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University of California
San Francisco
AIDS Research Institute
AIDS Policy Research Center
[Country AIDS Policy Analysis Project)
HIV/AIDS in India
Maria Ekstrand, PhD, MS
Lisa Garbus, MPP
Elliot Marseille, DrPH, MPP
AIDS Policy Research Center, University of California San Francisco
Published August 2003
Updated August 2003
© 2003 Regents of the University of California All Rights Reserved.
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(J8386
HIV/AIDS in India
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Table of Contents
(click on page number to go directly to that section)
PREFACE
Acknowledgments
Notes on State-Level Data...
Notes on Terminology
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5
EXECUTIVE SUMMARY
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Epidemiology
Political Economy and Sociobehavioral Context
Impact
....................
Response
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6
6
12
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EPIDEMIOLOGY
At a Glance: Summary Bullets...
Overview
HIV Sentinel Surveillance...
Latest NACO Estimates
Transmission Patterns
UNAIDS Estimates
AIDS Cases
AIDS Mortality
National Prevalence Trends ..
State-level Analyses
Data Quality Issues
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POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT
At a Glance: Summary Bullets....
Country Overview
Postcolonial Period
Economy
..................
Poverty
*
Governance
Population Mobility
Health
Sexually Transmitted Infections...
Stigma and Discrimination
Gender
’.
Awareness and Knowledge of HIV/AIDS
Sexual Behavior
.........................................
...............................................................
Youth
MSM
Sex Work
Alcohol and Drug Use
IMPACT
At a Glance: Summary Bullets....
Demographic
Macroeconomic
Household
Orphans and Other Vulnerable Children
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HIV/AIDS in India
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Agriculture
Industry.................
Prisons
RESPONSE
At a Glance: Summary Bullets
Budget Allocations
Government....,.....
Budget Allocations
Nonhealth Ministries....,
Human Rights
Donors.......................................
Civil Society
National NGOs and CBOs
HIV Prevention Trials Network (HPTN)
PMTCT
.......................
Care and Support....... .
Treatment of Opportunistic Infections (OIs)
Antiretroviral Therapy (ART)
Female-controlled Prevention Technologies
Economic Interventions ...
Vaccine Trials.... .
Industry
LINKS.
Ill
......... I............ Ill
Ill
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Error! Bookmark not defined.
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. ..................... 136
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REFERENCES
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HIV/AIDS in India
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Preface
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The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at
the University of California San Francisco. The project is funded by the U.S. Agency for
International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin,
PhD, is the project’s principal investigator. The project receives additional support from the
International Training and Education Center on HIV (I-TECH), a collaboration of the University
of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau
of the U.S. Health Resources and Services Administration. The views expressed in the outputs of
the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH.
The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of
effective and equitable HIV/AIDS prevention and treatment interventions through
multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of
the epidemiology of HIV/AIDS in tandem with analysis of countries’ political economy and
sociobehavioral context—at household, sectoral, and macro levels. This multidisciplinary
analysis aims to:
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help inform national HIV/AIDS policies
strengthen ability to plan, prioritize, and implement effective interventions
highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS
facilitate multisectoral/interministerial coordination
facilitate intercountry information sharing
increase national and subregional capacity for effective partnerships
The project develops and disseminates online, fast-download, continually updated analyses of
HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa,
Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India
<http://ari.ucsf.edu/ARI/policv/coun tries.htm>
The primary audience for the country analyses is in-country HIV/AIDS planners, including those
from government ministries and agencies, multi- and bilateral donors, international and local
NGOs, health care institutions, prevention programs, academia, affected communities, and the
private sector. International investigators and policymakers also report using the analyses in their
All country analyses undergo peer review at the AIDS Research Institute of the University of
California San Francisco. In addition, two in-country experts from each profiled country serve as
peer reviewers. A scientific advisory board also reviews all analyses.
Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support.
Analyses also include a comprehensive table of key indicators, drawn from a global database that
UCSF's AIDS Policy Research Center conceptualized and developed. The database comprises 73
HIV/AIDS and socioeconomic indicators for 168 countries and 13 regions; APRC collected and
organized data spanning HIV/AIDS, human development, gender, population, economy, public
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HIV/AIDS in India
expenditure trends (health, education, military), debt servicing, general health, sexual &
reproductive health, and educational attainment. Project staff assess and incorporate new data to
maintain the timeliness of the analyses.
Acknowledgments
The following individuals served as peer reviewers and provided valuable inputs to this paper:
Dr. Monica Gandhi of the University of California San Francisco; Dr. Lalit Dandona, Health
Policy Unit, Administrative Staff College of India, Hyderabad; and Dr. Jayashree Ramakrishna,
Department of Health Education, Indian National Institute of Mental Health & Neuro Science, ’
Bangalore. They are not responsible for any errors of fact or judgment.
Notes on State-Level Data
The scope of HIV/AIDS in India is enormous and rapidly changing. India has 35 states and
union territories, and over 600 districts. Accessing complete, comparable data for all regions,
states, union territories, and districts is a major challenge. Given this scenario, the present report
provides a multidisciplinary overview of HIV/AIDS in India, focusing primarily on six states in
which HIV prevalence has surpassed 1 percent among women attending antenatal clinics and
which India's National AIDS Control Organization has identified as high priority: Andhra
Pradesh, Karnataka, Maharasthra, Manipur, Nagaland, and Tamil Nadu.
Notes on Terminology
The use of the following caste categorizations and other nomenclature does not constitute an
endorsement of any particular terminology: scheduled castes (dalits), formerly referred to as
"untouchables"; backward castes (formerly low castes); and scheduled tribes (indigenous
peoples).
5
HIV/AIDS in India
Executive Summary
Epidemiology
The number of HIV infections in India is difficult to ascertain and the subject of ongoing
controversy. In late July 2003, NACO released new figures indicating that there were between
3.82 million and 4.58 million Indians living with HIV/AIDS during 2002, of whom 38.5 percent
were women. NACO also estimated that there were 610,000 new HIV infections in 2002.
UNAIDS estimated that between 2.6 million and 5.4 million Indians were living with HIV/AIDS
at the end of 2001, with adult prevalence at 0.8 percent.
Low overall prevalence masks crucial differences among regions, states, and subpopulations.
There are growing localized HIV epidemics in India. The heaviest impact of the epidemic is
currently being felt in six states that have been classified as "high prevalence": Maharasthra,
Tamil Nadu, Karnataka, Andhra Pradhesh, Manipur, and Nagaland. Moderate-prevalence states
such as Gujarat and Goa also contain hard-hit districts.
The first case of HIV infection in India was reported in 1986. In 1987, HIV sentinel surveillance
and AIDS case identification was launched. Initially, HIV spread among female sex workers and
t eir male clients, STI clinic patients, and professional blood donors. It subsequently began to
spread among populations including women attending antenatal clinics.
In July 2003, NACO announced that there has been a decline in HIV transmission through
blood/blood products, from 6.07 percent of all new infections in 1999 to 2.99 percent in 2002.
HIV transmission via IDU had also declined, from 5.29 percent of new infections in 1999 to 2.87
percent m 2002. The percent of HIV transmission attributed to mother-to-child transmission had
increased, from 0.33 percent in 1999 to 2.61 percent in 2002. It is difficult to determine actual
prevalence among MSM in India, given that NACO has only recently collected data on MSM
and in only two surveillance sites.
India HIV prevalence estimates are based solely on sentinel surveillance conducted at public
sites. The country has no national information system to collect HIV testing information
from the private sector, which provides over 80 percent of health care in the country. Moreover,
most Indian laboratories do not adhere to quality assurance standards for HIV testing.
Political Economy and Sociobehavioral Context
India is the world's largest democracy. Its mid-2003 population was 1.07 billion. In recent
decades, India has significantly improved the well-being of its people. Despite achievements,
however, the scope of poverty continues to be enormous.
Structural adjustment measures launched in the 1990s have had some highly beneficial effects on
the Indian economy, including higher growth rates, lower inflation, and significant increases in
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HIV/AIDS in India
7
ZifiSotX" param°“nt-In 2001’ “,a's GM
ot USS48°
Structural adjustment sought to shift more health care delivery to the private sector. Public
delivery to the private sector. Public
spending on health, as a percent of GDP, did not rise during the 1990s (0 9 percent) whereas
private expenditure on health now
------ -- for 4.0- percent of------whereas
now r
accounts
GDP, or 181.6percent},
percent'of
a'n health
spending.
---------There is an increasing gap between rich and poor states with regard to public resources available
for health, with resultant disparities in health outcomes. A major concern is thatZhe centJal
gojemment reduces its role m health care delivery, with decentralization and privatization to fill
he gap, safety nets for the poor (especially those in rural areas and women) are being threatened
This scenario is particularly worrisome as the ability of state governments to provide^asic health
care is imperiled, given their current and severe fiscal problems
There has been intense debate regarding recent poverty trends in India. The emerging consensus
ppears to be that there was some decline in poverty during the 1990s, but the size of the decline
lesTthaluSSra d "’H8 1““°nal P0,^ markers’in 1997’ 44-2 of the population lived on
over the Wdl and^’ “h
rT*
US$2 3 day' Richer states grew faster
over the 1990s and may have also been more successful at reducing poverty Poverty is
mX^P adeOshCentrated “
P001^ StateS’particularly Bihar’ Uttar Pradesh. Orissa, and
Constitutional amendments in 1993 provided a legal foundation to local governments and sought
to strengthen participatory processes at the local level. These amendments included a mandatory
requirement that one-third of local representatives be women, and that seats be reseXeZr
scheduled castes and tribes in proportion to their population. However, commitment to
decentralization has varied by state, as has capacity to strengthen local government.
SdTUPtl°11 ln India iS systemic- With decentralization, states are increasingly responsible for
to d^so is8 COryUptI2?’ *0 ,Ugh Wh,ether they have adecluate resources (in addition to political will)
to do so is unclear. The Indian judicial system is impeded by enormous backlogs slow
EXTo^theTaw80^6 dCTe °f C0rrUPti0n at the state Icvc1’ !ow level of knowledge about new
leS J T
W,eak enforcement of decisions. Unable to persuade the executive or
egislative branches to take action, many Indian NGOs are increasingly using public interest
itigation to defend rights. Some of these cases have involved the rights of PWHA.
viotoncp PaS‘Se771 yearS’Ind13 h3S exPer’enced a significant increase in organized and random
threat t P3111011
communal> ethnic, tribal, and caste-based violence. Kashmir is the largest
non t re8,Oiaal secunty m South Asia. Ethnic violence can, inter alia, spur significant
Population dislocation and regroupings of family units, which entail exposure to new sexual
abX to8^11!
ma>'bf18htcn vulnerability to HIV. It also affects state and local government's
ability to deliver essential services.
6
HIV/AIDS in India
There is enormous population mobility in India and throughout South Asia. Mobile populations
include
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permanent and seasonal labor migrants within the country
those entering and leaving India for work-related reasons
people dislocated by drought, floods, or other disasters
people dislocated by conflict
refugees seeking asylum in India
transport workers
traders/vendors
hotel and tourism workers
tourists (e.g., temple tourists)
prisoners
military personnel
sex workers
trafficked persons
MSM
India has a long history of mobility. During colonial rule, the British moved segments of the
population to Sri Lanka, Malaya, and other countries to work on plantations. Movement of
unskilled workers increased during the 1970s, including to the Gulf states, which sought cheap
labor. According to the 1993 National Sample Survey in India, 24.7 percent of the population
had migrated, either within India, to neighboring countries, or overseas.
Recent data on female-to-male sex ratios in urban and rural areas suggest that many more men
than women have migrated to urban areas. Urbanization has resulted in large slum populations.
Labor migration is a common livelihood strategy in India. India is also a country of origin,
transit, and destination for thousands of trafficked persons.
The communities from which migrants emigrate are vulnerable to HIV for several reasons.
While their male partners are away for long periods (and particularly if they do not send regular
remittances), some women may rely on sex work to supplement household income. Returning
migrants with HIV, many of whom do not know their status, may infect their wives or other sex
partners in the home community.
There are myriad challenges within the health sector, including the generally poor quality of
services delivered by both the public and private sectors. The public health infrastructure is vast,
comprising 600 district hospitals, 4,000 community health centers, 25,000 primary health
centers, 137,000 subcenters, and 160 medical colleges. Public health facilities suffer from poor
management, low-quality service, and underfunding. There is large variance in health financing
among Indian states, and the gap between rich and poor states regarding public resources for
health is increasing.
Sixty-five percent of Indian households go to private hospitals/clinics or doctors for treatment
when a family member falls ill. Only 29 percent normally use the public health sector. Even
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HIV/AIDS in India
9
among poor households, only 34 percent normally use the public health sector when family
ZrW,erStbeC°me * ‘ °nly 10 PerCent of Indians have some form of insurance, most of which are
inaueciuare.
According to WHO, India continues to have the world's highest burden of TB. Each year there
are an estimated 2 million new TB cases m India, representing about one-third of the global TB
adultTl
s
C0UnS/leading CaUS£ °f death- WH° eStimates that 4 0 Percent of
adult (15-49) TB cases were HIV-positive during 2001. An estimated 3.4 percent of new cases
iyear Wer multldrug‘resistant TB 1S *e most common opportunistic infection in India In
strat ’ iiT r ?? Pt n ? HIV/AIDS and TB was created> though WHO notes that concrete
strategies to link the two do not yet exist.
Several studies indicate that herpes simplex virus-2 may be fueling the HIV epidemic in India.
HIV/AIDS-related stigma in India is severe. Stigma and discrimination are most often
encountered in the health care setting and, to a lesser but still significant extent, in family and
community contexts. AIDS stigma and discrimination in India are often a gendered phenomenon
men are often blamed by their in-laws for infecting their husbands. In addition, HIV-positive
he?? ar£ m°re ’ke Y t0 tH? Care °f their husbands> neglecting their own health. After having
their i ei prima7 caregirt forJthe,r husbands, many women are asked to leave the house of §
w V
KXQiJ ?£lr husband die. Studies have also detailed how in addition to female sex
workers, MSM and transgenders with HIV/AIDS experience double discrimination.
