HIV/AIDS in India
Up to forty-two million people worldwide, including two to three million children under age fifteen, were living with HIV/AIDS at the end of 2003.7 In India, government statistics put the number of people living with HIV/AIDS at up to 4.58 million in 2002, of whom some 200,000 were said to be children under age fifteen.8 Many experts consider this figure to be a significant underestimate. The United States (U.S.) National Intelligence Council estimated that there were between five and eight million people in India living with HIV/AIDS in 2002, and projected that the number would increase to twenty to twenty-five million by 2010.9
Although by official counts South Africa has the largest number of people living with HIV/AIDS of any country in the world, many observers believe that India has many millions more than those accounted for in its official estimate.10 Given Indias massive populationover one billion in 2001the percentage of the population living with the disease is officially less than 1 percent.11 However, some individual localities and subpopulations are suffering much higher rates.12 All of India's states have reported AIDS cases, and surveys show that the virus is spreading from higher-prevalence urban areas into rural communities.13 The government considers six states to be high-prevalence, that is, with more than 1 percent of the general population believed to be living with HIV/AIDS: Andhra Pradesh, Karnataka, and Tamil Nadu in the south, Maharashtra in the west, and Manipur and Nagaland in the northeast of the country.14 However, the singling out of these states should not be allowed to obscure the spreading epidemic in other states, including states where little is known about the disease, such as Uttar Pradesh and other northern states that have very weak public health systems and limited HIV surveillance.15
According to Indias National AIDS Control Organization (NACO), the most common route of HIV transmission in India is by sexual transmission and, in the northeast, transmission through injection drug use.16 Other modes of transmission include blood transfusions and from mother to child during the course of pregnancy, birth, or breastfeeding. Among young children especially, perinatal transmission is the most common source; however, children in India are also acquiring the disease through sexual contact, including sexual abuse; blood transfusions; and unsterilized syringes, including injection drug use. Girls, when subjected to sexual abuse or early marriage or when denied an education, are especially vulnerable.17 (The role of education in HIV/AIDS prevention is discussed below.)
An estimated 2.8 million people died of AIDS in India from 1980 to 2000, and the United Nations (U.N.) projects 12.3 million AIDS deaths from 2000 to 2015.18 (This number alone suggests that many more people are living with HIV/AIDS than are officially recognized.) Most of those dying of AIDS are between fifteen and forty-nine years old, the age when many are raising children. The number of AIDS orphans has not been adequately measured, but some calculate as many as 1.2 million children under age fifteen in India have lost one or both parents to AIDS.19
Numerous national and state level government bodies in India have HIV/AIDS-affected children in their jurisdictions. These include bodies within the departments of health that are directly responsible for HIV/AIDS, as well as bodies that provide children with basic services and that should be ensuring the HIV/AIDS-affected children, who are often especially vulnerable, receive those services. However, most have largely failed to take any responsibility for these children.
NACO, an autonomous body within the Ministry of Health and Family Welfare, is charged with implementing the governments response to HIV/AIDS prevention and control. NACO is responsible for providing training, research, surveillance, and program management; collaborating with other ministries and large government-owned enterprises; conducting advocacy; and mobilizing resources.20 According to NACO, its programs for care and support of people living with HIV/AIDS include providing medications to treat opportunistic infections, training both private and public health care providers to improve the management of HIV/AIDS, supplying health care providers with post-exposure prophylaxis (antiretroviral drugs that can reduce the risk of contracting HIV following exposure), expanding the outreach of voluntary confidential counseling and testing centers, and increasing the number of community care centers (which, as it describes them, appear to be institutions).21
At the state level, state AIDS control societies, with funds and technical and policy guidance from NACO, are responsible for implementing the Indian governments HIV/AIDS strategy: the National AIDS Prevention and Control Policy. The state AIDS control societies are supposed to contract with NGOs to implement blood safety programs, interventions with high-risk populations, educational campaigns, voluntary counseling and testing, and care and support of people living with HIV/AIDS.22
While state AIDS control societies exist in every state and in certain municipalities, their effectiveness reportedly varies widely. International donors, central government officials, and activists often cited state AIDS control societies in Andhra Pradesh, Maharashtra, Manipur, and Tamil Nadu as being much more active than those, for example, in Uttar Pradesh, Bihar, and Haryana.23 According to the World Bank in 2003, one-third of the posts in all state AIDS control societies remained unfilled, as was the case in 1995; many NGOs lacked the technical capacity to implement national policies; interventions were still very few for high risk men other than truckers; and NACO was failing to provide sufficient technical assistance to state AIDS control societies, many of which, in turn, were not providing sufficient supervision or technical assistance to NGOs delivering services.24
The National AIDS Prevention and Control Policy does not address children specifically, and NACO and the state AIDS societies have focused little or not at all on children affected by HIV/AIDS. NACOs director explained: There has been no segment on children in NACO policy per se. Partly the reason is that there is not enough data generated in surveillance specifically on children.25 According to NACO, U.N. officials, and others, the third phase of the national AIDS program, scheduled to begin in 2004, is likely to contain some provisions for children; however, NACO officials said they could not tell Human Rights Watch what those provisions would be since planning for the third phase had not formally begun at the end of 2003.26 NACO and the state AIDS control societies primary activity targeting children has been prevention of mother-to-child transmission, which involves administering a short course of antiretroviral drugs to mother and newborn that greatly reduces the risk of HIV transmission during pregnancy and child birth. They have not implemented programs to address discrimination against HIV/AIDS-affected children in education, health, or other areas, and only a few states, such as Tamil Nadu, have funded small projects to care for children living with HIV/AIDS.
