Lexy Zhang laughs nervously as he talks about his first experiences picking up men for sex in a country where condoms are widely available for family planning but not always promoted to prevent AIDS.

"I was just having unsafe sex all the time," said the 26-year-old, sitting in a fashionable Beijing bar frequented by gay men.

"Lots of gay Chinese think it's great that you don't have to worry about pregnancy but have no idea about sexually transmitted diseases," said Zhang, adding he now would never consider having unsafe sex.

"There are just not enough organizations paying attention to this community. The government thinks it doesn't exist."

How to prevent the spread of AIDS in places like China will be a major focus of researchers and policymakers at the 16th International AIDS Conference, which opens on Sunday in Toronto.

In China, homosexuality, while no longer officially considered a mental disorder, is still an off limits subject for many. That taboo often extends to discussions about AIDS and condom use for men who have sex with men.

Condoms are widely available thanks to China's long-standing one-child policy, but conservative attitudes and an unwillingness to talk about sex mean the connection with AIDS prevention is not always made.

"Sex is taboo, and condoms have mainly been used as part of family planning rather than for safe sex," said Lee Folland, a graduate student doing research at Cambridge University on the social marketing of condoms in China.

In a Beijing survey, only 15 percent of 482 men who had sex with men understood that they were at risk of contracting HIV, according to a 2005 report by the United Nations' UNAIDS. Some 49 percent reported having had unprotected anal intercourse with men in the prior six months.

A survey in late 2004 by the Chinese Center for Disease Control and Prevention in the northeastern city of Harbin found that almost 20 percent of men who had sex with other men also slept with women. More than 10 percent were married.

"There is strong social pressure to get married -- or what would the neighbors say? It's not only about how your parents would react, but how others will react to your parents," Folland said, referring to fear of social ostracism for parents whose sons were thought to be gay.

Condoms and safe sex information are often not available in Chinese gay bars or saunas. Although they are starting to appear thanks to volunteer groups and outreach programs and a government belatedly waking up to the problem.

But even that information can sometimes be too tame to include pictures of how a condom is used.

"Otherwise in China it would probably be considered pornography," said Chinese AIDS activist River Wei.

BORDER COMPLICATIONS

In Hong Kong, Ricky Fan, 40, goes cruising once a week at one of the city's many gay saunas, venues that have become increasingly popular in recent years among men looking for anonymous sex with other men.

These places are invariably pitch black. But once acclimatized to the darkness, visitors are likely to be greeted by eyecatching flyers and postcards on safe sex, HIV testing and free condoms from the locker rooms to the many tiny cubicles.

The message is certainly not lost on the more frisky members of Hong Kong's gay population.

"I always use condoms, 100 percent of the time. Because it's safer," said Fan, who has visited saunas in the last five years in Hong Kong, mainland China, Thailand, Taiwan and Japan.

"I will push away anyone who doesn't use them."

But this attitude is far from the norm. New HIV infections among men who have sex with men have shot up in almost every big city in Asia in recent years.

Insiders attribute it to unsafe sex, made worse by a population that is relatively cash-rich and highly mobile.

"In Hong Kong, those who are unattractive and can't find anyone go to Shenzhen (across the border in southern China) to buy 'money boys,"' said sauna owner Ray Chong, referring to gigolos who service male clients in big Chinese cities.

"They pay more to get the boys not to use any condoms."

MOBILE POPULATION

Activist groups, which have done much to keep new HIV infections down in Hong Kong, say their work is complicated by the rise in the commercial sex trade on the mainland, which shares an increasingly porous border with Hong Kong.

"Infection rates have gone up among men who have sex with men in Asia because the population is so mobile, so our work cannot remain so localized. We have to go where they go," said Lau Chi-chung of AIDS Concern, a Hong Kong-based group which has promoted awareness of the disease since the mid-1990s.