Indian women's legal rights have generally not been implemented. India’s sex imbalance is
Ser facm?
ne.8leCt °f “ health and nUtrition’ Pearly during childhood.
mfantiH? • T
increasing cases of sex-selective abortions (illegal but widespread); female
infanticide, violence against women; suttee (wherein a widow is burned to death on her
. Usband s cre“atl°n Pyre, an illegal act); dowry murders (wherein a woman is killed due to
accesstXS5?01167??11
PTntS 3t
time °f her wedding)i and discrimination in
access to health care, nutrition and employment opportunities. Despite socioeconomic changes
preference for sons continues in India.
rinceU2e fr?1 evetr‘marTied w°men have experienced beatings or physical mistreatment
since age 15 and at least one m nine have experienced such violence in the last year. Most of
these women have been beaten or physically mistreated by their husbands.
HIV/AIDS in India
10
Pnor to HIV/AIDS, there were already strong gender biases in access to health care Recent
studies have found when both a husband and wife are infected with HIV/AIDS, men routinely
receive care and treatment ahead of their wives. Lack of money and distance to treatment are
also constraints to HIV-positive women’s ability to access care.
mmmT1 Baseline Behavioral Surveillance Survey (BSS) found that overall awareness of
HIV/AIDS in India is 76 percent, though variance among states is significant. There are also
major urban-rural differentials. Gender differences are also striking: overall, 82 percent of men
surveyed were aware of HIV/AIDS, whereas among women, this figure was 70 percent The
BSS found that awareness among SWs, MSM, and IDUs is much higher than in the general
population.
Overall, only 21 percent of general population respondents had no incorrect knowledge of HIV
transmission. Among higher-risk groups, misperceptions were far less prevalent. Twenty-seven
percent of MSM perceive themselves to be at very high risk of acquiring HIV. Among IDUs, 35
percent perceive themselves to be at very high risk of contracting HIV. Only 17 percent of sex
workers perceive themselves to be at very high risk of contracting HIV/AIDS. Moreover,
whereas 21 percent of brothel-based SWs perceived themselves at very high risk of HIV, only 14
percent of non-brothel-based SWs reported this level of perceived risk.
The general population BSS found that nearly 7 percent of adults surveyed reported having sex
with a nonregular partner in the last 12 months. The difference between men and women,
however, was dramatic: 12 percent of men versus only 2 percent of women report having had sex
with a nonregular partner. Thirty-two percent of these respondents reported consistent condom
use with all nonregular partners. However, consistent condom use varied widely by state.
Among MSM who had commercial sex in the month prior to the survey, 13 percent reported
consistent condom use with commercial male partners. This contrasts dramatically with the 30
percent of MSM reporting consistent condom with a noncommercial male partner in the month
pnor to the survey. Among IDUs who reported sex with any nonregular partner in the 12 months
poor to the survey, 12 percent reported using condoms consistently with these partners. Among
sex workers, 50 percent reported consistent condom use with paying clients in the last 30 days
(though the figure was higher for brothel-based [57 percent] vs. non-brothel-based [46 percent]
SWs). However, among those who had sex with a nonpaying partner in the three months prior to
the survey, only 21 percent reported using condoms consistently.
Indian Penal Code 377, based on a 19th-century British law, criminalizes "the act of anal and
oral sex performed either between two men or between a man and a woman. "(There is currently
a petition before the New Delhi High Court to repeal section 377.) Homosexuality is a taboo
topic in India, and MSM are severely marginalized. Several studies have found that men report
their male-to-male sexual activities as masti (fun or play) or to initiate sexual experiences and do
not equate them with sexual identities such as "gay," "bisexual," or "homosexual."
Data on MSM and TG in Mumbai have found that 17 percent of men and 68 percent of TG were
HIV-positive. For both men and TG, HIV was significantly associated with syphilis, hepatitis C,
HIV/AIDS in India
11
and herpes. Twenty-two percent of MSM were married, and 44 percent had visited female sex
workers.
Although sex work is legal in some states, concomitant activities including soliciting and
brothelkeeping are penalized. Poverty and marital abandonment are two reasons why women
enter sex work. Many girls and women are also coerced into it. Human Rights Watch reports
that Indian SWs are treated with contempt and commonly subjected to violations of their
fundamental rights by the police, both at the time of their arrest and while in detention. HRW
also documents increasing violence against outreach workers and peer educators who work with
SWs (and MSM).
The national BSS found that 61 percent of female SWs were illiterate. The percentage ofbrothelbased SWs who were illiterate was much higher (77 percent) than the percentage of illiterate
non-brothel-based SWs (51 percent). Mumbai has the country's largest brothel-based sex
industry, with over 15,000 sex workers. Between 62 and 70 percent of sex workers in Mumbai
are HIV-positive. Because of complex power dynamics, reaching SWs with HIV prevention
services is a major challenge.
In 1992, the All India Institute of Hygiene and Public Health launched a program to reduce the
transmission of HIV in Sonagachi, a red-light district in central Calcutta. The project began with
two key interventions: a health clinic and outreach by peer educators. In 1992, consistent
condom use with clients in Sonagachi was 1 percent. By 1998, this figure had reached 50
percent. During the same period, syphilis prevalence among SWs covered by the project fell
from 25 to 11 percent. In 1998, HIV prevalence among SWs was 5 percent. A key element in the
Sonagachi has been the participation of SWs in the project.
The BSS found that 16 percent of MSM respondents reported consuming alcohol every day.
Fifteen percent of respondents regularly drank alcohol prior to sex. Intoxicating drug use was
reported by nearly 13 percent of respondents. The BSS also found that 22 percent of SWs
reported daily alcohol consumption. About 15 percent-of SWs reported that they drink regularly
before sex. Six percent of SWs reported ever trying any addictive drugs. Among them, almost
one-third had injected drugs in the past 12 months.
The major drugs being abused in India are opium, heroin, morphine, buprenorphine, diazepam,
cannabis, pheniramine, promethazine, nitrazepam, spasmorproxyvon, codeine phosphate,
cocaine, ecstasy, amphetamine type stimulants, antihistamines, and codeine-based cough syrup.
Epidemiological surveys and rapid assessment studies show that polydrug abuse is growing. The
health of many drug users is often poor. Many IDUs do not inject properly and as a result
experience ulcers, abscesses, cellulitis, and throbophlebitis. Many are undernourished, and a
substantial number have experienced a drug overdose. The BSS found that among IDUs, 45.2
percent injected two to three times a day, whereas 16.1 percent injected more frequently. Fiftythree percent of respondents reported injecting buprenorphine, followed by heroin (34 percent),
crack (22 percent), dextroproxyphene (6 percent), tranquilizers (3 percent), and cocktail of
heroin and cocaine (1 percent). Forty-one percent of IDU respondents reported sharing (i.e.,
using) previously used needles/syringes. About 83 percent of respondents who cleaned
HIV/AIDS in India
12
treataent S hindered! t.OhWOmense5king assistance for drug use, and women! ability to Less
treatment is hindered by their myriad responsibilities and workloads (e g child caret Dnm
abuse by women m the northeast is believed to be growing.
g
Impact
to 4 apLeenteb!e2?5n0CyBv SoT u m
hTAIDS WiU reduce life expectancy by 2
- -=,er
000. During 2000-15, the U.N. projects that there will be 12.3 million AIDS deaths.
During the late 1990s, researchers estimated that the total annual cost of HIV/AIDS in India was
as the coXf ARtT0611 m°f GDR fH°\ever’this figure did not include numerous factors such
ost of ART, strengthening of the healthcare system, and the retraining of workers.
faZ? Mt.!
A...
+
1
“““ econ‘’m‘c "d P^osoeial difficulties tn
fitment imposes a heavy financial burden on Indian
■”
AUh™ henheudChl'<i Wel&re lns,itu,i°ns-a,ld “’ide-scale abuse and exploitation of children
stnd^ S
ye'b™8 ddsdsned by HIV/AIDS on a large scale in most cities'
is >1 a” Mlzora™,and csle»ita demonstrate that the problem of orphans in some areas of India
s already severe. The extended family is the tradittonal social security system “omh ns in
mXmpenledls’hXSs"'" ’d"”/
JaT'
°T>™s
become s”ataed
HIWAIDS spreads’
breadwinners die, and household resources
Response
iX'Z WTS; thte governm“t’s resP°nse to toe epidemic has been appropriate In other
toe first MDS cas
P?litical commitments have been too little and too late. After
! li
S W6re ldenttoed in the U.S., the Indian Council of Medical Research
estabhshed an AIDS task force. By 1986, surveillance centers designed to detect HIV were
established at several medical colleges throughout metropolitan India.
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HIV/AIDS in India
13
Following identification of HIV in India ini 986, the government took steps to target screening
and prevention efforts to populations at high risk of infection. A high-profile National AIDS
Committee was launched, and in 1987 the National AIDS Control Program was established,
focusing on increasing awareness of HIV/AIDS, screening blood for HIV, and testing of
individuals with high-risk behaviors. By 1991, the government perceived a need to establish a
multisectoral program for prevention and control of HIV/AIDS. There was also a need for an
agency to help establish a state-level response to HIV/AIDS. To fulfill these objectives, the
government established the National AIDS Control Organization in 1992. In 2001, the’
government adopted the National AIDS Prevention and Control Policy. Important among the
government s interventions are programs of condom promotion, behavioral changes, community
information and education, targeting and involvement of vulnerable groups at risk, blood safety
and STI treatment.
In July 2003, Dr. Meenakshi Datta Ghosh, project director of NACO, stated that HIV/AIDS is no
longer affecting only high-risk groups or urban populations, but "is gradually spreading into rural
areas and the general population." In the eyes of many critics, the allocation of only $38.8
million of the government’s own funds (excluding funds from the World Bank and other donors)
over the period 1999-2004 is a major indication of insufficient governmental commitment.
Critics also argue that there is inadequate governmental response in the area of IDU and MSM
interventions. Although the national policy on HIV/AIDS addresses discrimination, there is no
national legislation on HIV/AIDS-related discrimination to serve as an implementing instrument
Additional criticisms include the perception that although there has been much commitment to
addressing HIV/AIDS at the national level, this commitment is not matched at the state level.
Currently, approximately one-third of India’s 35 states and UTs have what the World Bank
deems "good" HIV-control programs, one-third are "making some effort," and one third “are not
on board, but are in denial.” nother frequent criticism of the government’s efforts is that during
the initial response phase, NACO was focused on centralized, top-down planning and
implementation. This led to insufficient buy-in” at the state level and to uneven implementation
of projects in the different states.
The country has 1,500 blood banks spread across large hospitals and small clinics, with quality
varying among them. In June 2001, the government passed a law making it mandatory to test all
donated blood for HIV, hepatitis C, hepatitis B, syphilis, and malaria. In December 2002, India’s
MOH announced that blood donors who tested positive for HIV would be told of their infection
and asked to seek confirmatory tests and counseling. However, doctors working in blood
transfusion services caution that the new policy will be difficult to implement given the current
decentralized, fragmented state of blood banking services in India.
NACO s budget for 1992 through 1998 was US$100 million, funded by government and external
donors. For 1999-2004, NACO's budget is US$300 million. Of this amount, the government
allocation is US$38.8 million; US$191 million is financed through a World Bank loan, and the
remainder from other donor. India's federal budget caps the amount that foreign donors can
contribute to HIV/AIDS. Thus, some Indian states have the capacity to absorb more resources
but are denied them. The government argues that its control of resources ensures that no one
disease receives favor over any other.
HIV/AIDS in India
ough the central government exerts considerable influence through the National Council of
Education Research and Training, it has thus far not elaborated a concrete policy on an HIV
curriculum. Persistent ambivalence about sex education has also impeded the full
implementation of a population and family life education program begun in the early 1980s
Some state and municipal governments are implementing school-based-prevention programs,
often m partnership with NGOs or multilateral donors such as UNICEF.
India's National Cadet Corps has implemented an HIV/AIDS awareness program. The program
implemented at the National Integration Camp in Delhi, has trained 600 cadets from all over the
country in basic HIV prevention. These cadets will be'further trained as resource persons, and
Will be responsible for training other cadets upon returning to their states.
Collaborations with the transport sector on HIV/AIDS prevention activities have been popular
replicable XoZs
18 3 m3JOr
t0 ldentlfying
In India, there is widespread discrimination against people infected with HIV. Indian PWHA
have great difficulty accessing support and are usually unable to discuss their HIV status for fear
°”eperc^ssl0^There is n° national legislation to protect the rights of Indians with HIV/AIDS.
HIJ\/AI°S:related court cases has been rising rapidly. In the absence of
HIV/AIDS-related legislation, the role of the judiciary in the evolution of legal principles
regarding the epidemic has become crucial.
NACO has developed a VCT policy that states that "No individual should be made to undergo
mandatory testing for HIV" and that "No mandatory HIV testing should be imposed as a
precondition for employment or for provision of health care facilities during employment"
(India s Armed Forces are exempt from this condition). NACO has also developed guidelines for
JY centers which address consent and confidentiality issues. However, many Indians are
tested tor HIV without their knowledge or consent. Some government officials (including
legislators in Goa and Andhra Pradesh) have voiced their support of mandatory premarital
testing tor HIV and are proposing related legislation.
In 1998 India's Supreme Court delivered a judgment that suspended the right of PWHA to
marry, despite that the issue of PWHA's marrying had never come before the Court. The
awyers Collective HIV/AIDS Unit contested the constitutionality of the 1998 ruling regarding
marriage. In early 2003, the Supreme Court passed an order that all observations relating to
marriage in the 1998 case were not warranted as they were not issues before the Court. However
the case highlights the massive stigma and discrimination faced by PWHA in India and their
vulnerability—-particularly given the lack of legal instruments—to human rights abuses
including those perpetuated by governmental institutions.
A July 2002 report from Human Rights Watch documented how HIV/AIDS projects, particularly
those that provide essential information and services to SWs and MSM, are undermined by
frequent and widespread police harassment and abuse of outreach workers.
Major HIV/AIDS donors include the World Bank, Bill & Melinda Gates Foundation Global
bund to Fight AIDS, Tuberculosis & Malaria, DFID, USAID, CDC, NIH, UNDP, JICA,
14
I
HIV/AIDS in India
15
marginalized populations. Although about 600 NGOs receive financial and technical support
rom the government academic institutions, and external donors, many more work without any
scalar1 anCe'
bcdiing up.
6 W°rk °f NG°S and CBOs has not been evaluated, an impediment to
r
prevention, care, and support information and services.