In addition to NACO and the state AIDS control societies, other government ministries and their state-level counterparts also have direct responsibility for children affected by HIV/AIDS, including those living with the disease.27 The Ministry of Education and state education departments are responsible for providing free primary education to all children, regardless of their or their caregivers HIV status. The Department of Women and Children in the Ministry of Human Resource Development develops government policies and legislation for children and women and coordinates other ministries activities in these areas. It also administers the Integrated Child Development Services (ICDS) program, which includes preschool, and health and nutrition for preschool children, services that are especially important for HIV/AIDS-affected children. The Ministry of Health and Family Welfare and state-level health departments administer the public health system and medical education. They also oversee NACO and the state AIDS control societies. The Ministry of Healths Department of Family Welfare and its state-level counterparts focus on family planning, and reproductive and child health, both of which should overlap with HIV/AIDS prevention and care for HIV-positive women and children. The Ministry of Justice and Social Empowerment and corresponding state-level departments are responsible for children in need of care and protection: orphans and neglected children; children out of school, including street children; children in conflict with the law; and other marginalized groups. The Ministry of Labor and state labor departments are responsible for removing children from hazardous and bonded labor, for prosecuting employers, and for rehabilitating the children.
With the exception of a few individuals, most government officials are leaving HIV/AIDS up to NACO and the state AIDS control societies and failing to take responsibility for protecting HIV/AIDS-affected children under their jurisdictions. For example, the Secretary of Family Welfare, J. Prasanna Hota, told Human Rights Watch that there was no need to meet with us to discuss his departments policies for HIV/AIDS-affected children because NACO is heading this.28 According to the Secretary, his departmentis implementing the prevention of mother-to-child transmission program but has no programs or policies of its own for HIV/AIDS-affected children.29 One of his state-level counterparts, Tamil Nadu Commissioner for Maternal, Child Health and Welfare, who was also the acting Director of Family Welfare, told Human Rights Watch that:
As the director of Family Welfare, our primary focus is on controlling the birth rate. We dont directly handle HIV. Even in child welfare we do not handle it. We provide condoms but their main purpose is birth control, not HIV. . . . We are under the Health Ministry and we take care of the health of the normal child. We dont have anything to do with HIV. . . . Our aim is a healthy mother, healthy child, and a decrease in the infant and maternal mortality rate.30
Department staff present during our meeting confirmed that they address only reproductive health, not HIV.31
According to an expert on the issue, who did not wish to be named: We have to get HIV/AIDS as a more multidisciplinary discussion than it is now. Other government departments besides NACO must be encouraged to see HIVAIDS as an area of concern within their own respective mandates.32
Bilateral, multilateral, foundation, and NGO donors have pledged hundreds of millions of dollars towards HIV/AIDS in India.33 Most donors have focused on traditionally high-risk adults rather than children and have not ensured that their programs include adequate human rights protections for these persons. Similarly, despite repeated requests, staff of the U.N. Development Program (UNDP) and the World Health Organization (WHO) in Delhi declined to meet with Human Rights Watch during the course of our research, on the grounds that the U.N. Childrens Fund (UNICEF) alone of the U.N. agencies was addressing children affected by HIV/AIDS.34
The Indian governments own contribution to addressing HIV/AIDS, U.S.$38.8 million from 1999 to 2004, has been criticized as a sign of insufficient commitment to public health generally, and HIV/AIDS in particular.35 The governments failure to ensure adequate absorption capacity for available funds is also a concern. For example, the World Bankproject to provide financing for the National AIDS Prevention and Control Policy was expected to end on July 31, 2004, but, as of June 2004, was expected to be extended, as only 70 percent of the funds had been disbursed at that point.36 Barriers to disbursement have included government-imposed funding caps for HIV/AIDS and other programs, and the weakness in most states to implement programs.37 Similarly, at the state level, the project director of Keralas state AIDS control society told journalists in July 2002: Availability of funds is not a problem. We get aid from the federal government and other agencies. The real problem is reaching out to the masses.38 In contrast, the director of NACO, referring to funds needed to provide antiretroviral drugs, told Human Rights Watch: There is a lot of hype about the money available, but in fact we are falling short of money.39