"What we can do is limited. We have to collaborate with the government, other NGOs (nongovernmental organizations) in mainland China to spread the message."

Another problem in China is that many men who have sex with men do not identify themselves as gay or bisexual. Indeed, thanks to a lack of education and cultural taboos they are not even be aware the concept exists, activists say.

"If you're 40, have been married all your life, have kids and live in the countryside then one day you discover your true self and have sex with a man, you aren't going to be thinking about using a condom," said Wei.

"But that one time could be enough to get you infected."

Three years after China launched an ambitious plan to provide free anti-retroviral treatment to all HIV/AIDS patients, it urgently needs better quality drugs and child medication, a top official says.

One of the biggest obstacles is finding patients in the vast country, said Zhang Fujie, head of China's AIDS treatment program.

"We definitely need to improve our treatment. There's no question about it," said Zhang, speaking to AFP before heading to the world's biggest International AIDS Conference in Toronto, which opens on Sunday.

"We're talking to pharmaceuticals. We definitely want to buy second-line drugs."

The drugs offered under China's free treatment program are older versions of the life-saving therapy drugs used in Europe and the United States with expired patents.

The drugs have strong side effects but are the only type China can afford to manufacture without breaking international patent laws and suffering trade repercussions.

China is also desperately short of trained medical workers to keep people on the medication so more patients are dropping out and developing resistance.

"The drugs no longer work as effectively for them," said Zhang.

Zhang did not give a timeline for when China would obtain the better quality second-line drugs and whether pharmaceuticals had agreed to allow China to buy them at lower costs, but he said it was a high priority.

Once the drugs become available, patients, who currently only have seven drug choices, will get a wider variety of therapy combinations. The death rate will then be reduced from the current estimated 10 percent of the drug-taking patients, Zhang said.

"In Europe and the United States, I believe the death rate is around three per 100 people on treatment each year. We hope in China we can come close to this," said Zhang.

Compared to African countries and other developing nations such as Vietnam where patients struggle to get any treatment, China's promise to provide free drugs to all patients is praised by international experts as a significant step forward.

But while the government is providing drugs to all patients it finds who need them since it launched the program in 2003, it has provided treatment to only 26,000 people despite an estimated HIV/AIDS population of 650,000 by the end of 2005.

Zhang said that is because China has found only a fraction of those infected.

"We have records for only 160,000 people with HIV/AIDS and that's cumulative from 1985 and we don't know where many of these people are," Zhang said.

Some are commercial sex workers who registered using fake names, making them hard to track down, Zhang said.

Others, including some people who sold blood and some lying on their death bed, refuse to be tested for fear of discrimination against themselves and their family, villagers and AIDS activists have told AFP.

Children have been especially hard to find, Zhang said.

"Definitely there are a lot of kids who haven't been found and a lot of kids who died without knowing they had AIDS," Zhang told AFP.

According to official figures, China has around 1,880 children with AIDS. Most of the children were found in AIDS villages in central China's Henan province where many farmers were infected from selling blood in unsafe schemes.

They were found during widespread testing of people in the hard-hit villages.

Few kids have been found in other areas including China's most infected AIDS regions, such as Xinjiang and Yunnan, Zhang said.

The government is meanwhile stepping up efforts to obtain children's AIDS medication, which it currently does not provide.

Other than 200 children getting child treatment donated by the Clinton Foundation, and another 50 from Medecins Sans Frontieres, children with HIV/AIDS in China either receive no treatment at all or have to resort to taking adult formulations, which is not ideal because the side effects are too strong.

"Many kids react strongly to adult formulation drugs. They vomit or become feverish," Li Qimin, deputy director of China's National Committee for the Care of Children (CNCCC), was quoted by Xinhua news agency saying last week.

The adult pills are cut in half for the children -- not a good method because the components of a pill are usually not distributed evenly.

Health experts estimate the real number of infected children in China is more than 9,000, Xinhua news agency said.