1th 2h thPUbhC lVCT5enters at state and local level (primarily in high-prevalence
■
states). Although the number of private laboratories (which utilize rapid tests) is increasing, these
aims to e ’hTvS
counseling. In its GFATM proposal, the government states that
™S t0 establish a VCT center in each of the country's approximately 600 district hospitals
t ART a S° mCOrp°rated int0 the ProPosal's P^ns for scaling up PMTCT and expanding access
In March 2000, AZT was introduced in a PMTCT feasibility study supported by UNICEF and
IN ACO in 11 medical colleges of the five most affected states. With GFATM funding the
go^mment plans to scale up prevention and care interventions among women of child-bearing
ATM proposal sets out that PMTCT interventions will be scaled up from 81 public sector
hXrevlletct sutes' “d PriV“”’
and
l’eal,h inS,i,U“m
in ,he six
Since the launch of the second phase of the National AIDS Control Program in 1999 the Indian
ItwT1 ‘r S eStablished 25 community HIV/AIDS care centers across the country. With
unding, it plans to create drop-in centers for PWHA in high-prevalence states As in
many countries, an enormous amount of HIV/AIDS care and support is provided by NGOs and
CBOs, including associations of PWHA. Twelve percent of NACO's budget is allocated to care
and support, including treatment of OIs.
!MdAP'?002?ruOPOSal ? the GFA™ states that only
PWHA are receiving (and adhering
) ART, and that another 8,000 to 10,000 are intermittent users or poorly adherent. ART has
genera y remained unaffordable for most Indians and has been prescribed primarily to those
who can pay out of pocket or who are enrolled in research studies. To reduce prices, the
effOrtS t0 eX6mPt CUStOmS and eXcise duty on a11 antiretroviral drugs
Indian pharmaceutical firms are currently manufacturing generic versions of ART and selling
them at less than US$1 a day. The manufacture of generic ART drugs has been an essential
HIV/AIDS in India
16
S™tnt H the d i?TiC reduction of dru- Prices- However, India is a member of the WTO and
India s GFATM proposal delineates the government's plans for increasing access to ART The
emphasis is on PMTCT (including ART for HIV-positive mothers and their families) The
tPhr;^Pp0MTCTPnZt0 State th;;beyo?d the 10’000 individuals projected to receive ART through
Private
WiH be reC£iving StrUCtUred ART through8 the
private sector by 2008. The GFATM proposal does not address the myriad constraints in the
adherencTegU
P™16
SeCt°r
WiU affeCt ART Provision’ monitoring, and
Concerns about adherence and the spread of resistant viral strains may be particularly pertinent
in India because the generic, low-cost, triple-drug formulations available in India inc^e
NNRTIs such as nevirapine. Evidence suggests that an easily acquired single point mutation can
confer resistance to all the agents in the NNRTI class when the virus becomes resistant to
couldE T YT7 In?aiJ d°CtOrS and Sovernment officials note that greater access to ART
Planned for 2003. Other research institutions involved in microbicide research include the
Remodnef511^6]^Education and Research and the Institute for Research in
based Female R1 1th
20°2’ Hindustan Latex Limited signed an agreement with the U.K.The femT H
C°^ny t0
<and eventually produce) female condoms in India,
comrn^ condom would be priced at Rs 45 per piece (approx US$0.95). HLL is exploring
commodity and funding assistance to subsidize the cost. There are numerous projects that seek to
inte^emZ
drablhty (part,Cularly Of y0Un8 women) through vocational education, literacy
interventions, and income-generating activities.
S n00?’Dthe Inte1mational AIDS Vaccine Initiative has been working with the Indian Council
Mcdica! Research and NACO to develop and evaluate AIDS vaccines in India. The National
earlvS2004
116 W11’laUnCh phaSC 1 trials of an AIDS vaccine in late 2003 or
cdiiy zuu4!.
Several pnvnte sector employer organizations are actively involved in HIV prevention including
'
HIV/AIDS in India
17
prominent companies with HIV/AIDS programs are Tata Tea, Ltd., Tata Steel, Hindustan
Petroleum Corporation, and Steel Authority of India Ltd.
HIV/A1DS in India
Epidemiology
At a Glance: Summary Bullets
Overview
The number of HIV infections in India is difficult to ascertain and the subject of ongoing
controversy. In late July 2003, NACO released new figures indicating that there were
between 3.82 million and 4.58 million Indians living with HIV/AIDS during 2002 NACO
estimated that there were 610,000 new HIV infections in 2002.
est’mate^that between 2.6 million and 5.4 million Indians were living with
HIV/AIDS at the end of 2001, with adult prevalence at 0.8 percent.
Low overall prevalence masks crucial differences among regions, states, and subpopulations.
There are growing localized HIV epidemics in India. The heaviest impact of the epidemic is
currently being felt in six states that have been classified as "high prevalence": Maharasthra,
1 amil Nadu, Karnataka, Andhra Pradhesh, Manipur, and Nagaland.
Moderate-prevalence states such as Gujarat and Goa also contain hard-hit districts.
■
The most recent surveillance data indicate that HIV transmission through unsafe blood/blood
products and via injecting drug use is declining, whereas mother-to-child transmission is
increasing.
Althciigh nW remains concentrated among marginalized groups such as sex workers, MSM
ID Us, and poor migrants, it is spreading rapidly within the general population.
HSS
The first case of HIV infection in India was reported in 1986. In 1987, HIV sentinel
surveillance and AIDS case identification was launched.
Initially, HIV spread among female sex workers and their male clients, STI clinic patients
and professional blood donors. It subsequently began to spread among populations including
women attending antenatal clinics.
NA CO Estimates
■
NACO estimated that there were 73.5" million Indians living with HIV/AIDS in 1998. In 2001,
NACO estimated that this figure had risen to 3.97 million^
18
HIV/AIDS in India
■
19
In late July 2003, NACO released new figures indicating that there were between 3.82
million and 4.58 million Indians living with HIV/AIDS during 2002. NACO estimated that
there were 610,000 new HIV infections in 2002. NACO also announced that 38.5 percent of
Indians with HIV are women.
In July 2003, NACO announced that there has been a decline in HIV transmission through
blood/blood products, from 6.07 percent of all new infections in 1999 to 2.99 percent in
2002. HIV transmission via IDU had also declined, from 5.29 percent of new infections in
1999 to 2.87 percent in 2002. The percent of HIV transmission attributed to mother-to-child
transmission had increased, from 0.33 percent in 1999 to 2.61 percent in 2002.
■
It is difficult to determine actual prevalence among MSM in India, given that NACO has
only recently collected data on MSM and in only two surveillance sites.
■
In July 2003, Dr. Meenakshi Datta Ghosh, project director of NACO, stated that HIV/AIDS
is no longer affecting only high-risk groups or urban populations, as it "is gradually
spreading into rural areas and the general population."
Data Quality Issues
■
India' HIV prevalence estimates are based solely on sentinel surveillance conducted at public
sites. The country has no national information system to collect HIV testing information
from the private sector, which provides over 80 percent of health care in the country.
■
Most Indian laboratories do not adhere to quality assurance standards for HIV testing.
■
Overview
The number of HIV infections in India is difficult to ascertain and the subject of ongoing
controversy. In 2001, India's National AIDS Control Organization (NACO) estimated that there
were 3.97 million Indians infected with HIV.1 UNAIDS published this figure in its July 2002
global update, but included an estimate range between 2.6 and 5.4 million.2
In late July 2003, on the eve of India's first Parliamentary Forum on HIV/AIDS, NACO released
new figures indicating that there were between 3.82 million and 4.58 million Indians living with
HIV/AIDS during 2002. NACO estimated that there were 610,000 new HIV infections in 2002.
It also estimated that there had been 110,000 new infections in 2001; 180,000 in 2000- and
210,000 in 1999.3
A September 2002 report by the U.S. National Intelligence Council estimated that the current
number of Indians infected with HIV is between 5 and 8 million and projected that this range
will increase to 20 to 25 million by 2010.4 The NIC report did state that its projections entailed a
"relatively high margin of error" and the data used to calculate these figures were not
declassified.
HIV/AIDS in India
20
Because India has a population of 1.069 billion (mid-2003),5 the HIV/AIDS figures cited above
epresent relatively low prevalence among the adult population. According to UNAIDS adult
HIV prevalence was 0.8 percent at the end of 2001.6
^u^aauir
However, low overall prevalence masks crucial differences among regions, states and
subpopulations There are growing localized HIV epidemics in India.^The most recent
■ u™11 aD,Ce data indl,Cat1e.that HIV transmission through unsafe blood/blood products and via
injecting drug use is declining, whereas mother-to-child transmission is increasing.8 Although
remams concentrated among marginalized groups such as sex workers, MSM, IDUs and
poor migrants, it is spreading rapidly within the general population.9
Regional Classifications
NACO classifies India's 35 states and union territories
as "high," "moderate," or "low" HIV
prevalence, based on the following definitions:
1’
pr^vaI^nce ^es: HIV Prevalence among women attending ANCs is 1 percent or
above. Based.on 2001 sentinel surveillance, these states currently include Maharasthra
ampur, Andhra Pradesh, Tamil Nadu, Karnataka and Nagaland.
2. Moderate prevalence states: HIV prevalence among women attending ANCs is less than
percent and prevalence in STI and other high risk groups is 5 percent or above.
3. Low prevalence states: HIV prevalence among women attending ANCs is less than 1
percent and HIV prevalence among STI and other high-risk group is less than 5 percent.
As seen in table I below, the heaviest impact of the epidemic is currently being felt in six states
Tam^Nd^ 3851
prevalence": Maharasthra in the western part of the country
north N?dU’ Kamataka’ and Andhra pradhesh in the south; and Manipur and Nagaland in the
uorLiieast.
HIV Sentinel Surveillance
NB. As mentioned above, in late July 2003, NACO announced new national HIV/AIDS figures
in conjunction with the Parliamentary Forum on HIV/AIDS. As of August 5 2003 NACO^ad
October 2001. Once NACO releases new data, they will be integrated into this paper.
8
Background
The first case of HIV infection in India was reported in 1986 at Madras Medical College in
heZ|ntem and mZefZce
r^Sm
HIV/AIDS in India
21
Initially, HIV spread among female sex workers and their male clients, STI clinic patients, and
professional blood donors (individuals who accept a monetary compensation in return for
donating blood). It subsequently began to spread among populations including women attending
antenatal clinics. By 1990, HIV prevalence among sex workers and STI clinic attendees in
Maharashtra and among IDUs in Manipur had surpassed 5 percent. By 1994 in Maharashtra,
HIV was no longer restricted to these subpopulations, but had spread to the general population.
HIV was also spreading in Gujarat and Tamil Nadu, where prevalence among high-risk groups
was over 5 percent.12
By 1998, HIV had spread rapidly in the four large southern states, not only within high-risk
groups but also in the general population, where it was over 1 percent. Infection rates among
women attending ANCs was 3.3 percent in Namakkal in Tamil Nadu and 5.3 percent in
Churachandpur in Manipur. Among IDUs in Churachandpur, HIV prevalence was 76 percent
and in Mumbai, 64.4 percent.13
In 1999, HIV prevalence in the ANC survey in Namakkal had risen to 6.5 percent. In some
Mumbai sites, about 60 percent of sex workers were infected with HIV. HIV infection among
STI patients was 30 percent in Andhra Pradesh and 14'to 60 percent in Maharashtra.14
By 2001, an estimated 15 to 35 percent of truck drivers nationwide were HIV-positive.15 HIV
prevalence in the general population had surpassed 1 percent in six states (Maharasthra,
Manipur, Andhra Pradesh, Tamil Nadu, Karnataka and Nagaland). These states accounted for 75
percent of the country's estimated HIV cases.16
Recent HSS
In 1994, HSS was conducted in 55 sites, expanding to 180 sites in 1998. In 2000, there were 232
sites. India's HIV sentinel surveillance system uses anonymous, unlinked blood sample
screening for HIV antibodies to estimate prevalence of HIV in various states and population
groups. Surveys are now conducted annually, and survey sites include STI and antenatal clinics,
as well as several sites that work with IDUs and MSM.
The most recent round of HSS was conducted in 320 sites from August to October 2001. These
sites include 135 STI clinics, 170 ANCs, 13 sites where IDUs were surveyed, and 2 sites for
MSM (in Mumbai and Chennai) (table 1).
Table 1. HIV Prevalence by State, 2001
S.N. State/UT
1
Andhra PdJ
2
Arunachal Pd.
3
Assam
Number of
Sites
STD 4
ANC9
STD 2
ANC 1
STD 2
ANC 3
HIV Prevalence 2001
(%)
26.60
1.50
0.00
0.00
1.49
0.00
HIV/AIDS in India
22
4
Bihar
ji
5
Chattisgarh
6.
Delhi
7
Goa
8
Gujarat
...
:
............
9
Haryana
10
Himachal Pd.
11
Jammu & Kashmir
12
Jharkhand
13
Karnataka
14
Kerala
15
Madhya Pd.
16
Maharashtra &
Mumbai
Bl 7
KB'/ •
18
Manipur
19
Meghalaya
20
Mizoram
2.1
Nagaland
22
Orissa
STD 5
ANC 7
STD 3
ANC 5
STD 4
ANC 4
IDU 1
STD 2
ANC 2
CSW 1
STD 8
ANC 7
STD 4
ANC 3
STD 5
ANC 7
STD 2
ANC 3
STD 3
ANC 6
STD 7
ANC 10
IDU 1
STD 3
ANC 3
STD 6
ANC 10
STD 9
ANC 14
IDU 1
MSM 1
CSW1
IDU 3
STD 2
ANC2
IDU1
STD 2
ANC 2
IDU 1
STD 2
ANC 3
IDU 2
STD 1
ANC 4
STD 7
ANC 4
1.20
0.13
1.40
0.33
4.65
0.13
15.00
0.50
50.79
4.14
0.50
1.08
0.41
0.26
0.13
0.80
0.25
0.25
0.08
16.40
1.13
2.00
6.42
0.08
2.69
0.25
9.20
1.75
41.38
23.60
52.26
56.26
10.50
1.75
1.39
0.00
0.00
2.00
2.20
0.33
5.50
7.40
1.25
0.80
0.25
HIV/AIDS in India
23
23
Punjab
24
Rajasthan
25
Sikkim
26
Tamil Nadu
27
Tripura
28
Uttar Pd
29
Uttranchal
30
West Bengal
31
A &N Islands
32
Chandigarh
33
34
35
D&NHaveli
Daman & Diu
L’dweep
36
Pondicherry
PleVvS« r'UCS “
STD 3
ANC 4
STD 6
ANC 6
STD 1
ANC2
STD 5
ANC 10
IDU1
MSM1
STD 1
ANC1
IDU 1
STD 10
ANC 11
STD 4
ANC 2
STD 6
ANC 8
IDU 1
STD1
ANC 3
STD 2
ANC 1
ANC 1
ANC 2
STD 1
ANC 2
STD 3
ANC1
1.61
0.40
4.00
0.00
0.00
0.00
12.60
1.13
24.56
2.40
3.20
0.25
0.90
0.00
0.40
0.00
0.60
0.13
1.20
0.16
3.78
0.00
0.25
0.25
2.00
0.25
mCd‘an Va'UeS’ WhereaS “ «ates/UTs with three
ui icwer sites, me values are mean values.
