Challenging Dogma

...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

Sex Work, Homosexuality, and HIV Discrimination: Social Limitations of India’s National AIDS Control Program (NACP) - Divya Reddy

More than 4.5 million people in India are infected with HIV, making it the second-largest HIV-positive population in the world, behind South Africa. Given India's large population, a rise of even 0.1 percent in the prevalence rate would increase the number of persons with HIV by 500,000 (1). AIDS is most prevalent in the Indian states of Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu, where the infection rate is higher than 1 percent (2). The World Health Organization estimates that 330,000 new AIDS cases occur in India each year and predicts that by 2033, AIDS will account for 17 percent of all deaths in the country (3). Such overwhelming numbers are a clear indication of the magnitude of the problem, suggesting the need for strategic interventions for the prevention and control of HIV/AIDS.

Soon after the first HIV/AIDS case was documented in 1986, the Indian government recognized the seriousness of the problem and undertook a series of important measures to tackle the epidemic (2). A multi-sectoral strategy for the prevention and control of HIV/AIDS was formulated with a focus on the following areas (4):

§ Program Management

§ Surveillance and research

§ Information, Education and Communication including mobilization through Non-Governmental Organizations (NGOs)

§ Control of Sexually Transmitted Diseases

§ Condom Programming

§ Blood Safety and

§ Reduction of impact

Eight years into the program, the government has achieved commendable success in creating awareness among the general population, and particularly among high risk groups like sex workers, intravenous drug abusers, migrants, and truck drivers. Educating them about the seriousness of HIV/AIDS, informing them about the modes of disease transmission, and precautions that can be taken to prevent the transmission of the infection has been the traditional approach followed by most of the HIV/AIDS prevention programs (5). The main focus of these programs is on the medical aspect of the infection. However, HIV/AIDS is currently not just a medical challenge, but also a political, social and an economic challenge. Behavior change, the key solution to the problem, will not occur without significant changes in all of these environments (6). The National AIDS Control Program fails to identify and target these non-medical factors.

The Structure and Pattern of Female Sex Work in India:

The Female Sex Workers (FSWs) in India can be classified into three categories: brothel-based, home-based, and street-based sex workers.

Due to social and legal problems there are no reliable estimates of the number of these FSWs in India. The Tata Institute of Social Sciences (TISS), Mumbai, estimates the numbers of FSWs to range from 1.0 to 16.2 million, out of which 2 million are estimated to be brothel-based FSWs (7). Brothel-based FSWs primarily solicit clients through an agent (such as pimp or madam) or a mediator and provide services at a brothel. The main method by which NACP targets them is by identifying the red light areas and brothels, getting the FSWs tested for HIV, and educating them about condoms and their right to be protected against this infection. This has controlled the transmission of HIV to a considerable extent.

However, it is also estimated that about 1.1% of adult women in India are engaged in home- and street-based sex work (8, 9). For the most part, these women are not identifiable and remain inaccessible to HIV prevention programs, thereby undermining HIV prevention efforts.

Ethnographic research has clearly shown that there is great diversity in the patterns and organization of sex work in India. For example, the most common form of traditional sex work in Karnataka is associated with the Devadasi system (10). In brief, the Devadasi tradition involves a religious rite in which girls and women are dedicated, through marriage, to different gods and goddesses, after which they become the wives or servants of the deities and provide sexual services to priests and patrons of the temples. This activity has been referred to by some as “sacred prostitution” (11, 12). The Devadasi women, like most other home-based sex workers, have a very distinctive way of functioning compared to the brothel-based sex workers. They tend to work more in rural areas providing sexual favors at their homes. They are independent and do not have an agent or a mediator. Their low level of education and India’s patriarchal system puts these women in a subservient position and as a result they are more likely to be exploited. Consequently they have less control over their own bodies and lack negotiating skills for their protection (13, 14).

The street-based FSWs also form an unreachable group because Indian society discriminates against FSWs as immoral women. Therefore many of them deny that they are sex workers in the first place. Further, most of the families of these women are unaware of their sex work. This group of FSWs, with lower social support, is relatively less likely to use and have access to preventive measures such as condoms (15).

Failure to acknowledge being a sex worker is more of an issue with the non-brothel based FSWs because being in a brothel can be interpreted as an acknowledgment of sex work. This unique characteristic of non-brothel based sex workers makes it difficult to organize them as a group that could be empowered to protect themselves and participate in HIV prevention efforts (16, 17).

Homosexuality in India: Repressed and Denied

Unlike most of the countries in the developed world, which are open to gay communities and accept homosexuality, many developing countries, like India discriminate against homosexuals (18-20). In such societies, men who have sex with men (MSM) are often under stress because of the social ostracism and the stigma associated with homosexuality. Globally 5-10% of all HIV cases are due to sexual transmission between men who have sex with other men (MSM) (21). In 2001, the contribution of MSM to the HIV/AIDS epidemic in India was officially reported at 1 percent (22). These figures are questionable, as the data available on the prevalence of male same-sex sexual activity across various parts of the country is scarce and unreliable.

In India, men who have sex with men (MSMs) form a diverse and often hard-to-reach group, spanning nearly all age groups and socio-economic backgrounds. MSMs include youth experimenting with sex who find male partners more available than women and cheaper than sex workers; bisexual men who marry and father children while continuing to have sex with men; and a tight-knit core group of men who self-identify as homosexuals (gays, homos). This core group shares a strong sub-culture, including a special vocabulary that allows them to communicate with each other. However, most MSMs hide their behavior from others, even from their families, realizing that society strongly disapproves of it. Because of this, MSMs in India are more numerous than most people realize (23).

