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Who is affected by HIV and AIDS in India?

HIV and AIDS affect all segments of India’s population, from children to adults, businessmen to homeless people, female sex workers to housewives, and gay men to heterosexuals. There is no single ‘group’ affected by HIV.

A general problem

In contrast to the common perception that HIV only affects injecting drug users and gay men, the overwhelming majority of infections in India occur through heterosexual sex. In large numbers of cases, women in monogamous relationships are becoming infected because their husbands have had multiple sexual partners. Women currently account for 39% of HIV infections in India, and it is thought that this figure is rising. ¹

Another significant trend is that most of the people becoming infected are in the sexually active and economically productive 15 to 44 age group. This means that most people living with HIV are in the prime of their working lives. Many are supporting families.

The people living with HIV in India are incredibly diverse, and many would not be considered to be members of ‘high-risk groups’. Nonetheless, it is possible to identify certain populations that face a proportionately greater risk than others. These risk groups include sex workers, injecting drug users, truck drivers, migrant workers and men who have sex with men.

Sex workers

Sex work is very widespread in India, and occurs on a much larger scale than in many other countries. Women often get involved as a result of poverty, marital break-up, or because they are forced into it. Although sex work is not strictly illegal in India, associated activities - such as running a brothel – are. The government has plans to introduce stricter legislation in regard to sex work, a move that has been opposed by organised sex worker groups who claim that such legislation would just push the trade underground and make it harder to regulate. ² It would also make it more difficult to reach sex workers with information about HIV, at a time when misinformation about AIDS among this group is rife – for instance, one national study suggests that 42% of sex workers believe that they can tell whether a client has HIV on the basis of their physical appearance. ³

Sex workers in the city of Mysore, southern India, are heavily affected by the AIDS epidemic. Around 26% of sex workers in Mysore are living with HIV – a situation that is unsurprising given that only 14% of sex workers in the city use condoms consistently with clients, and 91% never use condoms during sex with their regular partners.⁴ In comparison, 80-90% of sex workers in Tamil Nadu state report condom use, which correlates with a relatively low HIV prevalence of 9%. ⁵

One way in which authorities are trying to tackle the epidemic among sex workers in Mysore is through a ‘smart card’ scheme. Sex workers are provided with cards that contain their medical details, which must be presented at a health check up at least once every three months to remain valid. On the condition that these appointments are attended, the card can be used to get discounts for food and clothes in certain shops. As well as encouraging sex workers to look after their health, this initiative raises sex worker’s self-esteem by integrating them into mainstream culture. In turn, this can help them to taker a firmer stance on condom use when negotiating with clients. ⁶

Another positive initiative – possibly the most successful of its kind in India - has been the Sonagachi project, named after the district of central Kolkata (Calcutta) where it is based. This project was started in 1992, with the aim of reaching out to sex worker communities and helping them to overcome HIV on their own terms. Its approach is based around three R’s: Respect, Reliance and Recognition – respecting sex workers, relying on them to run the program, and recognising their professional and human rights. ⁷ Sex workers have been trained to act as peer-educators, and sent to brothels to teach others about HIV and AIDS, and the importance of using condoms with clients. The campaign also addresses the social and practical barriers that prevent sex workers from using a condom. Madams and pimps are educated about the economic benefits of enforcing condom use in their brothels, and police have been persuaded to stop raiding brothels, because such raids often resulted in sex workers losing income, making them less likely to insist on condom use. ⁸

By helping to put sex workers in a position where they can respond to their own needs, the Sonagachi project has achieved impressive results. Between 1992 and 1995, condom use among sex workers rose from 27% to 82%. By 2001, it was 86%. ⁹ The project continues to have an impact, with HIV prevalence among sex workers in the area falling from 11% in 2001 to less than 4% by 2004. ¹⁰ The Sonagachi project has become internationally famous for its achievements, and the UN has used the project as a ‘best practice’ model for other sex worker projects around the world. ¹¹

Read more about HIV prevention and sex workers.

Injecting drug users

Nationally, HIV prevalence among injecting drug users appears to have declined slightly in recent years, from 13% in 2003 to 10% in 2005. ¹² However, transmission through injecting drug use is still a major driving factor in the spread of HIV in India, particularly in north-eastern areas, such as Manipur and Nagaland and urban areas outside the north, such as Mumbai, Kolkata and Chennai. New epidemics fuelled by drug use are also emerging in Dehli, West Bengal and Pubjab. ¹³

The alarming levels of infection occurring through needle-sharing have implications that extend beyond networks of drug users. Some of those who inject drugs are also sex workers or truck drivers, and many are sexually active, which can result in infection being passed on to their partners. Experts have argued that there needs to be more information aimed at both injecting drug users and their sexual partners. ¹⁴

The Indian government’s approach to drug use is based around law-enforcement and prosecution, with very little done in terms of treating drug users or helping them to stop using drugs. Harm reduction – a method of HIV prevention that has been successful in other countries, which acknowledges that drug use occurs and seeks ways to reduce HIV transmission in this context – has not been adopted in the government’s drug policies. ¹⁵ Some states, however, such as Manipur, have adopted their own harm reduction policies and consider that:

“Harm reduction is the urgent, practicable and feasible HIV prevention method among Injecting Drug Users and their sex partners.” ¹⁶

In the majority of Indian states, though, tough regulations on drug users make it hard to reach this group with HIV messages, and to survey how they are being affected by the epidemic.

