"The overwhelming majority of infections in India occur through heterosexual sex"

A beggar woman sitting on a road crossing amidst the rush of traffic on a sunny afternoon.

Priyesha K. Nair

"Look at Me" by Khona Dlamini (poet, South Africa)

(copyright Art For Humanity)

Look at me
see me
do not let your eyes
turn away from the contours of my being
i am the child whose life
is ordered by numbers
who is mothered by the social system
fathered by the education system

look at me
not through me

let butterflies flow from your lips
to caress the catacombs in my heart
so that i
can
taste
LOVE
and know that

I AM/MATTER

look at me
not through me

"HIV and AIDS in India" by Avert

• "The overwhelming majority of infections in India occur through heterosexual sex."
• "HIV prevention and intervention strategies need to focus on married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behaviour of their husbands."
• "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...  migrants and other mobile individuals are bridge populations for HIV transmission from urban to rural areas and between high-risk and low-risk groups."
• "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."
• "Stigma and discrimination against sex workers means they can find it difficult to access healthcare, even if they actively seek it.
• "In India, many 'men who have sex with men' (MSM) do not consider themselves homosexual, and many have female partners and/or are married."
• "Transmission through injecting drug use is a major driving factor in the spread of HIV in India...  The alarming levels of infection occurring through needle-sharing have implications that extend beyond networks of drug users."
• "Prisons are in general high-risk environments for drug use and HIV transmission because of overcrowding, poor nutrition, limited access to health care facilities, continued drug use, unsafe injecting practices and unprotected sex."
   

"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.

 
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. 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. "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; women now account for around 39% of adult infections. 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.  Studies have shown that intimate sexual partner violence is also a risk factor for women.

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 stated aim of the third phase of India's National AIDS Control Programme (NACP III) is to halt and reverse the spread of the HIV epidemic in India by 2012. NACO aims to achieve this with targeted interventions that focus on high risk groups and 'bridging populations'. The high risk groups identified are female sex workers, men who have sex with men, and injecting drug users. The bridging populations, those who are the most likely to spread HIV into the wider population, are migrant workers and truck drivers.

Sex Workers

Women often get involved in sex work 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. This means that police hostility and brothel raids can be justified by the authorities. Stigma and discrimination against sex workers also means that they can find it difficult to access healthcare, even if they actively seek it.

One of the most successful initiatives among sex workers 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 and 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 are 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.

"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%.  HIV prevalence among sex workers in the area fell from 11% in 2001 to less than 4% by 2004. 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.

 
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.

"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".

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.

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. As part of the third phase of the National AIDS control programme (2007-2013) 60 truckers interventions have been set up at major trans-shipment locations tasked with providing behavioural change education, condom and STI services to truckers. So far these interventions reach about 1.4 million out of an estimated 3 million truck drivers.

Other campaigns have targeted the wives and partners of truck drivers, who often become infected when their partner returns home after a long absence. The HIV epidemic is found to be the highest among women whose spouses work in the transport industry. 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."

 
Injecting Drug Users

Transmission through injecting drug use is a major driving factor in the spread of HIV in India...  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.
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. The estimated HIV prevalence among MSM in India is 7.3 % but difficulties in surveying this stigmatised group mean prevalence could be much higher.

In India, many 'men who have sex with men' (MSM) do not consider themselves homosexual, and many 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.  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.

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. 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.

 
Migrant workers

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. Studies from across the world have linked migration to multiple sexual partners and increased HIV transmission. 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.

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.

"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

According to the Indian government, "clients of sex workers are the single most powerful driving force in India's HIV epidemic" and long distance truckers and male migrants both make up a significant proportion of the clients of sex workers.  Despite this risk, migrants have the lowest perception of risk in all high prevalence states. For example, in Andhra Pradesh, 60 percent of female sex workers believe they are at risk of HIV infection, compared with only 5 percent of male migrants.

A study in 2008 identified a notable proportion of contractual workers who had used alcohol and engaged in paid and unpaid sex with women.  The study also showed a significant number of the men had not used condoms, highlighting the need for increased prevention efforts among this group. NACO recommend targeted HIV prevention programmes primarily for men who are both migrants and part of high risk sex networks, due to the extremely large size of the migrant population in India.

 
Conclusion

There is evidence that some prevention strategies have been successful in reducing HIV prevalence among certain groups in India. However despite these successes, there are still around 2.3 million people infected with HIV and many parts of India's epidemic remain unnoticed. The risk of HIV infection among male sex workers, and the role of MSM in the epidemic, are just two largely ignored areas. As well as addressing high prevalence groups, more attention is needed for people perceived to be at low risk, such as married women, as HIV spreads amongst the general population.
"HIV prevention and intervention strategies need to focus on married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behaviour of their husbands".

AVERT has more information about prevention, stigma, treatment and the future of the HIV/AIDS epidemic in India.