Fearing stigma and discrimination from society, men who have sex with men are less likely to come out in the open. In India, there are laws against homosexual behavior, which complicates the situation even more. For these reasons the HIV prevention efforts of the NACP fail to target this high risk group sufficiently and this group has limited access to HIV prevention and care facilities.

Sexual networks - The specific sexual links between infected and uninfected individuals.

Sexual networks constitute the paths through which sexually transmitted infection (STI) agents flow and become distributed in a predictable pattern along the structures of society. The sexual network in India is large, and NACP does not pay adequate attention to the dynamics of this network.

The AIDS Epidemic Update, December 2005, by UNAIDS reported that a significant proportion of new infections in India were occurring in women who are married and who have been infected by husbands who frequented sex workers. This is an alarming trend, as these women are not targeted by HIV prevention programs and they can get pregnant and pass on the infection to their children (24). Testing all pregnant women for HIV would therefore be an effective intervention strategy to control the spread. Similarly, NACP only examines the impact of HIV on prostitutes and society by testing them for HIV antibodies, but it does not examine the role of others in the sex industry such as transvestites, transsexuals, male prostitutes, bar and brothel owners, taxi drivers, sex workers' partners, and sex business managers (25). Due consideration should be given to all of them as they play an integral role in transmitting HIV.

The factors influencing the structure, formation, and maintenance of sexual networks include patterns of sexual mixing, concurrency of sexual partnerships, and the existence of sexual bridges (26). As there are huge variations in the size, behavior, and disease burden among high-risk groups in India, it is important to study the interaction of these groups with the bridge populations, the migration and mobility of the bridge populations, and their interactions with the general population (27).

Sexual network analysis can thus provide unique insights into the spread of HIV that traditional individual-based epidemiological methods cannot capture (28). This can help explain why certain program strategies work well in some settings and populations but not in others. The success or failure of an intervention could then be pinpointed to differences in the organization of sex work, the social and cultural characteristics of FSWs, the prevailing political and economic situation, the implementation process of the prevention program, or a combination of all of these (29–32).

Stigma in health settings: An unresolved problem

People living with HIV/AIDS fear stigma and discrimination from society. This fear has been further compounded by discrimination against them by health care workers. These people prefer not to come out in the open and seek treatment, services, or support, thereby hindering effective control responses.

A National AIDS Research Institute-Yale University (USA) study conducted in a high-prevalence city in Maharashtra, India, used qualitative and quantitative methods to document stigma in health settings (33, 34). The study showed that clinicians exhibited a wide range of feelings about HIV-positive patients based on moral attributions about individuals’ past “misbehavior,” and “misconduct”. Initial testing and disclosure often occurred without counseling or the patient’s knowledge or consent. Having a separate AIDS ward, and writing HIV diagnoses on open charts served to facilitate discrimination against HIV/AIDS patients. There have been cases of refusal of treatment and other services to AIDS patients in hospitals and nursing homes both in government and private sectors.

The control of HIV infection is possible only by adequately addressing prevention and treatment issues. It is crucial to provide an environment of empathy and sensitivity to these patients in order to enable them to muster the courage to reveal their HIV status. NACP should therefore urgently address hospital-staff’s inconsistent knowledge, beliefs, and standards of care for HIV positive patients. Clear and candid information given through comprehensive training on HIV/AIDS care standards, universal safety precautions, and compassion to patients should be provided.

Social consequences of HIV/AIDS: A new phase of the HIV pandemic

In India, HIV/AIDS has been traditionally associated with high-risk and socially disfavored groups such as FSWs, MSMs, intravenous-drug users, migrants, and truck drivers. A person diagnosed with HIV/AIDS is thus faced with a dual stigma, first from identification of AIDS as a serious incurable illness, and second from the identification of AIDS with persons and groups already stigmatized due to their behavior prior to the epidemic (35, 36).

Stigma directed towards HIV-positive people may perpetuate the epidemic in several ways. First, fear of being stigmatized leads some to avoid HIV testing. Lack of knowledge about one’s sero-status may in turn lead to inadvertent transmission of the virus and delays in initiating treatment. Second, among those who have been tested and are HIV-positive, stigma constitutes a chronic stressor that may contribute to difficulty coping, inadequate self-care, and difficulty with safer sex negotiation and condom use (37). Sero-positive men and women are often shunned by family, friends, and intimate partners, and overt acts of discrimination in employment, health-care, and housing-related settings are not uncommon. Social rejection, disapproval, and discrimination related to HIV may heighten a person’s sense of shame regarding their illness and serve to lessen their motivation to maintain optimal health. Safer sexual practices may also be undermined by stigma-related experiences. Condom use negotiation may be inhibited because discussions about the need for safer sex often lead to questions about a partner’s sero-status.

The repercussions of HIV related stigma are so severe that these patients prefer to succumb to the disease rather than seeking medical help and improving their quality of life (38-40). This is highly detrimental to HIV prevention and control strategies. HIV/AIDS stigma exists at individual and societal levels, and all attempts to eradicate this stigma should target both these levels. The National AIDS Control Program in India needs to shift from being an individual-based epidemiological model to a social-based epidemiological model. There is an urgent need for public policies to address issues of prevention and treatment by establishing social norms based on acceptance and respect for HIV-infected persons.


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