Read more about injecting drug users and HIV.

Truck drivers

India has one of the largest road networks in the world, involving millions of drivers and helpers. Truck drivers spend long periods of time away from home, and it is common practice for them to have relations with sex workers while on the road. 24-34% of truck drivers in various surveys have reported engaging in sex with commercial sex workers. ¹⁷ Sometimes, this occurs at roadside ‘dhabas’, which act as both brothels and hotels for truck drivers. In other cases, drivers stop to pick up women by the side of the road, and transport them to another area after they have had sex with them. Both truck drivers and sex workers move from area to area, often unaware that they are infected with HIV.

”There is no entertainment. It is day-in-day-out driving... When they stop, they drink, dine and have sex with women. Then they transfer HIV from urban to rural settings.“¹⁸

There have been a number of major HIV/STI prevention projects aimed at truckers, many of which have aimed to promote condom use. Some of these projects include not just truckers, but also other stakeholders such as gas station owners and employees. A specific example from Mumbai is the AIDS Workplace Awareness campaign, which is mandatory and which targets the drivers at the regional transport authority, where the drivers get their licenses renewed annually. ¹⁹

Other campaigns have targeted the wives and partners of truck drivers, who often become infected when their partner returns home after a long absence. Yet as the testimony of one woman in Vijayavada demonstrates, these campaigns do not always manage to reach those at risk:

“My husband is a truck driver and I got HIV through him. I had never heard of HIV or condoms before that and because I can't read, I couldn't understand any of the posters or banners.” ²⁰

There are signs that some efforts to prevent HIV among truck drivers have been successful. For example, a recent survey of truck drivers in Tamil Nadu - carried out after an HIV prevention program - found that the proportion of drivers who reported engaging in commercial sex declined from 14% in 1996 to 2% in 2003. Of those who did report having commercial sex, the proportion that had not used a condom the last time they did so fell from 45% to 9%. ²¹

Men who have sex with men

Sex between men is highly stigmatised in India and is not openly talked about, making it easy for people to underestimate how commonly it occurs. Studies have shown that sexual activity between men is relatively common in both urban and rural areas of India, although it is illegal. ²²

In India, many men who have sex with men (MSM) do not consider themselves homosexual, and a large number have female partners. A large study in Andhra Pradesh found that 42% of MSM in the sample were married, that 50% had had sexual relations with a woman within the past three months and that just under half had not used a condom. ²³ As such, unprotected sex between men can also present a risk to any women that they may subsequently have sex with.

The stigma surrounding MSM, and the fact that their lifestyles are criminalised, makes it hard for both the government and NGOs to reach them with information about HIV. Outreach workers and peer educators working with MSM have frequently been harassed by police, and in some cases arrested. In 2001, four members of the Naz Foundation Trust (an Indian NGO that works with MSM and other groups affected by HIV) were jailed for 47 days after police raided their offices:

“I was arrested for promoting homosexuality. The leaflets we use for our outreach work were dubbed obscene. The police claimed that the replica of a penis used to demonstrate the proper use of condoms was actually a sex toy!” - Arif Jafar, Naz Foundation ²⁴

Since conditions are so restrictive, there is little information available to MSM in India. Because so many MSM also have heterosexual relationships, there is a high chance that rising levels of infection among MSM in India will aggravate the epidemic among the general population. ²⁵

Migrant workers

Large numbers of Indians have moved around within India, to neighbouring countries or overseas, in order to work. In some parts of India, three out of four households include a migrant. ²⁶

“Being mobile in and of itself is not a risk factor for HIV infection. It is the situations encountered and the behaviours possibly engaged in during mobility or migration that increase vulnerability and risk regarding HIV/AIDS.” - UNAIDS ²⁷

In many cases, migration does not change an individual’s sexual behaviour, but leads them to take their established sexual behaviour to areas where there is a higher prevalence of HIV. ²⁸ For some, though, migration does change their sexual behaviour. Long working hours, isolation from their family and movement between areas may increase the likelihood that an individual will become involved in casual sexual relationships, which in turn may increase the risk of HIV transmission. Cultural and language barriers can also make it harder for workers to access health services and information about sexual health when they are away from their home communities.

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AVERT.org has more about:

• HIV & AIDS in other regions and countries
• An overview of HIV in India
• The Caribbean and HIV & AIDS
• Sex workers and HIV/AIDS