China has released a Chinese AIDS patient and activist detained for nearly a month -- four days ahead of the world's biggest-ever AIDS conference, a group said.

Li Xige, a postal worker who contracted AIDS from a hospital blood transfusion during childbirth, was released on Thursday by police in Ningling county, central China's Henan province, the Beijing Aizhixing Institute said.

"The government is most concerned with its international image," Wan Yanhai, director of the AIDS non-government organisation told AFP.

"The Chinese government is planning to participate in the major AIDS conference. International AIDs groups planned to protest over the arrest. ... Also in the past three weeks, the government received a lot of criticism from international and domestic AIDS groups over the arrest."

The International AIDS Conference, an event held every two years, opens on Sunday in Toronto, with an expected attendance of some 20,000 researchers, campaigners and public health experts. It runs until Friday, August 18.

China's health ministry is sending a delegation there and a deputy health minister will attend the conference.

Police arrested Li and two other AIDS patients on July 20 while they and eight others were appealing in front of the health ministry in Beijing for government compensation for people like her infected because of the country's unsafe blood supply.

The group had intended peacefully to petition the ministry for better compensation but were taken in by authorities and driven back to Henan, according to Wan.

Li's family was later informed that she had been officially detained on suspicion of "assembling crowds to attack state organs," Wan said. The other participants in the failed attempt to petition the government were released before police freed Li.

Li did not know she was infected with HIV in 1995 when having her first baby. The child, a girl, died in 2004. A second child has also been infected.

Many people in China may have been infected with HIV while receiving blood transfusions in hospitals, but most only find out later as they develop symptoms or their family members die.

The government has made efforts to clean up its blood supply in recent years, but there are still occassional reports of infections through transfusions.

The AIDS virus is spreading rapidly among homosexuals and bisexuals in Asia, driven by stigma, ignorance and government inaction, according to a report issued.

The survey of 23 countries is released two days ahead of the world's biggest-ever AIDS conference, opening in the Canadian city of Toronto.

It said rates of HIV infection among men who have sex with men could be as high as 14 percent in the Cambodian capital of Phnom Penh; 16 percent in Andhra Pradesh, India; and 28 percent in Bangkok.

"More alarming, dramatic increases in some areas have been seen in just the past two years," said the authors, a Bangkok-based group called TREAT Asia, an initiative launched by the US AIDS campaign organisation amFAR on Friday.

"(...) These data represent an alarming trend, since male-male sexual activity in the region is diverse, often completely hidden, and beyond the reach of current prevention efforts."

At the end of last year, 38.6 million people were living with the human immunodeficiency virus (HIV), 8.3 million of them in Asia, according to the latest UNAIDS estimates. Around 4.1 million people globally became infected in 2005, 930,000 of them in Asia.

Southeast Asia, especially Thailand, was among the first of the world's regions to be badly hit by AIDS, and analysts have long worried that China and India could follow the same path.

The TREAT Asia estimates are based on a search of published studies and epidemiological data and on 45 interviews with AIDS researchers, counsellors and government officials in 19 countries.

The report says there are a range of factors behind a rapidly growing rise in HIV infection, which it says is being hidden -- often for cultural or legal reasons.

Gay sex is outlawed in nearly half of the countries surveyed, and many Asian men who have sex with men are also bisexual, which means they compartmentalise their behaviour and are rarely tested for HIV.

In Phnom Penh, for instance, 78 percent of such men used condoms consistently when visiting female sex workers, but only 47 percent did so when visiting male prostitutes.

Among gays who were studied in Beijing, half reported having had unprotected anal sex in the past six months, and only 15 percent considered themselves to be at risk from the AIDS virus.

"Governments in the region and international donors need to support appropriate prevention, care and treatment efforts for MSM [men who have sex with men] populations, or face a spiralling epidemic that could be far worse than any seen in gay communities in the West," TREAT Asia director Kevin Frost warned.