The committee which interprets the Convention on the Rights of the Child has noted that, regarding HIV/AIDS, resource constraints should not be used by States parties to justify their failure to take any or enough of the technical or financial measures required.40
The impact of HIV/AIDS has exposed many of the serious deficiencies in Indias health and education systems. According to the World Bank, without significant reforms, India will not achieve the health and education targets set in its own Tenth Five Year Plan, which sets forth the governments main development objectives for 2002-2007 and provides the framework for policy and funding decisions, or the Millennium Development Goals, a set of time-bound, measurable targets for combating poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women that U.N. member states adopted in 2000.41 The World Bank also noted in 2003 that the government must accompany spending increases with improvements in the transparency, accountability, and independence of both sectors if health and education outcomes are to improve.42
Indias health and education systems are the joint responsibility of the central and state governments, although states deliver most of the services.
The health care systems problems generally are reflected in its response to HIV/AIDS: poor quality of care, with the poor receiving on average fewer resources than the rich; inadequate infrastructure; a shortage of medicines; and a virtually unregulated private sector. As a World Bank official explained: If we expect the health system to perform well and there are weaknesses in the structure for reproductive health, immunization services, etc., it cant suddenly be super-effective for HIV/AIDS control programs.43
In July 2003, the World Bank noted that India's progress in health indicators has been slowing down precipitously.44 Dalits and indigenous groups, as well as people in rural areas generally, have much less access to health services and worse health outcomes than upper castes, especially those living in urban areas.45
Indias public spending on health as a percentage of gross domestic product ranks among the lowest in the world, standing at 0.9 percent in 2000.46 Per capita spending on health was U.S.$71 in 2000.47 According to the World Bank, this is lower than what most low-income countries spend, and it is far below what is needed to provide basic health care to the population.48 Public spending has also prioritized curative care that, on average, has gone to benefit the rich much more than the poor.49 Many public facilities charge user fees for their services, an additional burden on the poor.50 Some argue that even without additional resources, India has the capacity to provide basic health care for its citizens, were its resources more equitably distributed.51
The delivery of public health care lies primarily with the states. Poorer states, such as Bihar and Madhya Pradesh, spend much less per capita than richer states, such as Kerala and Tamil Nadu, and have significantly worse health outcomes.52 Although the central government funds some national programsfor example, for HIV/AIDS, family welfare, malaria, leprosy, blindness, and tuberculosisinternational donors, including the World Bank, are supporting decentralization of these programs to the states.53
On World AIDS Day 2003, then-Union Health Minister Sushma Swaraj announced that the government would begin providing antiretroviral therapy free of cost to up to 100,000 people in the six states officially considered to be high-prevalence.54 Persons in the following categories would be eligible: mothers who participated in prevention of mother-to-child transmission programs in government antenatal clinics, children under age fifteen, and people with AIDS presenting at government hospitals.55 The Chief Minister of Kerala, which was not one of the states included in the central governments program, announced on December 29, 2003, that the state would also provide free antiretroviral therapy.56 At the time of writing, small numbers of people living with AIDS in certain areas of the designated states and Delhi had begun to receive antiretroviral drugs.57
Around 80 percent of Indians are estimated to use private health care services that, as one U.N. official described them, range from quacks up to excellent private physicians.58 According to the World Bank, the largest type of private health practitioners are completely unqualified and used mainly used by the poor.59 Private practitioners are sometimes the only option when public health facilities are far away or lack basic supplies.