^z?7e/^^Vrer^ge of desircd samPle size (STI: 250; ANC: 400) are included for analysis
SWce NACO. HIV/AIDS Indian Scenario: HIV Estimates for Year 2001. New Delhi: n.d.
<nttp://www.naco.nic.in/indianscene/esthiv.htm >
As table 2 shows, high-prevalence states include some districts that have been particularly hard
hit. Moderate-prevalence states such as Gujarat and Goa also contain hard-hit districts.
pble 2. Districts with High Prevalence of HIV among STI Patients, IDUs. and A NG
Attendees, 2001
------- -------------
S. No State/UT
1.
Andhra Pradesh (7)
District
Hyderabad
Vishakhapatnam
Guntur
Chittoor
Kumool
Warrangal
HIV/AIDS in India
24
2.
3.
Goa (1)
Gujarat (3)
4.
Karnataka (10)
5.
Maharashtra (14)
6
Manipur (4)
7.
Nagaland (3)
8.
TamilNadu(7)
East Godavari
South-Goa
Ahmedabad
Surat
Bangalore
Mysore
Dharwad(HubIi)
Bellary
Belgaum
Gulbarga
Nagpur
Sangli
Pune
Aurangabad
Chandrapur
Latur
Ratnagiri
Imphal
CL
____
Churachanjjpur
Kohima
Tuensang
Madurai
Trichy
Salem
Coimbatore
Baroda
Dakshin Kannada
(Mangalore)
t nn™
Udipi
Bijapur
Shyamraj Nagar
(Kollegal)
Kolhapur
Nasik
Satara
Solapur
Thane
Mumbai
Jalgaon
Bishnupur
Thoubal
Mokok Chung
Namakkal
Tirunelveli
Chennai
Source: NACO. HIV/AIDS Indian S_____ II..
Scenario: HIV Estimates for Year 2001. New Delhi: nd.
<http://www.naco.nic.in/indianscene/esthiv.htm >
Latest NACO Estimates
?MnLeStl-mated th3t there Were 3-5 million Indians Iivin8 with HIV/AIDS in 1998. In 1999 and
, is figure rose to3.7 million and 3.86 million, respectively. In 2001 NACO estimated that
there were 3.97 million Indians infected with HIV.18
m °3’ NAC0 released new figures indicating that there were between 3.82 million
and 4.58 million Indians living with HIV/AIDS during 2002. NACO also announced that 38.5
percent of Indians with HIV are women. 9
N?C° e]StiKrnatfd that there were 610’000 new HIV infections in 2OO2.20 For previous years it
fooTtS*31*"6 had been 110’000 new infections in 2001; 180,000 in 2000; and 210,000 in
. ( nor to the release of the July 2003 figures, NACO had believed that the HIV/AIDS
epidemic in India might be plateauing, given its 1999-2001 data on number of new infections.22)
Transmission Patterns
HIV/AIDS in India
25
In October 2002, NACO released a study of cumulative AIDS cases reported since 1986. It
found that 84 percent of HIV infections were transmitted sexually. Perinatal transmission
accounted for 2.6 percent of infections, IDU 2.93 percent, and unsafe blood and blood products,
3.01 percent. NACO was unable to ascertain mode of transmission in 7.46 percent of cases.23
Data on occupational exposure are poor.24
In July 2003, NACO announced that there has been a decline in HIV transmission through
blood/blood products, from 6.07 percent of all new infections in 1999 to 2.99 percent in 2002. At
that time, NACO also announced that HIV transmission via IDU had also declined, from 5.29
percent of new infections in 1999 to 2.87 percent in 2002. The percent of HIV transmission
attributed to mother-to-child transmission had increased, from 0.33 percent in 1999 to 2 61
percent in 2002.25
Patterns of HIV differ by subregion. Among high-prevalence states such as Maharasthra, Tamil
Nadu, Karnataka, and Andhra Pradhesh, heterosexual transmission reportedly accounts for the
majority of HIV infections, whereas injection drug use has been driving the epidemic in Manipur
and Nagaland. Nevertheless, prevalence among IDUs are also high in Tamil Nadu and
Maharasthra (24.56 and 41.38 percent, respectively).26
It is difficult to determine actual prevalence among men who have sex with men (MSM) in India,
given that NACO has only recently collected data on MSM and in only two surveillance sites. In’
2001, MSM prevalence was 24 percent in Mumbai (Maharasthra) and 2.4 in Chennai (Tamil
Nadu). Many public health professionals working in the area of male-to-male transmission have
noted that the 3:1 proportion of male-to-female HIV cases does not fit with the reported
prevalence of heterosexual transmission, given that male-to-female transmission is much more
efficient than transmission from women to men. They'therefore suggest that male-to-male
transmission and/or the number of infections among women are underreported.
UNAIDS Estimates
At the end of 2001, UNAIDS estimated that 3.97 million Indian adults and children were living
with HIV/AIDS (estimate range: 2.6 million to 5.4 million) Of them, 3.8 million were adults
(ages 15 to 49), with adult prevalence at 0.8 percent.27 (At the end of 1999, UNAIDS estimated
adult prevalence at 0.7 percent.28) There were 170,000 Indian children (ages 0 to 14) living with
HIV/AIDS at the end of 2001.29
Using the most recent NACO figures indicates that India accounted for 87 percent (610,000) of
the 700,000 new HIV infections that occurred during 2002 in South & Southeast Asia.3®
UNAIDS estimated that of adults infected with HIV during 2001, 1.5 million (39.5 percent) were
women. (At the end of 1999, UNAIDS estimated that 37.14 percent of adults infected with HIV
were women.31) At the end of 2001, HIV prevalence among women ages 15 to 24 ranged from
0.46 to 0 96 percent; the comparable range for men in the same age group was 0.22 to 0.46
percent.32
HIV/AIDS in India
26
AIDS Cases
In October 2002, NACO published data on the number of AIDS cases reported to date (table 3).
Data for the most recent month suggest that the proportion of reported female AIDS cases is
increasing (from approximately 25 percent of the cumulative total, versus 35 percent of cases in
October 2002). - In July 2003, NACO announced that 38.5 percent of Indians with HIV are
women.
NACO’s October 2002 data indicate that slightly over half (53 percent) of reported AIDS cases
were diagnosed among individuals 30-44 years; 36 percent of cases were diagnosed among 15to 29-year-olds.
The three states with the highest absolute numbers of reported AIDS cases were Tamil Nadu, ■
Maharasthra, and Andhra Pradesh (representing 44, 21, and 5 percent, respectively of the
national total).
Table 3. Reported AIDS Cases, October 2002
AIDS CASES IN INDIA
MALES
FEMALES
This Month
587
311
Cumulative
31230
10376
.■■■■■41606
RISK/l^^VSMISSION CATEGORIES
Sexual
35075
84.30
Perinatal transmission
1082
2.60
1251
3.01
1217
2.93
History not available
2981
7.16
Total:
41606
100.00
Blood and blood products
•ISIS..........................
Injectable Drug Users
• Age group
Male
0 - 14 yrs
989
603
1592
10114
4800
14914
30 - 44 yrs.
17598
>8
4339
21937
>45 yrs.
2529
634
3163
Total
31 • '
15-29 yrs.
■
•
Total ■':
•
41606
1
)
HIV/AIDS in India
27
JJ
Andhra Pradesh
2157
Assam
149
3
Arunachal Pradesh
0
4
A & N Islands
24
Bihar
145
Chandigarh (UT)
618
Delhi
713
8
Daman & Diu
1
9
Dadra & Nagar Haveli
0
10
Goa
115
11
Gujarat
1925
12
Haryana
247
13
Himachal Pradesh
104
14
Jammu & Kashmir
2
15
Karnataka
1551
16
Kerala
267
17
Lakshadweep
0
18
Madhya Pradesh
918
19
Maharashtra
8723
20
Orissa
82
21
Nagaland
274
22
Manipur
1238
. 23
Mizoram
34
24
Meghalaya
8
25
Pondicherry
157
26
Punjab
211
27
Rajasthan
543
28
Sikkim
4
.
BKfi :5 ■
'• ’ <
J
6
, • 7
feB if'
z
HIV/AIDS in India
28
29
Tamil Nadu
30
Tripura
31
Uttar Pradesh
18276
5
753
-’’s
32
West Bengal
33
AhemdabadM.C
S -
930
267
Mumbai M.C
1165
Source: NACO, <http://naco.nic.in/> Accessed October 2002.
AIDS Mortality
in “es 4
The 5.
and
Table 4. India: Projected Number of Deaths with and without AIDS, 1980-2000 2000-2015
and 2015-2050
’
______________ '
Period
1980-2000
_________ 2000-2015
________2015-2050
With AIDS
Without
With AIDS
Without
AIDS
AIDS
J 82,307,000
•
179,533,000
179,533,000
140,546,000__________________
128,295,000
452,901,000
403,398,000
Source: Population Division of the Department of Economic
and Social Affairs of the United Nations Secretariat. World
ProsPects: The 2002
Highlights.
New
York: February
2003
. Revision.
.......
i'ivw i uijv
. February
2uu3
<httP.//www.un.org/esa/population/publications/wpP2002/wpp2002annextables.PDF >
With AIDS
Without AIDS
Table 5. India: Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050
---------------------------------------------- Period
Excess
Deaths
2,774,000
1980-2000
Percentage
Increase
2
2000-2015__________
2015-2050
Excess
Percentage
Excess
Percentage
Deaths
______ Increase_______ Deaths
Increase
12,251,000
10
49,503,000
12
<http.//www.un.org/esa/DODulation/Dublications/wpp2002/wDD2002annextables.PDF>
See the Impact section for more detailed discussion.
National Prevalence Trends
Although India's HIV/AIDS epidemic varies widely among regions, it is spreading rapidly along
coastal areas and inland, affecting all parts of the country, both rural and urban. Solomon and 8
HIV/AIDS in India
29
of YR,G Care’ a major NG0 dlscussed throughout this paper, note that early descriptions
o HIV created a general perception that HIV infection was largely restricted to sex workers
truckers, and IDUs. They underscore that the so-called general population was—and in many
cases still is—in demal UNAIDS also notes that the perception of risk among the general
population is still low. In high-prevalence states, HIV is increasing in rural areas.38 Yet many in
ntral areas—where 72 percent of India's population lives39 —believe that HIV/AIDS is an urban
disease.
As the data above demonstrated, the percent of adult HIV infections among women is increasing.
The most recent data from NACO indicate that 38.5 percent of Indians with HIV are women 41
HIV prevaknce among monogamous women is increasing through unprotected sex with infected
spouses. Despite this scenario, interventions have tended to focus on "high-risk" communities
ignoring monogamous women. Rural women are particularly vulnerable to acquiring HIV, given
that, among other reasons, they cannot easily access information on HIV/AIDS 43 (See the
Gender section for further discussion.)
Perhaps the single most important question concerning national prevalence trends is whether the
epidemic will pass a "tipping point." This tipping point represents the transition from an
epi emic that is largely confined to high-risk groups to one that has spread into the general
population. Once this transiting has occurred, the epidemic is far more difficult to control and the
scale of devastation will be far greater. As mentioned above, the most recent surveillance data
indicate that HIV transmission through unsafe blood/blood products and via IDU is declining
whereas mother-to-child transmission is increasing.44 In July 2003, Dr. Meenakshi Datta Ghosh
project director of NACO, stated that HIV/AIDS is no longer affecting only high-risk groups or’
urban populations, as it "is gradually spreading into rural areas
apnerai population. •» 45
areas and
and the
the general
(See the Response section for more detailed discussion.)
State-level Analyses
Karnataka
Among states, only Karnataka has published HIV sentinel surveillance data disaggregated by
sociodemographic markers. In 1999 and 2000, Karnataka included 14 sites in its HIV sentinel
surveillance. Four additional sites were included in 2001. Sites comprise seven STI clinics one
IDU-specific site, and 10 ANC sites. Results obtained in 2001 indicated that the highest HIV
prevalence was found in STI clinics (mean prevalence: 16.7 percent), followed by the IDU site
(2 percent). Mean prevalence among ANCs was 1.4 percent, suggesting that HIV had spread to
t e general population and placing Karnataka in the "high prevalence" group of states. However
these mean values obscure significant differences within the state. For example, three districts
reported HIV prevalence at ANCs of 1 to 1.9 percent and four districts (Bangalore,
Chamrajnagar, Bijapur, and Raichur) reported ANC prevalences of 2 percent or greater The four
districts with ANC prevalence of 2 percent or above are located in the southern part of the state
L’1 “d46around Bangalore> on the border with Tamil Nadu, or in northern Karnataka's "devadasi ’
belt
Devadasi women have historically been dedicated to divine service. This service has
evolved into a temple-based sex industry. Many women from this part of the country are
Box 1. Links Regarding India's "DeiWasZ Bdt"
HIV/AIDS in India
bttp-//www.twnside.org.sg/title/belt-cn him
supplied” to the sex trade in
large cities such as Mumbai.47
(See box 1 for links regarding
the "devadasi belt.")
http.//www.celrrd com/htmi/mandal.htm
http-//www.celrrd.com/html/poonam.htm
□tp.//www.clubs.psu.edu/aid/home/proiects/vimukti/Replv.First.htm
Within Karnataka, HIV
sites and among women whose husbands were in
was particularly strong within
prevaIence was highest in rural
male STI patients; only 6.7 percent of men under f 0w ;^rv
was seen in
increased to 16.4 percent in 20- to 29-year-oldseand to^2 1 V'P°®ItlVe’ whereas prevalence
year oms and to 22.1 percent among those ages 30-44.48
Data Quality Issues
msm, in additl0n t0 ANCs and STI clinics (A guide to
ana dirase . Mla ,s a mass,ve
ord
However, there are several issues ihul '
Should be noted with regard to the quality of India's HSS
data. India' HIV prevalence estimates are based solely on
public sites. The country has no national information s sentinel surveillance conducted at
information system to collect HIV testing infoimation
HIV/AIDS in India
31
Box 2. HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics
In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through HIV
seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently used
sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and treatment of
sexually transmitted infections. The objectives of sentinel seroprevalence surveys include:
1.