The International AIDS Conference, held every two years, opens on Sunday and runs until Friday, August 18. Some 20,000 researchers, campaigners and public-health experts are expected to attend.

The Bill & Melinda Gates Foundation said on Wednesday it was giving $500 million to the Global Fund to Fight AIDS, TB and Malaria, by far its biggest grant to the fund, which says it sorely lacks cash.

The money, to be given over five years, is the largest private donation to the fund, founded nearly five years ago to serve as the primary financing vehicle for efforts to fight the HIV pandemic, tuberculosis and malaria.

The fund has always struggled to persuade rich nations to contribute.

"Even with this support, it is likely that the fund will need an additional $500 million to reach our goal of $1.1 billion to fully fund all of the grants that we expect to approve for our sixth round of funding," said Richard Feachem, Executive Director of the Global Fund.

Richard Burzynski of the International Council of AIDS Service Organizations said the fund has a predicted $2.1 billion shortfall for this year and next year alone.

So far, the fund has committed a total of $5.4 billion in grants, mostly to poor countries. It prides itself on making recipients account for the money and earlier this year withdrew some funding for Nigeria.

"The Global Fund is one of the most important health initiatives in the world today," Gates, who founded Microsoft said in a statement.

Gates and the fund announced the cash gift less than a week before the 16th International AIDS Conference, being held this year in Toronto. The Gates Foundation pledged $100 million to the Fund in 2001, and $50 million in 2004.

The Geneva-based fund, administered independently, was responsible for about a fifth of all international funding for programs to fight HIV in 2005.

This included HIV drugs for 544,000 people, more than 1.4 million people treated for TB and more than 11 million bed nets distributed to protect children from malaria.

"As we move from crisis management to a sustained AIDS response, we will continue to rely on the Global Fund as the best model to provide strategic and predictable funding," said Dr. Peter Piot, Executive Director of the United Nations AIDS agency UNAIDS.

"A fully funded Global Fund is absolutely critical to the AIDS response."

Recipients also praised the Fund.

"The Global Fund has provided us with the support we need to drive back AIDS and other diseases, and I am happy to see that this contribution will help it continue to do so for years to come," President Paul Kagame of Rwanda said in a statement.

"Thousands of people who would otherwise be dead are healthy and working to build a better future for their families and our country."

A growing number of countries are supporting coercive or discriminatory HIV testing programs that fail to ensure confidentiality, a U.S. human rights group said on Thursday ahead of an international AIDS conference.

Human Rights Watch called on the World Health Organization and the U.N. Joint Program on AIDS to clearly and forcefully state that HIV testing programs must respect human rights and be linked to counseling and treatment.

"It is critical that we expand access to HIV testing," said Joe Amon, director of the HIV/AIDS program at Human Rights Watch. "But testing programs will fail if they do not also provide people protection from stigma, discrimination and abuse."

Human Rights Watch said a program in Uganda that provides treatment, counseling, condoms and voluntary HIV testing in people's homes had cut HIV transmission by 98 percent.

But involuntary programs in the Dominican Republic, Romania and Zimbabwe that failed to protect confidentiality and were not linked to counseling and care had discouraged people from seeking help and increased stigma and abuse, the group said.

Human Rights Watch also cited the government of the Indian state of Goa for wanting mandatory premarital testing and Saudi Arabia for testing all foreign workers and deporting them if they are positive.

The world's largest international AIDS conference starts in Toronto on Sunday. Worldwide, 39 million people are infected with HIV/AIDS with Sub-Saharan Africa the hardest hit region where about 25 million people are infected.

Canada, host to what organizers bill as the largest global gathering on AIDS and HIV, has not taken seriously its avowed effort to help defeat the pandemic, a top AIDS advocate said on Wednesday.

U.N. envoy Stephen Lewis urged Canada to follow through on legislation passed in 2004 that allowed the export of low-cost generic medicines to developing countries.