Millions of Indias 400 million children are out of school.60 Although figures vary widely, according to the U.N. Educational, Scientific and Cultural Organization (UNESCO), around 83 percent of primary school-aged children were enrolled in school in 2000-2001, but only around 47 to 59 percent of students made it to grade five.61 Proportionately fewer girls than boys attend school, and those that do, drop out at higher rates; a third of the adult population, including almost half of all women, is illiterate.62 Dalits also have higher illiteracy and drop-out rates and face significant discrimination in education.63 Both literacy and school enrollment rates overall have improved in the last decade, but millions of children remain illiterate and out of school.
Under the Indian Constitution, the state is obligated to provide free and compulsory education to all children ages six to fourteen.64 The central and state governments are jointly responsible for education, but in practice, states and local bodies finance and control the vast majority of schools in India, with the central government providing guidance and oversight, and directly administering only a small number of schools.65
India spent 4.02 percent of its gross domestic product on education in 2001-2002, representing little change from 1994 and a failure to reach the 6 percent minimum promised by the government in its 1986 National Policy on Education.66 Compared with other countries of similar per capita incomes, spending on education is skewed somewhat toward the secondary level and considerably toward higher education.67 The Committee on the Rights of the Child, which interprets and monitors compliance with the Convention on the Rights of the Child, in 2004 expressed concern at the slow increase of the budget allocations for education.68 According to the World Bank, [u]niversalizing the completion of schooling through the fifth standard [grade] and then through the eighth, across all Indian states will require additional public resources for these level of education and improvements in the effectiveness of using public resources.69
Although there are wide variations from state to state, many government schools are in dismal condition, without basic drinking water and toilet facilities, electricity, roof, walls, floors, or blackboards; teaching posts are often vacant or teachers absent, especially in rural areas, and teachers may not teach when they do attend.70 Classes are often very large and teaching materials in short supply.71
Private schools, including those run by religious organizations, play a significant and expanding role, although they are less accessible to rural and Dalit children.72 Even very poor parents may send their children to some form of private school, if they can manage the fees or get a scholarship, particularly when government schools are far away or of poor quality.73
Many private schools receive significant government funds; these are known as private-aided schools. Private schools must apply for government recognition if their students are to take the tenth grade national examinations, and private-aided schools also need recognition to receive government funding.74 In order to be recognized, private schools must agree to follow the national curriculum and adhere to certain minimum standards of quality; according to an official in the Ministry of Education Elementary Education Department, most states grant recognition very liberally but would, in theory, have the power to withdraw recognition from schools that discriminate.75
International donors to education in India include the European Commission, the Netherlands government, the World Bank, the United Kingdoms Department for International Development (DFID), and UNICEF.76 In 2004, the European Commission, DFID, the World Bank, and the Indian government announced a U.S.$3.5 billion project, including a U.S.$500 million credit from the International Development Association (IDA), the World Banks concessionary lending arm, to support Indias national program for universal elementary education, Sarva Shiksha Abhiyan.
 UNAIDS (Joint United Nations Programme on HIV/AIDS), AIDS Epidemic Update, December 2003, p. 3. In 2003, there were around five million new cases of HIV transmission worldwide, including around 700,000 children, and around three million people, including around 500,000 children, died. Ibid.
 NACO, HIV Estimates in India, n.d.,www.naco.nic.in/indianscene/esthiv.htm (retrieved February 23, 2004). According to data from the U.N. Childrens Fund (UNICEF), UNAIDS, and the World Health Organization (WHO), an estimated 650,000 to 1,360,000 young people ages fifteen to twenty-four were living with HIV/AIDS at the end of 2001, two-thirds of whom were female. UNICEF, UNAIDS, WHO, Young People and HIV/AIDS: Opportunity in Crisis, 2002, p. 40.
 U.S. National Intelligence Council, The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China, no. ICA 2002-04D, September 2002, pp. 7-8. The National Intelligence Council is a branch of the U.S. Central Intelligence Agency. The report stated that its projections entailed a "relatively high margin of error." UNAIDS put the number of people living with HIV/AIDS in India between four and six million in late 2003. UNAIDS, AIDS Epidemic Update, p. 21.
 According to government estimates, 5.3 million people in South Africa are living with HIV/AIDS. South African Department of Health, National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa: 2002, September 9, 2003, p. 11 & Appendix 1.
 NACO, Programme Implementation Guidelines for a Phased Scale up of Access to Antiretroviral Therapy for People Living with HIV/AIDS (Draft), n.d. www.naco.nic.in/nacp/arvimp.htm (retrieved February 23, 2004).