2.
3.
4.
obtaining information on the prevalence of HIV infection in the sentinel population
monitoring trends in HIV prevalence in the sentinel population
providing information for estimating future number of AIDS cases
providing information for program planning and evaluation of interventions
Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women attending
antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The surveys areconducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a current pregnancy.
Surveys are usually conducted in an unlinked manner, in which serqm remaining from routine syphilis screening is tested
for HIV infection after all personal identifying information is removed from the specimen. Sampling is usually conducted
during an 8- to 12-week period, and all eligible women are sampled consecutively until the desired sample size is achieved.
In general, samples of 250 and 400 women are usually sufficiently large as to provide reasonable estimates of HIV
prevalence over time.
Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey results.
The surveys are not based upon a probability sample and therefore may not be representative of the population as a whole.
True population-based surveys have found antenatal clinic data may overestimate or underestimate HIV prevalence.
Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition, although
monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in prevalence
cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence in younger
populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired HIV infection , as
this group is unlikely to have been infected for a long period of time.
Prepared by Sandy Schwarcz, MD, MPH
Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health
Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San Francisco
from clinical laboratories in the private sector.49 (As discussed in the next section, the private
sector accounts for an increasingly large share of health care provision in India. In 2000, India’spublic spending on health was 0.9 percent of GDP, whereas private expenditures on health
accounted for 4.0 percent of GDP.50) Another issue involves the characteristics of those being
tested. Some researchers note that individuals dying from opportunistic infections associated
with HIV are generally not being tested, and thus prevalence may be underestimated .51 ,52
However, this scenario may be changing with the increase in the number of VCT sites (see
below), such that a larger proportion of people who are being tested are symptomatic.53
Solomon and Ganesh also stress that most Indian laboratories do not adhere to quality assurance
standards for HIV testing. HIV test results are often inaccurate for several reasons: test kits are
used after expiration dates; kits are not stored at the correct temperature; electricity is shut down
at night; air-conditioning for the testing equipment is erratic; poor-quality water is used; and
equipment is often recycled.54
HIV/AIDS in India
32
Political Economy and Sociobehavioral Context
At a Glance: Summary Bullets
Overview
■
India is the world's largest democracy. Its mid-2003 population was 1.07 billion.
■
In recent decades, India has significantly improved the well-being of its people. Despite
achievements, however, the scope of poverty continues to be enormous.
Economy
■
Structural adjustment measures launched in the 1990s have had some highly beneficial
effects on the Indian economy, including higher growth rates, lower inflation, and significant
increases in foreign investment. However, both the central and state governments are
currently facing a deteriorating fiscal situation.
■
Moreover, vast income disparities between and within India’s states persist and poverty
reduction remains paramount. In 2001, gross national income per capita was US$480. This
figure is somewhat higher than that for the South Asia region and for all low-income
countries. However, globally, India's GNI per capita ranks 162 (of a total 208 countries).
■
Structural adjustment sought to shift more health care delivery to the private sector. Public
spending on health, as a percent of GDP, did not rise during the 1990s (0.9 percent), whereas
private expenditure on health now accounts for 4.0 percent of GDP, or 81.6 percent of all
health spending.
■
There is an increasing gap between rich and poor states with regard to public resources
available for health, with resultant disparities in health outcomes.
■
A major concern is that as the central government reduces its role in health care delivery,
with decentralization and privatization to fill the gap, safety nets for the poor (especially’
those in rural areas and women) are being threatened. This scenario is particularly worrisome
as the ability of state governments to provide basic health care is imperiled, given their
current and severe fiscal problems
Poverty
*
There has been intense debate regarding recent poverty trends in India. The emerging
consensus appears to be that there was some decline in poverty during the 1990s, but the size
of the decline remains unclear. Richer states grew faster over the 1990s and may have also
been more successful at reducing poverty.
HIV/AIDS in India
33
■
Poverty is increasingly concentrated in the poorest states, particularly Bihar, Uttar Pradesh,
Orissa, and Madhya Pradesh.
■
Using international poverty markers, in 1997, 44.2 of the population lived on less than US$1
a day, and 86.2 percent lived on less than US$2 a day.
Governance
Decentralization
■
Constitutional amendments in 1993 provided a legal foundation to local governments and
sought to strengthen participatory processes at the local level. These amendments included a
mandatory requirement that one-third of local representatives be women, and that seats be
reserved for scheduled castes and tribes in proportion to their population.
■
However, commitment to decentralization has varied by state, as has capacity to strengthen
local government.
Corruption
■
Corruption in India is systemic. With decentralization, states are increasingly responsible for
addressing corruption, though whether they have adequate resources (in addition to political
will) to do so is unclear.
Judiciary
■
The Indian judicial system is impeded by:
enormous backlogs
extremely slow processing times
some degree of corruption at the state level
low level of knowledge about new aspects of the law
weak enforcement of decisions
■
Unable to persuade the executive or legislative branches to take action, many Indian NGOs
are increasingly using public interest litigation to defend rights. Some of these cases have
involved the rights of PWHA.
Violence
■
Over the past several years, India has experienced a significant increase in organized and
random violence, particularly communal, ethnic, tribal, and caste-based violence.
■
Kashmir is the largest threat to regional security in South Asia.
HIV/AIDS in India
■
Ethnic violence can, inter alia, spur significant population dislocation and regroupings of
family units, which entail exposure to new sexual networks and thus may heighten
vulnerability to HIV. It also affects state and local government's ability to deliver essential
services.
Population Mobility
■
There is enormous population mobility in India and throughout South Asia. Mobile
populations include
permanent and seasonal labor migrants within the country
-> those entering and leaving India for work-related reasons
people dislocated by drought, floods, or other disasters
people dislocated by conflict
-► refugees seeking asylum in India
-> transport workers
traders/vendors
->■ hotel and tourism workers
tourists (e.g., temple tourists)
prisoners
military personnel
-* sex workers
-> trafficked persons
-> MSM
■
India has a long history of mobility. During colonial rule, the British moved segments of the
population to Sri Lanka, Malaya, and other countries to work on plantations.
■
Movement of unskilled workers increased during the 1970s, including to the Gulf states,
which sought cheap labor.
■
According to the 1993 National Sample Survey in India, 24.7 percent of the population had
migrated, either within India, to neighboring countries, or overseas.
■
Labor migration is a common livelihood strategy in India.
■
The communities from which migrants emigrate are vulnerable to HIV for several reasons.
While their male partners are away for long periods (and particularly if they do not send
regular remittances), some women may rely on sex work to supplement household income.
Returning migrants with HIV, many of whom do not know their status, may infect their
wives or other sex partners in the home community.
■
Recent data on female-to-male sex ratios in urban and rural areas suggest that many more
men than women have migrated to urban areas. Urbanization has resulted in large slum
populations.
34
HIV/AIDS in India
35
India is a country of origin, transit, and destination for thousands of trafficked persons.
Health
Over the past several decades, India has made significant progress in improving health and
well-being.
Despite achievements, the country continues to bear a heavy burden of both communicable
and noncommunicable diseases. There are myriad challenges within the health sector,
including the generally poor quality of services delivered by both the public and private
sectors.
■
India's state governments are primarily
]_
responsible for health care, although some national
health programs (including HIV/AIDS)) are supported by central government funds.
■
The public health infrastructure is vast, comprising 600 district hospitals, 4,000 community
health centers, 25,000 primary health centers, 137,000 subcenters, and 160 medical colleges.
Public health facilities suffer from poor management, low-quality service, and underfunding.
There is large variance in health financing among Indian states, and the gap between rich and
poor states regarding public resources for health is increasing.
Sixty-five percent of Indian households go to private hospitals/clinics or doctors for
treatment when a family member falls ill. Only 29 percent normally use the public health
sector. Even among poor households, only 34 percent normally use the public health sector
when family members become ill.
■
Only 10 percent of Indians have some form of insurance, most of which are inadequate.
■
The World Bank argues that the private health sector in India is unlikely to substantially
improve the health and nutritional status of the poor. The private sector remains virtually
unregulated and has highly variable quality of care.
■
However, the government's response to HIV/AIDS, at least with regard to ART, is predicated
on strong partnerships with the private sector.
Tuberculosis
■
According to WHO, India continues to have the world's highest burden of TB. Each year,
there are an estimated 2 million new TB cases in India, representing about one-third of the
global TB burden. TB remains the country’s leading cause of death; annually, about half a
million Indians die because of TB.
■
WHO estimates that 4.0 percent of adult (15-49) TB cases were HIV-positive during 2001.
An estimated 3.4 percent of new cases that year were multidrug-resistant.
HIV/AIDS in India
36
■
TB is the most common opportunistic infection in India.
■
India has had a national TB control program since 1962. In 1993, the government designed
the Revised National TB Control Program (RNTCP). In 1997, DOTS was launched. In 2003,
RNTCP reported that during the first quarter of that year, DOTS coverage increased to about
62 percent.
■
In 2001, a joint action plan on HIV/AIDS and TB was created, though WHO notes that
concrete strategies to link the two do not yet exist. WHO highlights other constraints in the
TB system, including:
lack of confidence in government TB services due to poor services in the past
vacancies of key staff, especially laboratory technicians
-> poor quality services and poor results in the private sector
lack of full involvement of medical colleges
->■ poor drug distribution to local level
-► ineffective lab quality control
-► lack of local electrical supply .
Sexual and Reproductive Health
■
UNFPA ranks India a category '’A” country, meaning that it is furthest from achieving the
sexual and reproductive health and rights goals of the International Conference on Population
and Development (ICPD), held in Cairo in 1994. Group A countries have the greatest need
for external assistance and the lowest capabilities for mobilizing domestic resources to close
this gap.
Sexually Transmitted Infections
■
Several studies indicate that herpes simplex virus-2 may be fueling the HIV epidemic in
India.
Stigma and Discrimination
■
HIV/AIDS-related stigma in India is severe. Stigma and discrimination are most often
encountered in the health care setting and, to a lesser but still significant extent, in family and
community contexts.
■
AIDS stigma and discrimination in India are often a gendered phenomenon. Women are
often blamed by their in-laws for infecting their husbands. In addition, HIV-positive women
are more likely to take care of their husbands, neglecting their own health. After having been
the primary caregivers for their husbands, many women are asked to leave the house of their
in-laws after their husband die.
■
Studies have also detailed how in addition to female sex workers, MSM and transgenders
with HIV/AIDS experience double discrimination.
HIV/AIDS in India
37
Gender
■
Indian women's legal rights have generally not been implemented.
India s sex imbalance is related to the comparative neglect of female health and nutrition,
particularly during childhood. Other factors include increasing cases of sex-selective
abortions (illegal but widespread); female infanticide; violence against women; suttee
(wherein a widow is burned to death on her husband’s cremation pyre, an illegal act); dowry
murders (wherein a woman is killed due to insufficient gifts/money given by her parents at
the time of her wedding); and discrimination in access to health care, nutrition, and
employment opportunities.
■
Despite socioeconomic changes, preference for sons continues in India.
■
There are acute gender disparities in literacy and education.
Forty-eight percent of ever-married women are not involved in making decisions about their
own health care.
There are significant and persistent gaps between women's legal rights and their actual
ownership and control of land.
■
About 20 percent of ever-married women have experienced beatings or physical
mistreatment since age 15 and at least one in nine have experienced such violence in the last
year. Most of these women have been beaten or physically mistreated by their husbands.
Prior to HIV/AIDS, there were already strong gender biases in access to health care. Recent
studies have found when both a husband and wife are infected with HIV/AIDS, men
routinely receive care and treatment ahead of their wives. Lack of money and distance to
treatment are also constraints to HIV-positive women’s ability to access care.
Awareness and Knowledge ofHIV/AIDS
The National Baseline Behavioral Surveillance Survey (BSS) found that overall awareness of
HIV/AIDS in India is 76 percent, though variance among states is significant. There are also
major urban-rural differentials.
■
Gender differences are also striking: overall, 82 percent of men surveyed were aware of
HIV/AIDS, whereas among women, this figure was 70 percent.
■
The BSS found that awareness among SWs, MSM, and IDUs is much higher than in the
general population.
Misperceptions
HIV/AIDS in India
•
38
Overall, only 21 percent of general population respondents had no incorrect knowledge of
HIV transmission. Among higher-risk groups, misperceptions were far less prevalent.
Perception ofRisk
■
Twenty-seven percent of MSM perceive themselves to be at very high risk of acquiring HIV.
Among IDUs, 35 percent perceive themselves to be at very high risk of contracting HIV.
*
Only 17 percent of sex workers perceive themselves to be at very high risk of contracting
HIV/AIDS. Moreover, whereas 21 percent of brothel-based SWs perceived themselves at
very high risk of HIV, only 14 percent of non-brothel-based SWs reported this level of
perceived risk.
Sexual Behavior
The general population BSS found that nearly 7 percent of adults surveyed reported having
sex with a nonregular partner in the last 12 months. The difference between men and women,
however, was dramatic: 12 percent of men versus only 2 percent of women report having had
sex with a nonregular partner.
■
Thirty-two percent reported consistent condom use with all nonregular partners. However,
consistent condom use varied widely by state.
"
Among MSM who had commercial sex in the month prior to the survey, 13 percent reported
consistent condom use with commercial male partners. This contrasts dramatically with the
30 percent of MSM reporting consistent condom with a noncommercial male partner in the
month prior to the survey.
"
Among IDUs who reported sex with any nonregular partner in the 12 months prior to the
survey, 12 percent reported using condoms consistently with these partners.
■
Among sex workers, 50 percent reported consistent condom use with paying clients in the
last 30 days (though the figure was higher for brothel-based [57 percent] vs. non-brothelbased [46 percent] SWs). However, among those who had sex with a nonpaying partner in
the three months prior to the survey, only 21 percent reported using condoms consistently.
MSM
Indian Penal Code 311, based on a 19th-century British law, criminalizes "the act of anal and
oral sex performed either between two men or between a man and a woman. "(There is
currently a petition before the New Delhi High Court to repeal section 377.) Homosexuality
is a taboo topic in India, and MSM are severely marginalized.
•
Several studies have found that men report their male-to-male sexual activities as masti (fun
or play) or to initiate sexual experiences, and do not equate them with sexual identities such
as "gay," "bisexual," or "homosexual."
