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
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
The Female Sex Workers (FSWs) in
Due to social and legal problems there are no reliable estimates of the number of these FSWs in
However, it is also estimated that about 1.1% of adult women in
Ethnographic research has clearly shown that there is great diversity in the patterns and organization of sex work in
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).
Unlike most of the countries in the developed world, which are open to gay communities and accept homosexuality, many developing countries, like
Fearing stigma and discrimination from society, men who have sex with men are less likely to come out in the open. In
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
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
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
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
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
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