SIDA & VIH
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. However, HIV prevalence among certain groups (sex workers, injecting drug users, truck drivers, migrant workers, men who have sex with men) remains high and is currently around 6 to 8 times that of the general population.1
A general problem
It is thought that HIV has spread among the general population in India because the epidemic has followed what is know as the 'type 4' pattern.2 This is where new infections occur first among the most vulnerable populations (such as injecting drug users and female sex workers), then spread to 'bridge' populations (clients of sex workers and sexual partners of drug users) and then finally enter the general population.3
“The overwhelming majority of infections in India occur through heterosexual sex.”
In contrast to the common perception that HIV is transmitted predominantly through injecting drug use and sex between men, the overwhelming majority of infections in India occur through heterosexual sex;4 women now account for around 39% of adult infections.5 In many cases married men have acted as 'bridge populations' between vulnerable populations and general populations; women who believe they are in monogamous relationships are becoming infected because their husbands have had multiple sexual partners. Often social norms restrict women from making decisions about their sexual relations, contributing to their vulnerability to HIV.6 Studies have shown that intimate sexual partner violence is also a risk factor for women.7
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.
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.8 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.9
Members of the Vamp sex workers collective meeting with a local NGO.
Sangli, India, 2005.
HIV prevalence among sex workers varies between districts and states, although there has been a general decline in prevalence in recent years.10 One study found prevalence ranged between 2 percent and 38 percent (averaging at 14.5 percent) among districts in the four high prevalence south Indian states Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka.11
In the city of Mysore, southern India, around a quarter of sex workers are infected with HIV.12 This situation is not surprising given that in one study only 20 percent of sex workers had always used condoms with commercial clients in the past month.13
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 take a firmer stance on condom use when negotiating with clients.14
"Now the card-holders feel they are part of the mainstream. Their self-esteem has gone up." - Sushena Reza-Paul, Karnataka Health Promotion Trust15
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. 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.16
“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.”
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%.17 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 2004.18 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.19
A neglected group of people who may be at risk of HIV infection in India is male sex workers (MSW). One study in suburban Mumbai reported an HIV prevalence of 33 percent among the study group (17 percent in men and 41 percent in transgenders).20 All of the individuals in the study had reported anal sex and 13 percent had never used a condom, highlighting the need for increased attention and prevention efforts among this group.
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. A 2008 study showed that nearly a third of the long-distance truckers had paid for sex in the past twelve months.21
"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". - 22
Sometimes, relations with sex workers occur 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.
A member of the sex worker community educating truck drivers near Sangli.
India - 2005
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.23
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.”24
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%.25
Injecting drug users
Nationally, HIV prevalence among injecting drug users (IDUs) appears to have declined slightly in recent years to around 7 percent in 2006.26 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. One study found HIV prevalence ranged from 23 percent to 32 percent in different areas of Manipur.27 In 2006 new sites of high HIV prevalence among IDUs were identified in Punjab, Tamil Nadu, West Bengal, Kerala and Maharastra.28
“Harm reduction is the urgent, practicable and feasible HIV prevention method among Injecting Drug Users and their sex partners.”
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.29
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.30 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.”31
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.
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.32
Prevention work with men who have sex with men in India.
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.33 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 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 34
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.35 It is hoped that since the law that criminalises homosexuality was abolished in July 2009, MSM will be easier to reach with HIV prevention, treatment and care services.36
Migrant workers
Studies from across the world have linked migration to multiple sexual partners and increased HIV transmission.37 It has been said that migrants and other mobile individuals are bridge populations for HIV transmission from urban to rural areas and between high-risk and low-risk groups. A large number of people move around India for work; it is estimated that 258 million adults in India are migrants, the majority are men migrating for employment.38
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. 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. Therefore not all migrants are at equal risk of HIV.39
“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 40