HIV/AIDS in India
■
39
Data on MSM and TG in Mumbai have found that 17 percent of men and 68 percent of TG
were HIV-positive. For both men and TG, HIV was significantly associated with syphilis,
hepatitis C, and herpes. Twenty-two percent of MSM were married, and 44 percent had
visited female sex workers.
Sex Work
■
Although sex work is legal in some states, concomitant activities including soliciting and
brothelkeeping are penalized.
■
Poverty and marital abandonment are two reasons why women enter sex work. Many girls
and women are also coerced into it.
Human Rights Watch reports that Indian SWs are treated with contempt and commonly
subjected to violations of their fundamental rights by the police, both at the time of their
arrest and while in detention. HRW also documents increasing violence against outreach
workers and peer educators who work with SWs (and MSM).
■
The national BSS found that 61 percent of female SWs were illiterate. The percentage of
brothel-based SWs who were illiterate was much higher (77 percent) than the percentage of
illiterate non-brothel-based SWs (51 percent).
■
Mumbai has the country’s largest brothel-based sex industry, with over 15,000 sex workers..
Between 62 and 70 percent of sex workers in Mumbai are HIV-positive.
SWs in Mumbai are controlled by madams, pimps, and moneylenders. Because of complex
power dynamics, reaching SWs with HIV prevention services is a major challenge.
In 1992, the All India Institute of Hygiene and Public Health launched a program to reduce
the transmission of HIV in Sonagachi, a red-light district in central Calcutta. The project
began with two key interventions: a health clinic and outreach by peer educators.
■
In 1992, consistent condom use with clients in Sonagachi was 1 percent. By 1998, this figure
had reached 50 percent. During the same period, syphilis prevalence among SWs covered by
the project fell from 25 to 11 percent. In 1998, HIV prevalence among SWs was 5 percent.
■
A key element in the Sonagachi has been the participation of SWs in the project.
Alcohol and Drug Use
Alcohol
■
The BSS found that 16 percent of MSM respondents reported consuming alcohol every day.
Fifteen percent of respondents regularly drank alcohol prior to sex. Intoxicating drug use was
reported by nearly 13 percent of respondents.
’
HIV/AIDS in India
40
The BSS also found that 22 percent of SWs reported daily alcohol consumption. About 15
percent of SWs reported that they drink regularly before sex. Six percent of SWs reported
ever trying any addictive drugs. Among them, almost one-third had injected drugs in the past
12 months.
Illicit Drug Use
The major drugs being abused in India are opium, heroin, morphine, buprenorphine,
diazepam, cannabis, pheniramine, promethazine, nitrazepam, spasmorproxyvon, codeine
phosphate, cocaine, ecstasy, amphetamine type stimulants, antihistamines, and codeine-based
cough syrup.
■
Epidemiological surveys and rapid assessment studies show that polydrug abuse is growing.
The health of many drug users is often poor. Many IDUs do not inject properly and as a
result experience ulcers, abscesses, cellulitis, and throbophlebitis. Many are undernourished,
and a substantial number have experienced a drug overdose.
The BSS found that among IDUs, 45.2 percent injected two to three times a day, whereas
16.1 percent injected more frequently. Fifty-three percent of respondents reported injecting
buprenorphine, followed by heroin (34 percent), crack (22 percent), dextroproxyphene (6
percent), tranquilizers (3 percent), and cocktail of heroin and cocaine (1 percent).
The BSS found that 41 percent of IDU respondents reported sharing (i.e., using) previously
used needles/syringes. About 83 percent of respondents who cleaned needles/syringes in the
past month reported using cold water for cleaning; 9 percent used hot water, 2 percent used
bleach or alcohol, and 1 percent boiled needles/syringes.
The majority of drug users in India are male. However, use of drug treatment data may
underestimate the number of female drug users, with women addicts a hidden population. '
There is great stigma attached to women seeking assistance for drug use, and women’s ability
to access treatment is hindered by their myriad responsibilities and workloads (e.g., child
care). Drug abuse by women in the northeast is believed to be growing.
In a paper prepared for the WHO Commission on Macroeconomics & Health, David Bloom of
Harvard and his colleagues note that:
Existing data provide some indication that the relationship between poverty and HIV is
growing stronger over time, both between and within continents. But it is not possible to
infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or
vice versa—or whether another variable, such as war, inadequate health, or poor education,
explains the relationship....In sum, the link between economic status and AIDS is complex.’
While many micro level studies point to a significant link between poverty and HIV
prevalence rates, macro data is unconvincing, particularly in terms of the causality of the
link. Some risk factors for HIV, such as a high level of disposable income, are more
HIV/AIDS in India
41
prevalent amongst the rich than the poor. Others, such as lack of education, are more
prevalent among the poor than the rich. Both groups exhibit the kind of mobility that appears
to be associated with HIV transmission. On balance, it seems plausible that the rich are more
at risk in the early stages of an epidemic, and that a combination of factors, including lack of
education and other economic exigencies, put the poor at increasing risk as an epidemic
progresses....The connection between AIDS and economics is complex, and drawing firm
conclusions is complicated by the lack of concrete data in many areas. The poor appear to be
most vulnerable to AIDS, but it is possible that this is not just because they are poor, but
because of the interaction between poverty and other factors such as poor education,
migration and weak health systems. Poverty reduction may decrease risk from the epidemic,
but it is also possible that ill-planned development efforts will temporarily increase the risk
that poor people face.55
Hakan Bjorkman, a senior adviser on HIV/AIDS to UNDP’s Bureau for Development Policy,
states that:
HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income
levels. But evidence from some countries at advanced states of the epidemic shows that new
HIV infections disproportionately affect poor people, unskilled workers, and those lacking
literacy skills—esp. young women in each of these categories. The relationship among
poverty, gender, and HIV vulnerability has important policy implications.56
(NACO, Yale, Harvard, the London School of Hygiene & Tropical Medicine, and Delhi
University are analyzing societal-level variables to determine the extent to which these variables
can explain the different HIV rates across India's districts. These variables include GNI per
capita; percentage foreign-bom in the population; religion; income equality; male-female literacy
gap; sex ratio; and percentage of male population in military forces. Once findings are available,
they will be included here, <http://cira.med.yale.edu/research/indiadetermin.html >)
This section does not seek to demonstrate causality; rather, it aims to analyze key political
economy and sociobehavioral contextual elements to highlight the range of sectoral policies and
interventions that may affect or be affected by HIV/AIDS. In addition to the table of key
HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also want
to consult the 2003 indicators related to progress on Millennium Development Goals, which are
published by UNDP <http://www.undp.org/>.
Country Overview
India is a federal republic57 comprising 35 states and union territories.58 India, which has a
secular constitution,59 is the world’s largest democracy.60 Though it occupies only 2.5 percent of
the world’s land area, the country is home to about 16.9 percent of the world’s population.61
(Only China has a larger population.) India’s mid-2003 population was 1.0686 billion.62 In 17
states, the population exceeds 20 million; 10 Indian states have populations over 50 million.63
To provide a sense of the scale of the country, consider that India accounts for:
■
36 percent of the world's poor (i.e., those living on less than US$l/day)64
>
Hiv/AIDS in India
42
*
J
20 percent of the World’s °Ut ,Of'Sch°o1 children65
23 percent of the world’s fhdddeX^
educa^n 66
*
'
22 percent of the
maternal deaths68
30 percent of the Xld’s deX^^pT^
''
ealth services69
.70
nsing about 200 towns a°d
S£XX7ou^
Religion cast
ethnicity’ reJi*m and
are 18
is Hindu (855 mfllion)- 12 n °Wed by Dravidian (25 percent) AboJt^)m’nant ethnic group is
(25 million) and 1-9
and Parsis).-
enrsTpo^r^0111128
Slkh
I X? °f
P°puJad-
mdhon) (other religious group^^XX^
The caste system reflects Tnd‘
'hntouiLwTs-^utVow^0"68 °f CaS'“ (^^X deluding a cat'116'1 hierarchies- Traditionally,
thousands of castes anLub™^011^ referred to as dalits. within thtslb°f T038165’ earIier calI^d
-jor6^“mPx“a”
to
Proportion to their population
economy.79
'
Se3tS be reserved for sc^duhd^111
One'third
ndla has become much more integrated with"the wmld11^ “
die from preven°tZ7eZ°Or’ W°men’ and scheduled tribes and .
pr0portlon the
malnutrition.81 AlthounM?0118’pregnancy “d childbirth-related eT'?0'1'1'11'65 to suffer and
^8h..ttracy„dsctooIemoIImenBar:^^^^
■
HIV/AIDS in India
43
Postcolonial Period
After about 100 years of British colonial rule, India became a dominion within the
Commonwealth in August 1947, with Jawaharlal Nehru as prime minister. Hostility between
Hindus and Muslims led the British to partition British India and create East and West Pakistan,
where there were Muslim majorities. India became a republic within the Commonwealth in
January 1950.83
After independence, the Congress Party, the party of Mahatma Gandhi and Jawaharlal Nehru,
dominated Indian politics until the late 1980s. In 1966, Nehru’s daughter, Indira Gandhi, became
prime minister. In 1975, as India faced deepening political and economic problems, Gandhi
declared a state of emergency and suspended many civil liberties. Seeking a mandate at the polls
for her policies, she called elections in 1977, but was defeated by Moraji Desai, who headed the
Janata Party, a consortium of five opposition parties.84
In 1979, Desai s government collapsed. Charan Singh formed an interim government, which was
followed by Indira Gandhi’s return to power in January 1980. In October 1984, Indira Gandhi
was assassinated, and her son, Rajiv, was chosen by the Congress Party to take her place. His
government was brought down in 1989 by allegations of corruption. Governments led by V.P.
Singh and Chandra Shekhar followed.85
Since the 1980s, the power of the Congress Party has been declining and has led to the
development of religious, regional, caste-based, and nativist (e.g., Shiv Sena in Maharashtra
State) parties. While this phenomenon has broadened the political spectrum and permitted more
voices to be heard, it has also led to greater government instability and the prevalence of
coalition politics, rendering implementation of reforms difficult.86
In the 1989 elections, although Rajiv Gandhi and the Congress Party won more seats than any
other single party, they were unable to form a government with a clear majority. The Janata Dal,
a union of opposition parties, was able to form a government with the help of the Hindunationalist Bharatiya Janata Party (BJP) on the right and the communists on the left. This loose
coalition collapsed in November 1990, and the government was controlled for a short period by-a
breakaway Janata Dal group supported by the Congress Party, with Chandra Shekhar as prime
minister. That alliance also collapsed, resulting in national elections in June 1991.87
In May 1991, while campaigning in Tamil Nadu, Rajiv Gandhi was assassinated, apparently by
Tamil extremists from Sri Lanka. In the June elections, Congress won 213 parliamentary seats
and formed a coalition, returning to power under the leadership of P.V. Narasimha Rao. This
Congress-led government, which served for five years, initiated a process of economic
liberalization (discussed below).88
The final months of the Rao-led government in spring 1996 were marred by several major
political corruption scandals. The BJP emerged from the May 1996 national elections as the
single-largest party but without a majority of Parliament. Under Prime Minister Atal Bihari
Vajpayee, the BJP coalition was in power for 13 days. To avoid another round of elections, a 14party coalition led by the Janata Dal emerged to form a government known as the United Front.
The Congress Party withdrew its support from the United Front in November 1997. New
elections in February 1998 brought the BJP the largest number of seats in Parliament but not a
majority. In March 1998, the president inaugurated a BJP-led coalition government, with
HIV/AIDS in India
44
Vajpayee again serving as prime minister. In May 1998, the government conducted a series of
underground nuclear tests, which led then U.S. President Bill Clinton to impose economic
sanctions on India pursuant to the 1994 Nuclear Proliferation Prevention Act.89
In April 1999, the BJP-led coalition government fell apart, leading to new elections in
September. The National Democratic Alliance—a new coalition led by the BJP—gained a
majority to form the government, with Vajpayee as prime minister in October 1999.90
The National Democratic Alliance government led by the BJP remains in power. However, the
BJP has lost several state-level elections to Congress, which now rules in 14 states. The BJP
rules in just four states, as a junior member of coalitions in another two, while its allies rule
three. 1
Economy
About 63 percent of the Indian workforce is in the agricultural sector, which accounts for 25
percent of GDP. Major agricultural products include wheat, rice, coarse grains, oilseeds, sugar,
cotton, jute, and tea. Twenty-two percent of the population works in industry and commerce
(representing 29 percent of GDP); major products include textiles, processed food, steel,
machinery, transport equipment, cement, aluminum, fertilizers, mining, petroleum, chemicals,
and computer software. Of the remaining workforce, 11 percent are in services and government
and 4 percent in transport and communications. India’s natural resources include coal, iron ore,
manganese, mica, bauxite, chromite, thorium, limestone, barite, titanium ore, diamonds, and
crude oil. Major exports are agricultural products, engineering goods, precious stones, cotton
apparel and fabrics, handicrafts, and tea.92
Structural Adjustment
In the early 1990s, India was facing a severe financial crisis. During 1990-91, the gross fiscal
deficit of the government (central and states) reached 10 percent of GDP, and the annual
inflation rate peaked at nearly 17 percent in August 1991. Given that foreign currency reserves
had fallen to US$1 billion by mid-1991, India utilized emergency measures to avoid defaulting
on its immediate debt service obligations and the financing of imports.93
In 1991, India embarked on a structural adjustment program, including liberalizing foreign
investment and exchange regimes, significantly reducing tariffs and other trade barriers, and
reforming and modernizing the financial sector. The reform process has had some highly
beneficial effects on the Indian economy, including higher growth rates, lower inflation, and
significant increases in foreign investment.94 Real GDP growth was 6.8 percent during 1998-99,
an increase from 5 percent during 1997-98.95 Since 1991, foreign direct investment has risen
significantly. The IT sector has shown tremendous growth in recent years, with revenues
estimated at US$8 billion in 2000.97
However, foreign direct investment, though higher than in the early 1990s, is still very low
compared to other large developing countries (US$2.5 billion per year compared to US$32
billion in Brazil and nearly US$40 billion in China, during the second half of the 1990s).98 GDP
t
HIV/AIDS in India
45
growth has slowed; during 2000-01, it averaged 5.4 percent," far short of the government target
of 8 percent.100 Large fiscal deficits remain a major obstacle.101 From 1998-99 to 2001-02, the
general government deficit increased from 8.8 to 10.3 percent of GDP. During this period,’
general government debt rose from 68 to 81 percent of GDP.102
The World Bank notes that "structural reforms have moved at a mixed pace," and that a series of
scandals in 2001 related to corruption in defense procurement, stock market manipulation, and
mismanagement of the country's largest state-owned mutual fund "may have distracted the
central government from its ambitious reform agenda."103 The Bank goes on to note that the
both the central and state governments are facing a "deteriorating fiscal situation."104
Most important, despite the structural reforms of the 1990s, vast income disparities between and
within India's states persist and poverty reduction remains paramount (see Poverty section
below).'“j’er capita income has increased, from US$390 in 1990 to US$380 in 1995 to US$450
in 2000.106 In 2001, gross national income (GNI) per capita (terminology that has replaced GDP
per capita) was US$480,107 This figure is somewhat higher than that for the South Asia region
(US$450) and for all low-income countries (US$430). However, globally, India's GNI per capita
ranks 162 out of208 countries.108
In a July 2003 report, the World Bank itself noted that structural adjustment had led to "uneven"
progress in India and that government attention to inequality is critical:
Development progress has been steady, but uneven. It has been uneven across indicators of
living standards, with notable progress in some areas, but little or no progress in others.
