whose mother is negative and the old patients whose spouses are negative with no history of blood transfusion, appear unusual and an infected needle looks like the most possible cause in these patients,” said the gynaecologist Dr Rekha Daver, a member of the organisation’s mother-to-child transmission committee. “However, this issue needs to be thoroughly investigated from medical and social angles by experienced epidemiologists.”

In 2017, the Uttar Pradesh State AIDS Control Society has held more than 160 camps, like the one in Premganj in November. according to Ajay Shukla, assistant director of the society’s Integrated Counseling and Testing Centre. The camps are organised at the block level along with the local non-government organisations.

“This includes districts like Basti, Maharajganj, Siddarth Nagar, Jaunpur and Unnao which have high migrant population and HIV prevalence,” said Shukla. “HIV counseling and testing of high risk population is the major objective of the camp but it is not publicised because of the stigma attached to the disease. Based on their risk level, family HIV history and symptoms, the attendees are advised to go for HIV test.”

Poor healthcare

Malti Devi choked up talking about her 11-year-old son. He has contracted HIV like his father who died last year. “We had no other choice but to go to the doctor as he offered affordable and effective treatment,” she said. “Little did I know that the lives of my husband and son were put at risk in exchange for Rs 10. I do not know how my child will survive this disease.”

Many other villagers also said they were compelled to go to the same doctor because of the lack of accessible and affordable government health services. “Government hospitals are usually less responsive and do not provide medicines,” said Ram Khilawan. “Moreover, their doctors prescribe costly drugs that we can’t afford. His low fee suited us as we struggle to make ends meet.”

Some people such as Shivsharan, 70, have been treated by the local doctor as well as at the Unnao district hospital and other health facilities. “And I do not know from where I got this disease,” Shivsharan said, with tears in eyes.

Sengupta of the Jan Swasthya Abhiyan said that almost everyone living in rural areas end up consulting unqualified medical practitioners. “In government hospitals, mostly three to five kilometres away, doctors are either missing or available only during day time for a few hours,” he said. “Poor daily wagers need to skip work should they wish to consult a government doctor which they can’t afford. Public transport services are usually unavailable. Hence, they go to quacks who stay closer home, are available early morning or late evening and agree to visit them at home.”

In Premganj, meanwhile, the infected villagers are adjusting to their new reality and the regimen of antiretroviral therapy that government health workers have put them on. “The drugs are very strong and have side effects, I have nausea all the time,” said a woman who was visibly frail and pale. “The worst part is we are supposed to travel all the way to Kanpur which is around 70 kilometres away to get the medicine, which is cumbersome especially in this condition.”

Some names have been changed to protect identities.