 For a breakdown of prevalence by state recorded by the government sentinel survey in antenatal and sexually transmitted disease clinics, and data for injection drug users and men who have sex with men, see NACO, HIV Estimates in India.
 World Bank, Issue Brief: HIV/AIDS, South Asia Region (SAR)-India, October 2003, http://lnweb18.worldbank.org/sar/sa.nsf/Attachments/IndiaAIDS/$File/India+Final+AIDS+Brief.pdf (retrieved February 25, 2002).
 NACO, Programme Implementation Guidelines for a Phased Scale up of Access to Antiretroviral Therapy for People Living with HIV/AIDS (Draft). Compare NACO, HIV Estimates in India, (listing Andhra Pradesh, Goa, Karnataka, Maharashtra, Manipur, Mizoram, Nagaland, and Dadra and Nagar Haveli as states and union territories in which more than 1 percent of antenatal clinic patients tested positive for HIV).
 UNAIDS, AIDS Epidemic Update, p. 21; Human Rights Watch interview with U.N. staff, New Delhi, December 1, 2003.
 NACO, Programme Implementation Guidelines for a Phased Scale up of Access to Antiretroviral Therapy for People Living with HIV/AIDS (Draft); Country Coordinating Mechanism for the Global Fund to Fight AIDS, Tuberculosis and MalariaIndia, Proposal: Expansion of Effective Public and Private Sector Interventions in HIV, Tuberculosis and Malaria Prevention and Treatment in India, September 24, 2002, http://www.theglobalfund.org/search/docs/2IDAH_59_140_full.pdf (retrieved April 13, 2004), p. 21.
 The Indian government reported to the Committee on the Rights of the Child, the treaty body that monitors implementation of the Convention on the Rights of the Child, that the incidence of child rape increased and . . . . [t]here has also been an increase in the buying of girls for prostitution . . . and child marriages. Government of India, Second Periodic Reports of States Parties due in 2000, U.N. Doc. CRC/C/93/Add.5, July 16, 2003, para. 236 (citing Crime in India-1996).
 Maria Ekstrand, Lisa Garbus, Elliot Marseille, HIV/AIDS in India, Country AIDS Policy Analysis Project, AIDS Policy Research Center, University of California-San Francisco, August 2003 (citing Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2002 Revision, Highlights, February 2003).
 HIV/AIDS Causes Orphan Crisis, Mail & Guardian/All Africa Global Media via COMTEX, July 12, 2002 (interpreting data published by UNAIDS, UNICEF, and the U.S. Agency for International Development (USAID) to reach 1.2 million); Anil Purohit, Executive Director, FXB U.S. Foundation, Keynote Speech, reprinted in Orphans and Vulnerable Children in India: Understanding the Context and the Response, Report on Town Hall Meeting, Aspen Institute Conference Center, Washington D.C, June 2, 2003 (estimating 1.26 million AIDS orphans in India). In total, there are over twenty-six million orphans under age fifteen in India, from AIDS and other causes, with an orphan being defined as a child who has lost one or both parents. UNAIDS, UNICEF, USAID, Children on the Brink 2002: A Joint Report on Orphan Estimates and Program Strategies, July 2002, appendix 1.
 Country Coordinating Mechanism for the Global Fund to Fight AIDS, Tuberculosis and MalariaIndia, Proposal: Expansion of Effective Public and Private Sector Interventions in HIV, Tuberculosis and Malaria Prevention and Treatment in India, p. 26.
 Meenakshi Datta Ghosh, Additional Secretary and Project Director, NACO, Ministry of Health and Family Welfare, National AIDS Control Programme India: A Paradigm Shift, powerpoint presentation delivered November 11, 2003, slide entitled Care and Support: Current Programmes.
 Dr. D.L. Joshi, Additional Project Director, NACO, Ministry of Health and Family Welfare, NACOs Battle Against the Pandemic, presentation at the Fourth International Conference on AIDS India, Chennai, Tamil Nadu, November 9, 2003; Country Coordinating Mechanism for the Global Fund to Fight AIDS, Tuberculosis and MalariaIndia, Proposal: Expansion of Effective Public and Private Sector Interventions in HIV, Tuberculosis and Malaria Prevention and Treatment in India, p. 26.
 See, e.g., World Bank, Project Performance Assessment Report, India, National AIDS Control Project (Credit No. 2350), no. 26224, July 2, 2003, para. 13.