Maternal and under-five mortality, for instance, has hardly improved, while the new threat of
HIV/AIDS is spreading quickly. And unemployment, although still low by international
standards, has increased. Progress has also been uneven across regions. There is evidence of
divergence in per capita incomes across states, with richer states increasing incomes faster
than poorer ones. As a result, poverty has become increasingly concentrated in the country’s
slower growing states.109
Weaknesses in service delivery are of special concern in the social sectors: education, health
and social safety nets. While India has made substantial progress towards achieving better
social indicators over the past two decades, the rates of improvement have not been sufficient
to achieve the targets set in the Tenth Plan or even the less ambitious Millennium
Development Goals (MDGs).110
Spending on Health
Structural adjustment has sought to shift more health care delivery to the private sector. Public
spending on health, as a percent of GDP, did not rise during the 1990s (0.9 percent), whereas
private expenditure on health now accounts for 4.0 percent of GDP, or 81.6 percent’of all health
spending.
Dr. Brijesh Purohit of the Administrative Staff College of India states that:
'
I
HIV/AIDS in India
46
In the period prior to liberalization, between 1974-82, grants to the States from Central
government for the health sector comprised 19.9 percent of the States’ health expenditure.
However, following liberalization, this component of central grants fell to 5.8 percent (in
1982-89) and further to 3.3 percent (in 1992-93). This decline is most noticeable in the case
of specific-purpose central grants for public health and disease control programs. The central
component for the former of these (public health) dropped from 27.92 percent (in 1984-85)
to 17.7 percent (in 1992-93). The latter in the same duration declined from 41.47 to 18.50
percent. The other component of health expenditure, family welfare, also faced a decline of
central grants, from 99 to 88.59 percent of the States’ health expenditure....This falling share
of central grants had a more pronounced impact on the poorer states, which found it more
difficult to raise local resources. The likelihood of increasing state expenditure on [the]
health care sector is further limited in future with tjie continued pace of reforms.112
As discussed in the Health section below, there is an increasing gap between rich and poor states
with regard to public resources available for health, with resultant disparities in health
outcomes. Indeed, in July 2003, the World Bank noted that India's "progress in health
indicators has been slowing down precipitously."114 Concurrently, the Bank believes that "the
private health sector in India is unlikely to substantially improve the health and nutritional status
of the poor.
In its most recent health review of India, the Bank called for more explicit
targeting of the poorest sections of society, including exploring the "viability of providing the
poor with some insurance against catastrophic health events." 116
Dr. Nirupam Bajpai of Harvard’s Center for International Development believes that India’s
overall government spending must decline substantially to achieve macroeconomic stability and
long-term rapid growth; however, Bajpai argues for an increased role for government in health,
particularly vis-a-vis major infectious diseases, including HIV/AIDS:117
The government needs to give greater attention to, and provide larger resources for,
education and health. In the sphere of raising the literacy levels and providing greater access
to basic health services, the state governments are required to play a much more enlarged
role.118
Both the federal and state governments have a particularly urgent and critical role in
spreading literacy and access to primary health care to all the Indians so that they can all
participate in a meaningful manner and benefit fully from India’s economic
transformation....The federal government needs to undertake aggressive public health
campaigns to address major infectious diseases (pneumonia, diarrheal diseases, and malaria)
and especially the incipient AIDS epidemic, which now threatens India with tens of millions
of cases unless properly addressed.119
The reforms implemented so far have helped India attain 6 plus percent growth, however,
should India be able to implement these remaining reforms and re-orient governmental
spending away from inessential expenditures towards high priority areas of health and
education and infrastructure development, then it is very likely to attain and sustain even
higher rates of economic growth.120
HIV/AIDS in India
47
Certainly, a major concern is that as the central government reduces its role in health care
delivery, with decentralization and privatization to fill the gap, safety nets for the poor
(especially those in rural areas and women) are being threatened. This scenario is particularly
worrisome as the ability of state governments to provide basic health care is imperiled, given
their current and severe fiscal problems.121 (Further discussion in Health section below.)
Poverty
There has been intense debate regarding recent poverty trends in India. Statistical problems in
recent household surveys render it difficult to ascertain precisely poverty dynamics during the
1990s. The emerging consensus appears to be that there was some decline in poverty during the
1990s, but the size of the decline remains unclear.122
The official estimates are that the national poverty rate fell from 36 percent of the population in
1993-94 to 26 percent by the end of the decade. Some studies, however, have found that poverty
fell at a somewhat lower rate, from 36 to 29 percent.123 Using international poverty markers, in
1997, 44.2 of the population lived on less than US$1 a day, and 86.2 percent lived on less than
US$2 a day (i.e., the percentages of the population living on less than US$1.08 a day and
US$2.15 a day, respectively, at 1993 international prices [equivalent to US$1 and US$2 in 1985
prices, adjusted for purchasing power parity]).124
Richer states grew faster over the 1990s and may have also been more successful at reducing
poverty.125 Poverty is increasingly concentrated in the poorest states, particularly Bihar, Uttar
Pradesh, Orissa, and Madhya Pradesh (see table 6).126
Table 6. Percent of Population below National Poverty Line in Orissa, Bihar, Madhya
Pradesh, and Uttar Pradesh, 1999-2000
State
Population, 2001
(millions)______
Orissa
36.7___________
Bihar________
82.9___________
Madhya Pradesh 60.4___________
Uttar Pradesh________
166.1
Percent of Population below National
Poverty Line, 1999-2000___________
47.2
'
4Z6
_________________
374
31.1
'
Sources'. Census of India. Census of India 2001: Provisional Population Totals. New Delhi: April 4, 2001
<http://www.censusindia.net/results/provindial.html>; Nirupam Bajpai. A Decade of Economic Reforms in India:
The Unfinished Agenda. Harvard Center for International Development Working Paper no. 89. Cambridge, Mass.:
April 2002 <http://www2.cid.harvard.edu/cidwp/089.pdf>
Nirupam Bajpai of Harvard notes that:
There is no doubt that geography heavily influences economic performance....The
[Indian] interior has done much less well [than coastal states]. GDP growth in the
hinterland has lagged behind the coastal states by several percentage points per year.
There is a vast amount of economic reform that can be carried out to improve conditions
HIV/AIDS in India
48
in rural India, especially in the Gangetic valley....In particular, Bihar, Uttar Pradesh, and
Orissa are in desperate need of reform.127
Chronic poverty is disproportionately high among casual agricultural laborers, scheduled castes
(formerly called "untouchables"), and scheduled tribes (indigenous groups).128 In rural areas, the
incidence of poverty is highly correlated with lack of access to land.129
According to a 2001 report of the World Food Program:
India has achieved self-sufficiency in food grain production and currently holds
substantial stock in reserves. Yet more than 200 million people remain hungry and
chronically food insecure, and the statistics on hunger and deprivation reveal the depth of
vulnerability faced by women and children. Although India has one of the largest targeted
food assistance programs in the world, the effectiveness of that program has been
The primary cause of food insecurity is poverty. Chronic, limited access to food results from low
income, poor access to basic agricultural inputs, low farm incomes, and few alternative sources
of rural income. Transitory food insecurity results from seasonal fluctuations in food availability
and access, as well as from natural disasters.131
Since the early 1950s, the Government of India and most state governments have implemented
direct antipoverty programs providing wage employment, productive assets (such as land or
animals), training, credit, and food security to the poor. For the most part, these programs have
been poorly targeted, inefficiently managed, and highly fragmented.132 There has been very slow
progress on social justice and equality for the poor, particularly vis-a-vis minorities, scheduled
castes, and scheduled tribes. Court decisions on behalf of the poor may go unenforced, whereas
the police often act for the rich (or at least are perceived to do so). 133
Governance
Decentralization
As mentioned above, constitutional amendments in 1993 provided a legal foundation to local
governments and sought to strengthen participatory processes at the local level. These
amendments included a mandatory requirement that one-third of local representatives be women,
and that seats be reserved for scheduled castes and tribes in proportion to their population.134
However, commitment to decentralization has varied by state, as has capacity to strengthen local
government. Although a new political structure of local, mid-level, and district councils exists,
the authority and resources of these entities may be minimal. In many states, although the district
remains the basic unit of administration, the state legislature and administrative structure, subject
to limitations imposed by the central government, still control service delivery, such as the
availability of health clinics and schools. In Andhra Pradesh, for example, little authority has
been turned over to local councils.135
f
HIV/AIDS in India
49
wer^ewected toTd
SCfheduled CaStCS gained a voice ^panchayat councils, these councils
were expected to advocate for propoor and gender-sensitive expenditures. However experience
on the ground 1S nuxed. One study found that although decentralization in Karnataka hT
instTtTt^
°f P°llt,Cal PartlcIPation, enhanced accountability, and rendered government
institutions more responsive to citizens, the net effect in two of the state's district h“ to
is betmt
Shar® °f resources allocated to well-off groups at the expense of poorer groups- this
because local elites now control the councils' agenda.1* How decentralization is retlizfd on
Corruption
TI goes on to state that:
ector problems, the chronic region-wide failure to pay taxes, poor public service
delivery and inadequate enforcement of financial regulations. Banks and state-sponsored
compX”1106 and PenSI°n C°mpanies have been the chief targets of private sector
Sai wLT n"uer°"S’ “?h-visibilil>' afiegations of corruption leveled at the ntling
though whether they have adequate resources (in addition to political will) to do so is
questionable, given the fiscal crisis described above.
141 •
Judiciary
hcrebaseiro1PerSUade
eXecutive or legislative branches to take action, many Indian NGOs are
■
The Indian judicial system is impeded by:
HIV/AIDS in India
50
'
enormous backlogs (about 28 million cases)
exSon
ffleT™8“d
*
some degree of corruption at the state level
XX)f kn0WledSe ab0Ut neW aSPeCtS °f the laW (e'g'’ neW commercial ’eolation,
■
weak enforcement of decisions145
inmates, only 2 000 are convicted criminals; the remaining 9,000 are all awaiting processing 146
The very poor do not use the courts, as they do not have the financial resources nor the time
(litigants must appear each time a case is scheduled or rescheduled). There are also customary
STh
u"6111
°f 10Wer castes d0 not challenSe membcrs of higher castes. Many
Indians do not know that they have certain rights or that redress is an option.147
The above scenario has wide import for the human rights of PWHA, as well as for police
and ?UT °f SWS’ MSM’ and the Staff of HIV/AIDS projects that work with them.148
(See the Human Rights section for detailed discussion.)
Freedom ofInformation
In India, a national freedom of information bill passed the committee stage in March 2002 but
e amendments introduced were severely criticized by civil society activists as undermining the
tT /mT5 ''S' ? TPOnCd IcSlslatl0n' Karnataka, Kerala, Goa, Maharashtra, Rajasthan and
mil Nadu, and Andhra Pradesh have enacted their own access to information laws. However
again, activists raised concerns that loopholes were deliberately inserted into state legislation to
enable officials to deny access to information when convenient. Many state laws also fail to
include penalty clauses for not providing information.149
Violence
See also the Human Rights section below.
Over the past several years, India has experienced a significant increase in organized and random
I10 u06’ partlcularly communal, ethnic, tribal, and caste-based violence. A 1998 study found
that about half of the country’s over 600 districts faced some form of unrest, whether communal
violence, insurgency, or gang rule. 50
The political mobilization of religious communities has led to a scenario in which politicians
exacerbate differences between groups to consolidate support among their own group. A major
iactor has been the rise in Hindu nationalism since the early 1980s. Hindu nationalist
organizations include the largest student organization in India, the largest trade union in the
country, t e ruling Bharatiya Janata Party, the VHP (which concentrates on strengthening Hindu
identity and unity and which led the Ayodha temple movement), and the Bajrang Dal (a
paramilitary group). All these groups have facilitated an environment that gives rise to violence
against religious minorities (Muslim, Christian).151
51
HIV/AIDS in India
In January 2001, Gujarat sustained the most severe earthquake in India over the last 50 years.
The earthquake killed an estimated 16,480 people. In the worst-affected areas, 95 percent of
buildings were destroyed, and almost 1 million people’lost their homes.152 Following the
earthquake in 2002, there was an outbreak of ethnic violence. The International Federation of
the Red Cross noted that the prolonged rioting severely hampered rehabilitation efforts.
Although the situation was gradually improving, the terrorist attack on the Hindu Akshardham
temple in the state capital of Gandhinagar in September 2002, in which 31 people were killed
and 100 injured, led to further violence between Hindus and Muslims.153
The "Seven Sisters" — the northeastern states of Assam, Manipur, Tripura, Nagaland, Mizoram,
Meghalaya, and Arunanchal Pradesh — encompass 200 ethnic groups. All these states are
plagued by some degree of civil conflict. In Assam, for example, the influx of migrants from
West Bengal and of illegal immigrants from Bangladesh has generated communal tensions
(native Assamese are Hindu). There are 43 insurgent groups in Assam; the United Front for the
Liberation of Assam is the largest and controls portions of the state. Ongoing conflicts have led
to the deaths of civilians, security forces, and members of the UFLA. In Manipur, 18 ethnic
•
insurgent
groups are active. 154
India's relations with Pakistan are influenced by the centuries-old rivalry between Hindus and
Muslims, which led to Partition in 1947. The principal source of contention has been Kashmir. In
1947, Kashmir's Hindu Maharaja chose to join India, despite that a majority of his subjects were
Muslim. India maintains that his decision and subsequent elections in Kashmir have rendered the
state an integral part of India. Pakistan asserts Kashmiris' rights to self-determination through a
plebiscite in accordance with an earlier Indian pledge and U.N. resolution.155
A recent report undertaken for USAID notes that:
Obviously, Kashmir is the biggest threat to regional security in South Asia. India is not
going to release Kashmir, and Pakistan is unlikely to give up its support for Kashmiri
independence or incorporation into Pakistan itself...The human rights abuses on the
government side, just as on the militant side, are profound and serious. They include
targeted assassinations, custodial killings, torture and disappearances.156
Ethnic violence, among other things, can spur significant population dislocation and regroupings
of family units, which entail exposure to new sexual networks and thus may heighten
vulnerability to HIV (see Population Mobility section below). It also affects state and local
government's ability to deliver essential services.
