A Tale of Two Indias; On the cusp: The country stands on the brink of an Africa-style disaster. But things may be turning around in the south.(AIDS spreads)(Cover story)

Byline: Jaya Shreedar, Daniel Pepper and Geoffrey Cowley

Thirty-five-year-old Rama Devi is not exactly an icon of good fortune. She and her five children live in a dusty, thatched-hut village called Kashiou, in the northern Indian state of Uttar Pradesh. She once had a husband, a man who spent most of the year selling fruit on the streets of Mumbai, but he contracted HIV during his travels and came home a few years ago to die. Devi is now HIV-positive herself. She works as a casual laborer in the wheat fields around her village, receiving her daily pay in grain. But Devi's luck could be worse. She happens to live within 20 kilometers of Allahabad, where the Uttar Pradesh Network of Positive People runs a drop-in center--and she has a brother who can spare a few precious rupees to get her there each month for a free checkup, followed by a five-hour bus ride to the nearest government treatment center. Nearly 800,000 of India's 5.1 million HIV-positive people are now sick enough to need the kind of medication that keeps Devi alive to feed her kids. She is among the 10 percent who are getting it.

Experts call India a "next wave" country--ripe for the kind of devastation that South Africa has experienced during the past decade, but also capable of the bold action that has helped countries like Thailand and Brazil contain their epidemics. As you travel through this vast land, those possible futures really do appear as a fork in the road. To the south, in hard-hit states like Tamil Nadu, vigorous public-health efforts now appear to be slowing the spread of the virus. But to the north, poorer states such as Bihar and Uttar Pradesh look more and more like disasters in the making. Though their HIV rates are still far lower than those in the south, their large migrant workforces provide a ready conduit for infection--and their crumbling health systems are woefully ill prepared for the onslaught. The lesson of the south is that intervention works. The question is whether the rest of India--indeed, the rest of Asia--will learn it in time.

Until recently, India's AIDS outlook has seemed uniformly grim. But that changed this spring, when Indian and Canadian researchers published findings from a four-year study involving 294,000 pregnant women from 18 states. The results showed that HIV prevalence had fallen by some 35 percent among young women throughout the "high-prevalence" states of the south and west (Tamil Nadu, Andhra Pradesh, Karnataka and Maharashtra). Sometimes, a drop in new infections means only that the most vulnerable people have died. But behavioral surveys suggest the decline in this region has more to do with public safety measures, including the increased use of condoms among sex workers and their clients. "AIDS was a great opportunity for Tamil Nadu to better its entire public health system," says Vijaya Kumar, former director of the state's official AIDS control society. "We cleaned up our blood banks and trained our health workers down to the village level to educate the community."

That kind of success is harder to find in Uttar Pradesh. With a population of 170 million, it is home to 25 percent of India's migrant workers. In villages like Tardeo, near Allahabad, almost a quarter of the men are working in the big cities, and many bring HIV home with them. The local women have seen enough AIDS to have their own name for it. They call it the ...