"I feel almost personally duped ... I actually believed with a kind of charming innocence that the governments of Canada -- Liberal and Conservative -- would really take this act seriously," Lewis, a Canadian, told a news conference ahead of the International AIDS Conference in Toronto.

"All it takes, and it could be done this week, is for the government of Canada to issue a compulsory license for the manufacture and export of generic drugs."

Canada has a number of generic drug manufacturers, and while one of them, privately held Apotex Inc, has made a generic version of an AIDS drug, there have been no exports, the news conference organizers said.

The AIDS conference, which starts on Sunday, is expected to draw some 20,000 participants to Canada's largest city for a week of events including films, fashion shows and seminars and scientific discussions about AIDS.

Speakers will include Bill and Melinda Gates, whose foundation on Wednesday pledged $500 million over five years to the Global Fund to fight AIDS, TB and Malaria -- the largest private donation the fund has ever received.

Figures from the U.N. population fund estimate that 38.6 million people were living with HIV/AIDS last year. The 2005 AIDS death toll was 3.1 million.

Indian health groups welcomed a government plan on Tuesday to involve tens of thousands of rural politicians in the fight against an HIV/AIDS epidemic, which has made deep inroads in the countryside.

India recently overtook South Africa as the country with the most number of people living with HIV/AIDS, according to the United Nation's AIDS agency, and nearly 60 percent of the 5.7 million people infected with the virus live in rural areas.

On Tuesday, ministers and officials attending a national meeting of mayors and district council chiefs called upon local leaders in rural areas to join the anti-AIDS campaign.

"This is a very good idea. If local leaders talk about AIDS or even mention it at public meetings it helps," said Anjali Gopalan, executive director of Naz Foundation India, a leading anti-HIV group.

"These leaders speak in the language people can understand."

India has a three-tier system of local government across its 604 districts, home to hundreds of millions of villagers, where conservative social attitudes mean many people find it hard to discuss issues like sexual health.

"I would request chairmen of zilla parishads (district councils) to set up reporting lines with respect to HIV and to monitor the action taken," said Mani Shankar Aiyar, the minister for local self-government.

"At gram sabha (village council) meetings, local leaders can get people together and inform them about AIDS," Aiyar said, adding: "We need a caring, sympathetic gram sabha for people with AIDS."

At the end of the meeting, the rural leaders pledged to step up social awareness campaigns, openly promote the use of condoms and allocate funds for HIV work. They also vowed to tackle discrimination.

Last month, a six-year-old boy in the eastern state of Orissa was forced to leave school on fears he was HIV positive after his father tested positive for the virus, underlying the stigma attached to the disease, especially in rural areas.

Aiyar said his ministry was also considering the idea of a dedicated TV channel for rural India, which would regularly include anti-AIDS messages.

But some rural politicians said it would be hard to change mindsets in the villages.

"(State) money goes into the hands of state bureaucrats and many of them are corrupt," said Nagendra Nath Singh, the chairman of the Annupur district council in the central state of Madhya Pradesh. "And people feel ashamed if sex is talked about openly."

An HIV/AIDS epidemic may kill 11 million people in India over the next 20 years, the Times of India reported on Wednesday, citing official census figures.

Along with the 5 million children not born to women who died young because of the virus, India's forecast 2026 population of 1.4 billion would be trimmed by 1.2 percent, the paper reported.

The United Nations AIDS agency (UNAIDS) says that 5.7 million Indians live with the HIV virus, and that India has the world's highest caseload, overtaking South Africa earlier this year.

"If we do not stop it (the AIDS epidemic) now, the fate of South Africa will overtake us," India's minister for local self-government, Mani Shankar Aiyar, told a meeting of rural politicians on Wednesday.

More than one of every nine South Africans in a population of 45 million are HIV-positive.

Indian officials have not accepted the UNAIDS figure for India and continue to cite the Health Ministry's number of 5.2 million people living with HIV/AIDS.