 Ray Marcelo, Fears Grow that AIDS Could Spin Out of Control in India, Financial Times, October 22, 2003 (citing World Bank Mid-Term Review of Second National HIV/AIDS Control Project, June 5-July 3, 2003).
 Human Rights Watch interview with Meenakshi Datta Ghosh, Additional Secretary and Project Director, NACO, Ministry of Health and Family Welfare, New Delhi, December 3, 2003.
 The National AIDS Prevention and Control Policy calls on other government ministries to devise and own HIV/AIDS programs within their jurisdictions. NACO, National AIDS Prevention and Control Policy, n.d., para. 5.1.1.
 Human Rights Watch telephone interview with J. Prasanna Hota, Secretary, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India, New Delhi, December 2, 2003.
 Human Rights Watch interview with M. Mutia Kalaivanan, Tamil Nadu Commissioner for Maternal, Child Health and Welfare, and acting Director of Family Welfare, Government of Tamil Nadu, Chennai, Tamil Nadu, November 17, 2003.
 Ibid. The staff also told us that the department was planning to conduct some training on HIV in the future and might take up testing of mothers and providing antiretrovirals.
 Human Rights Watch interview with expert on HIV/AIDS in India, New Delhi, December 1, 2003.
 NACO's budget for 1999-2004 was $300 million, of which the government was providing $38.8 million, a World Bank loan $191 million, and other donors the rest. Country Coordinating Mechanism for the Global Fund to Fight AIDS, Tuberculosis and MalariaIndia, Proposal: Expansion of Effective Public and Private Sector Interventions in HIV, Tuberculosis and Malaria Prevention and Treatment in India, p. 23, 28. International donors include the Australian Agency for International Development (AusAID), the U.S. Centers for Disease Control (CDC), the Canadian International Development Agency (CIDA), the U.K.s Department for International Development (DFID), the European Union, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Bill and Melinda Gates Foundation, the Gesellschaft für Technische Zusammenarbeit (GTZ), the Japan International Cooperation Agency (JICA), the U.S. National Institutes of Health (NIH), the Swedish International Development Cooperation Agency (SIDA), the U.S. Agency for International Development (USAID), and the World Bank. The Bill and Melinda Gates Foundation has committed $200 million to HIV prevention in India, and in 2004 India became eligible for assistance under the U.S.s Emergency Plan for AIDS Relief, a $15 billion, five-year scheme announced by George Bush in January 2003.
International NGOs working on HIV/AIDS in India include the Cooperative for Assistance and Relief Everywhere (CARE), the Center for Development and Population Activities (CEDPA), Family Health International (FHI), International AIDS/HIV Alliance, Marie Stopes International, Médecins sans Frontières, and the Population Council. Ekstrand, et al, HIV/AIDS in India, Country AIDS Policy Analysis Project, pp. 130-135.
 Various multilateral and U.N. agencies working on HIV/AIDS in India include the International Labor Organization (ILO), UNAIDS, the U.N. Development Program (UNDP), UNICEF, the U.N. Population Fund (UNFPA), and WHO.
 Jaya Shreedhar, Time for Midcourse Corrections, The Hindu, June 7, 2004; When Silence is Not Golden, The Economist, April 15, 2004; Ekstrand, et al, HIV/AIDS in India, Country AIDS Policy Analysis Project, p. 123.
 Email from Dr. K. Sudhakar, Senior Heath Specialist, World Bank, to Human Rights Watch, June 9, 2004.
 IANS, Surge in HIV Positive Cases in Kerala, Times of India, July 20, 2002,www.healthlibrary.com/news/July2002/15_20_July2002/surge.htm (retrieved September 30, 2003).
 Human Rights Watch interview with Meenakshi Datta Ghosh, Additional Secretary and Project Director, NACO, Ministry of Health and Family Welfare, New Delhi, December 3, 2003.
 Committee on the Rights of the Child, General Comment 3: HIV/AIDS and the Rights of the Child, March 17, 2003, para. 14.
 World Bank, South Asia Region, Poverty Reduction and Economic Management Sector Unit, India: Sustaining Reform, Reducing Poverty, no. 25797-IN, July 14, 2003, p. 42.
 Ibid. pp. 35, 43.
 Human Rights Watch interview with Dr. K. Sudhakar, Senior Health Specialist, World Bank,New Delhi, December 3, 2003.
