By Prakruti Maniar:
When was the last time you had a discussion about HIV/AIDS?
I had one in school. Sex education classes and a small chapter on the topic in textbooks were my last conscious interaction with the subject. And all somehow only preached abstinence and eventual monogamy as the only solution. Somehow, in our obsession with trying to curb sexual activity, we forgot to face reality. This article looks to provide a perspective regarding how one can target high-risk groups without coming across as a condescending breed of moral police.
It’s been 30 years since a case of HIV first emerged and recently scientists traced back to where HIV emerged — Kinshasa, the capital of the Belgian Congo. This was in 1920. One of the main reasons attributed to its spread was the colonial railway network to parts of central Africa. And the problem of mobility persists, in the form of migrants and truck drivers who are largely ignored and kept out of the focus of HIV intervention.
HIV or the human immunodeficiency virus, is the cause for AIDS, which is the last stage of HIV. Before any discussion of the subject is to be held, it must be remembered that, if checked for early on, one can live a healthy and long life with HIV and prevent it from growing into AIDS. With proper treatment, called “antiretroviral therapy” (ART), you can keep the level of HIV virus in your body low and in check through medication.
What’s new?
The problem again lies not with the amount of information available but our society’s acceptance of it, reaction to it and most importantly, the willingness (or lack of it) to bring a change in our collective attitudes. Basics continue to elude major chunks of the population whose first reaction at the mention of the word is to sit on the high seat of moral judgement.
India ranks third in number of people living with HIV and accounts for more than half the AIDS related deaths in Asia-Pacific. In 2012, 140,000 people died in India due to it. HIV and the high-risk populations included sex-workers, transgenders, men who have sex with men, and migrants.
But the problem of tackling the spread of the epidemic lies in the sociological understanding of people. The difficult part is that HIV has no symptoms, only many years later as it grows to AIDS, do signs show. Regular check-ups thus are essential to curb it at the first levels, and given the taboo surrounding the subject of sex itself, a routine of this kind is unlikely.
Yet India has a host of mechanisms in place — National AIDS Control Organization (NACO), State level AIDS Societies etc., to battle the problem. Their primary focus is sex workers and transgender communities. It has been observed that intervention levels are as high as 80% in these sections. MSM is a trickier issue, especially with the re-criminalisation of gay sex in 2013. Yet, if one has to look at the broader picture — these groups seem relatively better off. They roam in integrated communities and it is easier to target solutions at them. Chances are that 90% of say, sex workers, could be covered in one shot simply because they will be present in clusters which are easily traceable.
This is where migrants and truck drivers require special focus –
There are about 7.2 million migrants in India, with an HIV prevalence of 1 percent. Only 41.3 percent are covered in the HIV prevention activities. On the other hand, there are 2 million truckers with a prevalence of 2.6 percent according to Avert, and 4.6 percent according to some independent surveys, and HIV prevention coverage is 48.4 percent. An estimated 36 percent of the sex worker clients are truck drivers. It doesn’t take a lot to connect the dots. The migrants and truck drivers are hidden threats, looming in dark streets and being the harbingers of the virus, ravens who need to be attended to carefully.
“Truckers and migrants form what is called in AIDS intervention terms as a “bridge population” since they interact with the high risk groups like sex workers, and may risk to transmit HIV to their wives, partners and so on and from high-risk to low-risk areas” says Proshant Chakraborty who has worked as a field researcher for an independent monitoring and evaluation team for the Mumbai District AIDS Control Society (MDACS), between 2011-2012.
The prime destinations for the migrants include Maharashtra, Andhra Pradesh, and Karnataka, which are also states with high HIV prevalence. Maharashtra is also a destination for International migration. A research on Nepali migrants found that a lot of the male returnees had HIV or syphilis, infections presumed to have occurred during contact with Indian sex workers.
There is no one major problem in curbing this issue. Many small difficulties, as discussed below, weave together –
1. Limited data – Numerous surveys have been conducted to dig deeper into this problem. It has been a pattern that a good number of the sample population were hesitant to divulge if they had had sex with transgenders or indulged in MSM. The social stigma attached with the topic is high and not everyone comes forward to talk about it.
2. They have low risk perception of HIV. A study in Andhra Pradesh found that 60 percent of female sex workers acknowledged their risk to HIV as against 5 percent of the male migrants. This is glaring. It reveals how HIV prevalence has been restricted to just one side of the prostitution industry — the client-point of risk is hardly considered (sexism anyone?). This partial understanding of target groups needs stop.
3. General awareness of HIV in itself is a huge problem. By 2014, there were nearly 15,000 healthcare facilities offering HIV testing and counselling. Only 13% of people living with HIV in India are aware of their status.
4. Comments of new Health Minister notwithstanding, India has seen a steady increase in condom awareness, 60 percent on an average, truck drivers interviewed have reported inconsistent use of condoms with both paid partners and wives.
5. Drugs-Alcohol-Education-Working Conditions — Put yourself in their shoes. You’re staying away from home for days on stretch, you drive all day through all sorts of terrains, you hangout with guys your age. Cheap booze and cheap sex are readily available. Remember, you are from a background that is less educated and have even lower levels of awareness. It doesn’t take rocket science to connect the dots.
6. “Also, since the State AIDS Control Society are responsible for the activities within each state, it becomes difficult to coordinate between states when it comes to reaching out to migrants and truckers. Lack of information, stigma and the sense of “shame” associated with HIV acts as a hindrance to communication” adds Proshant.
7. A report on October 1 suggested that India could run-out of a critical medicine in its free HIV/AIDS programme in three weeks, thanks to bureaucratic incompetency, potentially risking lives of 150,000 patients. Forget targeting relief, even general measures seem to be in shambles.
What is being done?
Lack of medicines aside, NACO has started several projects to target high-risk communities. Project Kavach is one of them, reaching out to 21,000 truckers in a year in Panjabi Bagh and Magol Puri.
The specific objectives:
– Using Behaviour Change Communication (BCC), with the help of current and ex truckers, for adopting safer sexual behaviour and practice.
– Promoting use of condom among long distance truckers through improving access to clinic services.
– Reducing the incidence of various sexually transmitted infections (STI) through appropriate clinical intervention.
The results have shown — With the support of 20 transport companies, there has been a shift in percentage of drivers using protection — 5 to 60 in the last decade.
In 2012, there was a count of truck drivers in Chandigarh in the high risk group who can transmit HIV. National AIDS control organization (NACO) has given its consent as it believes that the truckers from all the three adjoining states have their transit here.
“So far, the most common way to reach out to truckers and migrants are IEC (Information, Education, Communication) strategies, like street plays in truckers junctions, construction sites and so on. Sex with sex workers is also normalised as a biological need, but one that needs to be done with protection” says Proshant. Many large construction sites collaborate with MDACS and NGOs, and give basic services to migrant workers.
However, it isn’t enough and a lot more can be done. It would seem that in curbing the spread of HIV, eventually we will need to acknowledge and accept several realities — people have sex, people pay for it too. Like Proshant said, normalising it is a crucial step in breaking the ice of taboo that makes all efforts to address it infinitely difficult. Clearly, sex should not be enough. Safe sex should.