But anti-AIDS groups say the real figure is higher as the stigma attached to the disease prevents some people from reporting their status. Other deaths are not recorded as HIV-related in medical records.

On Wednesday, government officials announced plans to rope in thousands of rural politicians to spread the anti-AIDS message in the countryside, where more than 60 percent of Indians live.

A proposal in Congress to require that more of the federal money spent on uninsured AIDS patients go to drugs and doctor visits is drawing criticism from some AIDS groups, who say it will force cuts in basic services like meals and housing.

Opponents, including the Gay Men's Health Crisis and New York Democratic Sen. Hillary Clinton, say it would undermine care of the nation's most vulnerable patients.

Support for the main Senate bill on the issue, sponsored by Republican Mike Enzi of Wyoming and Democrat Ted Kennedy of Massachusetts, is coming from many health-care providers who want to establish national care standards and increase access to life-saving drugs.

The bill would mandate that three-fourths of the funds from the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, the nation's largest HIV-specific federal grant program, be used for medical services.

Opponents say the mandate would force them to cut non-medical services they consider critical for overall patient care.

Designed to fill gaps in local funding, the Ryan White program has never in its 16-year history included a broad prescription for how money should be spent.

Another divisive proposal on the table includes revamping the formula that directs money from the program in a way that could reduce funding to such historic hot spots like San Francisco and New York City. Those seeking change want more money for rural areas and emerging AIDS centers like Oakland, California.

The Ryan White program, which was named for the boy who got the disease from a blood transfusion and helped raise mainstream awareness, provides care for tens of thousands of patients with no insurance or inadequate coverage and has a budget this year of just under $2.1 billion.

The Enzi-Kennedy legislation is stalled in Congress. The program must be reauthorized by Congress every five years and its next authorization is scheduled for next month.

More than 1 million people living in the United States are HIV-positive. Half are not in treatment and a study has suggested that one-fifth of them do not have insurance.

AIDS ESTABLISHMENT

One of the more outspoken supporters of the change is AIDS Healthcare Foundation President Michael Weinstein, whose Los Angeles-based group's mandate over more than two decades has gone from helping people die with dignity to getting them the drugs they need to live.

Weinstein said the Ryan White program needs to change to reflect the 1996 debut of drug cocktails that turned AIDS into a treatable, although still life-threatening, illness.

"If we reauthorize Ryan White without recognizing that, it would be criminal negligence," he said, adding that it's time for a shakeout among AIDS service providers who have not kept pace with the fast-moving HIV virus.

"Ryan White is not about maintaining the AIDS establishment. We have to examine all of the sacred cows and we have to slaughter most of them," he said.

As demand rises amid a lack of significant funding increases for the Ryan White program, Weinstein worries that there won't be enough money to pay for new, more costly treatments to battle drug-resistant HIV strains.

Janet Weinberg, managing director of development and legislative funding at Gay Men's Health Crisis, which feeds 350 people a day in New York City and offers help with housing and legal issues, said her group could lose up to $1 million per year at a time when clients are coming in sicker, poorer and with other problems like Hepatitis C or addictions.

"If you don't know where you're putting your head at night, are you going to get to the doctor?" she asked.

The drugs Shyamal Kumar Dey takes to fight AIDS don't work anymore.

The 38-year-old father of one has been swallowing antiretroviral pills for the last five years, enough time for the HIV virus to mutate into a drug-resistant form.

Since then, the virus has found a new lease on life in his body, sapping both his immune system and his hopes for the future.

Ditching his current pills and switching to so-called "second-line" drugs would almost certainly bring Dey's disease back under control.

Unfortunately, these drugs are so expensive that even the Indian government, which pays for Dey's now useless first-line drugs, says it cannot afford to include second-line drugs in its national program.

A month's supply costs between 4,000 and 8,500 rupees ($85-$180), compared to the 450 rupees cost for first-line drugs.