 World Bank, India: Sustaining Reform, Reducing Poverty, p. 42.
 Ravi Duggat, Operationalising Right to Healthcare in India, paper presented at the Tenth Canadian Conference on International Health, Ottawa, Canada, October 26-29, 2003, www.cehat.org/rthc/rthpaper.htm (retrieved March 11, 2004), p. 5 (citing NSS data from 1996 and 1998).
 See World Bank, Human Development Network, Better Health Systems for Indias Poor: Findings, Analysis, and Options, 2002, p. 235-36; UNDP, Human Development Report 2003 (New York: Oxford University Press, 2003), p. 256; and Duggat, Operationalising Right to Healthcare in India, table 1 (charting health expenditure as percent of gross domestic product and percent to government total from 1951 to 2000).
 UNDP, Human Development Report 2003, p. 256.
 World Bank, Better Health Systems for Indias Poor, pp. 3, 43. By comparison, Vietnam spent 1.4 percent of its gross domestic product on health and $130 per capita on health; Sri Lanka spent 1.8 percent of its gross domestic product and $120 per capita; Pakistan spent 0.9 percent of its gross domestic product and $76 per capita; Egypt spent 1.8 percent of its gross domestic product and $143 per capita; and Zimbabwe spent 3.7 percent of its gross domestic product and $170 per capita. UNDP, Human Development Report, pp. 237-40, 254-57.
 World Bank, Better Health Systems for Indias Poor, chapter 7. According to the World Bank, the poorest 20 percent of the population captured only about 10 percent of the total net public subsidy from publicly provided clinical services. . . . The richest quintile received more than three times the subsidy received by the poorest quintile, indicating that publicly financed curative care services are unambiguously pro-rich. Ibid., p. 218. Kerala, Tamil Nadu, and Maharashtra are exceptions, with public spending on health nearly uniform across income groups. Ibid., p. 223.
 Center for Reproductive Rights, Women of the World: Laws and Policies Affecting Their Reproductive Lives, South Asia (New York: Center for Reproductive Rights, 2004), p. 79 citing (National Development Council, Planning Commission, Tenth Five Year Plan (2002-2007), vol. II, ch 2, para. 2.8.192-2.8.193, fig. 2.8.33).
 See Duggat, Operationalising Right to Healthcare in India; Abhay Shukla, The Right to Health Care: Moving from Idea to Reality, revised version of article presented by the author at the Asian Social Forum, Hyderabad, January 3-4, 2003, www.cehat.org/rthc/paper1.htm (retrieved March 11, 2003).
 Ekstrand, et al, HIV/AIDS in India, Country AIDS Policy Analysis Project, pp. 45-46, 65, 125.
 World Bank, Memorandum of the President of the International Bank for Reconstruction and Development, the International Development Association, and the International Finance Corporation to the Executive Directors on a Country Assistance Strategy Progress Report of the World Bank Group for India, no. 25057-IN, January 15, 2003, para. 14.
 These six states are Andhra Pradesh, Karnataka, Tamil Nadu, Maharashtra, Manipur, and Nagaland.
 Human Rights Watch interview with JVR Prasada Rao, Health Secretary, Ministry of Health and Family Welfare, Government of India, New Delhi, December 3, 2003.
 John Mary, Kerala Boost to AIDS Battle, The Telegraph (Calcutta, India), December 29, 2003.
 According to the Affordable Medicines and Treatment Campaign (AMTC), because of inadequate procurement of drugs, only seven hospitals were delivering antiretroviral therapy under the governments program in June 2004, at a rate that would cover around 1,200 people living with HIV/AIDS in the programs first phase. Letter from Anand Grover, Lawyers Collective HIV/AIDS Unit; Ashok Rau, Freedom Foundation, Bangalore; Jayasree, FIRM; on behalf of the Affordable Medicines and Treatment Campaign, to Dr. Anbumani Ramadoss, Minister of Health and Family Welfare, Government of India, June 9, 2004.
 World Bank, Memorandum of the President of the International Bank for Reconstruction and Development, the International Development Association, and the International Finance Corporation to the Executive Directors on a Country Assistance Strategy Progress Report of the World Bank Group for India, para. 43; Human Rights Watch interview with U.N. official, New Delhi, December 1, 2003. See also Government of India, Second Periodic Reports of States Parties due in 2000, paras. 444-45.
 World Bank, India: Policies to Reduce Poverty and Accelerate Sustainable Development, January 31, 2000,para. 2.32, 2.34.
 UNICEF, At a Glance: India, The Big Picture, n.d., http://www.unicef.org/infobycountry/india.html (retrieved April 30, 2004) (for number of children ages 0-18).
 UNESCO Institute for Statistics, Global Education Digest 2004 (Montreal: UNESCO, 2004), pp. 64, 74 (citing data from 2000-2001, and 1999-2000 to 2001-2002); and UNESCO Institute for Statistics, South and East Asia: Regional Report (Montreal: UNESCO, 2003), pp. 73-75. According to the Committee on the Rights of the Child in 2004, around sixty million children were not attending primary school. Committee on the Rights of the Child, Concluding Observations: India (unedited version), 35th sess., U.N. Doc. CRC/C/15/Add.228, January 30, 2004, para. 64. Compare World Bank, India: Sustaining Reform, Reducing Poverty, p. 48 (stating that forty-two million children ages six to fourteen do not attend school). According to the Indian government, 69.6 million children ages fourteen to eighteen did not attend school in 1997-98. Government of India, Second Periodic Reports of States Parties due in 2000, para. 898.
 Literacy Rate, Census of India2001, http://www.censusindia.net/results/provindia3.html (retrieved April 14, 2004).
 See, e.g., Suhas Chakma, The Status of Children in India, Asian Centre for Human Rights (New Delhi: Asian Centre for Human Rights, 2003), pp. 61-62 (literacy and drop out rates). Discrimination against Dalit children in education is well documented. See, e.g., Geetha B. Nambissan and Mona Sedwal, Education for All: The Situation of Dalit Children in India, in National Institute of Educational Planning and Administration, India Education Report: A Profile of Basic Education, R. Govinda, ed. (New Delhi: Oxford University Press, 2002), pp. 72-86; Jyotsna Jha and Dhir Jhingran, Elementary Education for the Poorest and other Deprived Groups: The Real Challenge of Universalisation (New Delhi: Center for Policy Research, 2002), pp. 81-107; Human Rights Watch, Broken People: Caste Violence Against Indias Untouchables (New York: Human Rights Watch, 1998) http://www.hrw.org/reports/1999/india/; National Campaign for Dalit Human Rights, Black Papers: Broken Promises and Dalits Betrayed (India: National Campaign on Dalit Human Rights, 1999).
 The Constitution (86th Amendment) Act, 2002.
 As the government itself explains: The states are largely responsible for the organization and structure of education. The central government is responsible for the quality and character of education. Chapter 5: Education, India 2000, n.d., www.indianembassy.org/indiainfo/india_2000/chapters/chp05.pdf (retrieved November 6, 2003).
 Ministry of Education, Government of India, Education Statistics, n.d., www.education.nic.in/htmlweb/edusta.htm (retrieved March 1, 2004); Government of India, Second Periodic Reports of States Parties due in 2000, para. 770 (stating that 4.0 percent of the gross domestic product went to education in 1994-95 and 1995-96, dropping to 3.6 percent in 1997-98); National Policy on Education (1986), para. 11.4
 World Bank, India: Sustaining Reform, Reducing Poverty, p. 49.
 Committee on the Rights of the Child, Concluding Observations: India (unedited version), para. 11.
 World Bank, India: Sustaining Reform, Reducing Poverty, p. 49.
 Jyotsna Jha and Dhir Jhingran, Elementary Education for the Poorest and other Deprived Groups, pp. 42-74; PROBE Team, Public Report on Basic Education in India (New Delhi: Oxford University Press, 1999); World Bank, India: Sustaining Reform, Reducing Poverty, p. 48.
 Ibid.; Tania Boler, The Sound of Silence: Difficulties in Communicating on HIV/AIDS in School, Experiences from India and Kenya ( London: ActionAid, 2003), pp. 39-41.
 For more information about private schools in India, see Anuradha De, et al, Private School and Universal Elementary Education, India Education Report, R. Govinda, ed., pp. 131-150. Dalit and rural children are more likely to attend a government school than a private school, if they attend school at all. Ibid.
 See, e.g. Amy Waldman, Indias Poor Bet Precious Sums on Private Schools, New York Times, November 15, 2003; PROBE Team, Public Report on Basic Education in India.
 Human Rights Watch interview with Vrinda Sarup, Joint Secretary, Department of Elementary Education, Ministry of Education, Government of India, New Delhi, December 4, 2003.
 Ministry of Education, Government of India, Annual Report 2002-2003, p. 13.