Dey's job as a counselor to other HIV sufferers pays about 4,000 rupees a month, barely enough to cover the rent, feed his family and school his 6-year-old son.

Although India is one of the world's largest manufacturers of generic antiretrovirals, Dey has no idea how to get his hands on second-line drugs that could prolong and improve his life.

"I don't know what's going to happen," Dey said. "Whatever God will do I must accept."

AIDS researchers will debate the plight of people like Dey and other issues at the 16th International AIDS Conference, the world's biggest conference about the disease, in Toronto next week.

SECOND-LINE MUST WAIT

One in every seven HIV-positive people lives in India, home to an estimated 5.7 million people with the virus, according to UNAIDS, the United Nations' HIV and AIDS prevention agency.

A good half a million of those are likely to have immune systems so weak that they need antiretroviral drugs.

Of these, the government reaches only 35,000 people -- or 7 percent -- with free first-line drugs through its National AIDS Control Organization (NACO).

Many people, particularly in rural India, simply do not know they have the virus and die without treatment.

India is finalizing this month the next five years of its AIDS control strategy and has decided it is more important to get more needy people taking first-line drugs than to introduce second-line medication, according to the World Health Organisation's Dr Po-Lin Chan, an adviser to the program.

The country, which began its free antiretroviral program in 2004, aims to get 300,000 people on first-line drugs by 2012.

"We have to ask ourselves what the priorities are," said Chan. "Probably 90 percent of patients will need first-line drugs for quite some time, so let's keep them on them as long as possible."

But critics say problems in the first-line drug delivery systems are causing resistance to become more widespread.

PROBLEMS AHEAD

Immunity to first-line drugs develops particularly quickly -- perhaps within a year or two -- if AIDS patients repeatedly fail to gulp down their two or three pills a day.

Even among the most diligent takers of pills, NACO expects 2 to 3 percent of these patients to develop immunity annually -- at least 1,000 HIV patients every year at current treatment volumes.

But many other patients are developing resistance because they have been poorly advised or because clinics have run out of drugs -- problems NACO is working hard to fix.

A forthcoming study by the YRG Center for AIDS Research concludes that between 15 and 20 percent of antiretroviral patients in the south Indian city of Chennai have a strain of HIV immune to first-line drugs.

Second-line drugs are more expensive than first-line medications because they are made using a more complex synthesis process out of costlier raw materials and are given in higher doses.

Economists say the gap would narrow if governments around the world moved jointly to include the drugs in their programs.

"I think prices can be considerably lower than they are today," said Indrani Gupta, head of the health policy research unit at New Delhi's Institute of Economic Growth.

"But there isn't yet a critical mass of demand for second-line drugs so there's no incentive for manufacturers to bring down prices," he added.

A DIFFERENT APPROACH

For the time being, Brazil remains the only "resource-strapped" country to supply free second-line drugs to its citizens, says the WHO's Chan.

It spends considerably more on its HIV/AIDS program than India despite having roughly a tenth of the caseload, with most of its budget spent on treatment.

By contrast, India spends the bulk of its money -- a total of $200 million for 2006 to 2007 -- on AIDS prevention programs rather than treatment. But not everyone believes it has struck the right balance.

So long as few people have access to second-line drugs, there is a greater risk of first-line-resistant strains of HIV becoming more widespread.

But even more fundamentally, India needs to identify and treat HIV-positive people to prevent the virus spreading.

Loon Gangte of the Delhi Network of Positive People advocacy group, said a good treatment program including a second-line treatment option can help encourage suspected HIV sufferers to get themselves diagnosed and take precautions.

"Prevention starts with positive people," says Gangte, who is himself HIV positive.

"Two people without HIV can have sex a thousand times in one night and they're not going to get HIV. But if I go tonight and have sex with one man there is a risk of passing on the infection."

($1=46.5 Indian rupees)