Military Spending
Violence within India, as well as the tensions with Pakistan, also means that significant resources
are directed to the military. Military expenditures as a percent of GDP decreased slightly during
the 1990s, from 2.7 percent in 1990 to 2.5 percent in 2001. By comparison, in 2000, India's
public expenditure on health was 0.9 percent (a figure that did not change during the 1990s).
(According to UNDP's Human Development Report 2003, in addition to India, the governments
'pl S ' 3'7- <
08386
P02,
vA. *
HIV/AIDS in India
52
of 41 other countries [for which comparable data were available] also spent more on the military
than on health during 2000-01.158) (See also the accompanying table of key HIV/AIDS and
socioeconomic indicators for comparative indicators on the military, arms imports, etc.)
Nevertheless, more recent figures on military spending, which may have increased after events in
1999 and 2001, have not been released. Given India’s ongoing tensions with Pakistan, the events
of 9/11/01, and a terrorist attack on the Indian Parliament in December 2001,159 one might infer
that military spending will remain high.
Human Development
One method of tracking human development in India is to analyze trends in its Human
Development Index. The HDI was created by UNDP to measures average achievements in life
expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross
enrollment ratios; and GNI. An HDI of 0.800 or above = high human development; 0.500 - 0.799
= medium human development; less than 0.500 = low human development. India's human
development index has been increasing, from 0.407 in 1975 to 0.473 in 1985 to 0.545 in 1995 to
0.577 in 2000.160 In 2001, India's HDI had reached 0.590.161
However, these improvements mask enormous inequalities within the country. For example, in
1997, the richest 20 percent of the population represented 46.1 percent of income/consumption,
where the poorest 20 percent of the population represented just 8.1 percent of
income/consumption.162 The mortality, malnutrition, and fertility rates of the poorest 20 percent
of Indians are over double those of the richest quintile.163 Broadly, human development
indicators are better for smaller states and union territories.16^ (More detail on the Health section
below.)
Durmig65the 1990s’ India's public expenditures on education rose from 3.9 to 4.1 percent of
GDP.
In education, India has steadily raised primary enrollment rates since independence and
today has the world's second largest education system after China, with 108 million children ages
six to 10 attending primary school. However, over 25 million primary school age children are not
in school. Children from poorer families are at a greater disadvantage. The dropout rate for the
poorest households is about four times that of the richest ones. There are large gaps in access to
education; quality of education; and educational attainment according to gender, social class, and
region. (See the Gender section below.)
Health is discussed in a separate section below.
Population Mobility
There is enormous population mobility in India and throughout South Asia. Mobile populations
include
■
■
■
■
permanent and seasonal labor migrants within the country
those entering and leaving India for work-related reasons
people dislocated by drought, floods, or other disasters
people dislocated by conflict
HIV/AIDS in India
53
■ refugees seeking asylum in India
■ transport workers
■ traders/vendors
■ hotel and tourism workers
■ tourists (e.g., temple tourists)
■ prisoners
■ military personnel
■ sex workers
■ trafficked persons
■ MSM
India has ajong history of mobility, with various groups having invaded the country over the last
centuries. During colonial rule, the British moved segments of the population to Sri Lanka,
Malaya, and other countries to work on plantations. Movements of unskilled workers increased
during the 1970s, including to the Gulf states, which sought cheap labor. 168 According to the
1993 National Sample Survey in India, 24.7 percent of the population had migrated, either within
India, to neighboring countries, or overseas. 169 Applying this percentage to the mid-2003
population of 1.069 billion,170 about 264 million Indians are mobile.
Labor migration is a common livelihood strategy in India. Poverty and lack of economic
opportunity pushes many to migrate to urban and manufacturing areas for jobs in the formal or
informal sectors. Other reasons include the desire to leave more traditional rural communities for
urban areas. Some women may be forced to migrate, as they are perceived as a burden to their
family and as a reliable source for remittance income. Some women may also be fleeing
domestic violence. 171 ,172 Low-skill female migrants are particularly vulnerable to acquiring
HIV, as discussed below.173 India is also a country of origin, transit, and destination for
thousands of trafficked persons.174
The communities from which migrants emigrate are vulnerable to HIV for several reasons.
While their male partners are away for long periods (and particularly if they do not send regular
remittances), some women may rely on sex work to supplement household income. Returning
migrants with HIV, many of whom do not know their status, may infect their wives or other sex
partners in the home community.175
Intracountry Migration
India's second National Family Health Survey (NFHS-2), conducted during 1998-99, found that
the national sex ratio was 957 females for every 1,000 males in rural areas but only 928 females
for every 1,000 males in urban areas. Among the rural population ages 20-29 and 50-59, the sex
ratio rises even further, to 1,075-1,221 women for every 1,000 males. These data suggest that
many more men than women have migrated to urban areas.176 Urbanization has resulted in large
slum populations.177 (India’s first National Family Health Survey was conducted in 1992-93.
The Ministry of Health and Family Welfare subsequently appointed the International Institute for
Population Sciences [UPS] in Mumbai to initiate a second survey [NFHS-2], which was
conducted during 1998-99. The NFHS-2 sample covered over 99 percent of India’s population
living in (then) 26 states; it did not cover union territories. NFHS-2 was conducted with financial
HIV/AIDS in India
54
STwe^CenteJ™)
UNICEF- Technical assistance was provided by ORC Macro and the
At the XIV International AIDS Conference in Barcelona in July 2002, numerous Indian and
international researchers highlighted the vulnerability of migrant populations. For example:
Maharashtra
htpTbai .D1Stn?S AIDS.Contro1 Society rePorts that about 60 percent of the city's population
lives in slums. To examine attitudes and behaviours regarding HIV/AIDS and sexuality
onTftr C°n
ed a SAUrVey among 1’373 male? and 1’631 females ages 15-24 residing in
nradef7 Ah h3/ " ' UmS’ m°n8 311 resPondents’ 63 Percent had educational attainment up to
females t? 8
aVerage agC at marriage for males was 20-° a°d for
lemales, 17.8. Almost 90 percent of respondents had not heard of STIs (89.1 percent).181
Kerala
Search for employment opportunities leads many in Kerala to migrate, both to other Indian
states as well as to the Gulf countries. Concurrently, a thriving tourism industry is spurring
much movement within the state. 182
*
Though Kerala has low HIV prevalence, vulnerability is high, given large-scale out- and in
migration. India HIV/AIDS Alliance and Kerala State Management Agency state that 80
percent of reported AIDS cases m the state are "migration-related" (abstract did not define
inis term).
Rajasthan
FXB *ajas. han Society and FXB India Society are very active in the state. In a baseline
suivey of 13 villages in rural/remote areas of Rajasthan, FXB found that all males who tested
HIV-positive were either migrant workers or had a history of migration. The three adult
lemales who tested positive were wives of migrant workers. 184
FXB examined the sexual histones of HIV-serodisconcordant couples with a past history of
migration who had visited the FXB Center in Jodhpur from July to December 2001 (these
HIV/AIDS in India
55
data were originally collected through a confidential and voluntary interview). Of the total 43
individuals newly diagnosed with HIV, there were 17 HIV-serodisconcordant couples. All 17
males had a history of migration, whereas none of the 17 females did so. Ten males of the 17
had a history of paid casual sex without protection. The remaining seven males either had
died or had not wanted to discuss casual sex; their female partners reported no extramarital
sexual relations. None of the 17 women reported a history of unprotected casual sex. FXB
concluded that migrant workers—who are usually male—are exposed to HIV when away
from home and appear to be the primary factor with regard to their spouses' HIV infection.185
Gujarat
•
Gujarat has identified and is working with several subpopulations with particularly high
vulnerability to HIV; these include seafarers, industrial workers, prison inmates, and
diamond cutters. (Discussion of prison interventions in Gujarat is found below.) Currently,
the Gujarat State AIDS Control Society and its partners are managing about 50 targeted
interventions among high-risk groups across all districts. Slums interventions, for example,
cover occupational groups such as construction workers, daily wage earners, rag pickers, and
other low- or no-skill self-employed workers.186
Sex Workers
India's first national behavioral surveillance survey (BSS) was conducted in 2001 and is
discussed in depth below. It found that almost 25 percent of sex workers were engaged in sex
work before they came to the city/town where the BSS interview was carried out. One-third of
SW respondents reported traveling to other places for sex work.187
Prisoners
Indian Penal Code 377, based on a 19th-century British law, criminalizes "the act of anal and
oral sex performed either between two men or between a man and a woman."188 (There is
currently a petition before the New Delhi High Court to repeal section 3 77.189) Thus, distributing
condoms inside prisons is illegal.190 However, actors from government and civil society
acknowledge the existence of high-risk sexual activities, both coercive and consensual, in prisons
and are designing related interventions. The context of prisoners' vulnerability to HTV/STIs is
related to lack of awareness of these diseases, lack of access to preventive interventions,
overcrowding, poor sanitary conditions, loneliness, lack of social control, lack of entertainment,
and separation from family.191 A summary of selected Barcelona abstracts from 2002:
■
Hindustan Latex Limited has established a Technical Resource Unit under agreement with
the Andhra Pradesh State AIDS Control Society to manage targeted interventions among
vulnerable populations, including prisoners. The prison program was initiated through
discussions with the state's senior prison officials. Four prisons were initially selected and a
rapid assessment of needs conducted. A proposal was developed with prison authorities and a
contract signed for the intervention. Committees, which included prisoners, were formed to
oversee project implementation. The intervention focuses on behaviour change
communication sessions, STI care and counseling, peer education, and a referral system for
partner treatment. Also, the project is distributing condoms in prisons. The intervention has
'
HIV/AIDS in India
56
been scaled up to include eight more prisons. A statewide rapid assessment survey was
conducted and identified 30 new prisons for inclusion in the program. Raising awareness
among and including key stakeholders—such as prison officials and inmates—in the
program was critical, as were needs assessments and a phased approach.192
■
Gujarat has 10 major prisons, all of which are overcrowded, with large number of detainees
awaiting trial.193 In 1998, the Gujarat State AIDS Control Society piloted a behavior change
communication intervention in the Surat District Prison. Obtaining prison officials' approval
as well as involvement in implementation were major challenges. However, by 2001, the
program was working in nine prisons across the state.194 At each prison, activities are
implemented in collaboration with prison authorities. Exit counseling and linkages with
prisoners after release is crucial. The program has also found that linkages with other
recreational, spiritual, or physical entertainment have a catalytic effect.195
Truck Drivers
India's national highway network of 52,000 km spans 35 states.196 There are 2 to 5 million
truckers and helpers on Indian transport routes. The extended periods of time that they spend
away from their families place them in close proximity to "high-risk" sexual networks, and often
results in their having an increased number of sexual contacts. 197
There is wide variation in the prevalence of STIs/HIV and in sexual behavior among Indian
truckers. During 2000-01, FHI and local NGOs PREPARE, BPWT, and VOICE conducted
STI/HIV prevalence surveys among male truckers in West Bengal (east India) (n=335), Andhra
Pradesh (south) (n=375), and Haryana (north) (n=410. Most of the truckers were from the states
in which they were surveyed. They found that HIV prevalence patterns in truckers tended to
mirror the local epidemics. In east India, prevalence of HIV was 2.99 percent; syphilis: 6.3
percent; and gonorrhea: 1.8 percent. In the north, the HIV prevalence among association-based
truckers was 1.9 percent; syphilis: 7.2 percent; and gonorrhea: 4.8 percent. Prevalences of HIV
and syphilis were higher among truckers from halt points in the north: HIV: 6.9 percent; syphilis:
8.4 percent. In south India, HIV prevalence was 10.9 percent; syphilis: 9.6 percent; and
gonorrhea: 7.5 percent.
About 27 percent of truckers from the east, 49.4 percent from the south, and 29 percent of
association-based and 45.3 percent f truckers from halt points from the north reported having sex
with female sex workers or nonregular partners in the preceding year. Reported condom use
during last sex with FSW/NRP was 30.4 percent in the east, 57.2 percent in the south, and 16.6
percent among association-based and 12 percent among halt point based truckers in the north.198
According to the BSS, 18 percent of truck drivers in the western part of the country reported
intercourse with a sex worker in the last year; 21 percent in the south, 25 percent in the east, 40
percent in the northeast, 48 percent in the north, and 49 percent in the central region. Truck
drivers were the largest client segment of female sex workers, ranging from 62 percent in the
west to 98 percent in the north.199 Truckers are among the best clients of women in prostitution
since they pay well and are least violent.200
HIV/AIDS in India
57
Sex workers’ reported condom use with last paying partner ranged from 54 percent in the central
region to 96 percent in the south. Condom use during every act of intercourse in the last 30 days
ranged from 31 percent in the central region to 85 percent in the south.201
Major HIV/STI prevention projects aimed at truckers include PATH and Healthy Highways (see
Response and Links sections). These projects are noted for including not just truckers, their
helpers, and sex partners, but also other key stakeholders such as truck loaders, gasoline station
owners and employees, and motel and lodge owners along highways.
Forced Migration as a Result ofDrought, Floods, or Other Disasters
According to a 2001 report of the World Food Program, 40 million Indians are exposed to
recurring natural disasters.202 For example, in July 2003, over 3 million Indians had been
displaced by floods and monsoon storms.203 Further population mobility ensued, as the Indian
army was mobilized to assist in related rescue operations.204
FXB has found that promoting awareness of HIV/AIDS issues in rural Rajasthan is rendered
difficult by poverty, famine, and drought. These three factors play a major role in spurring
migration—primarily, of young males—from rural areas to large urban centers. Given, inter alia.,
their lack of sexual education, as well as the lifestyle changes that migration itself entails, these
migrant workers are particularly vulnerable to acquiring STIs/HIV. FXB developed an outreach
program whereby two peer educators in each of the 180 villages in its target area are being
trained on HIV/AIDS. Subsequently, these peer educators will each train 10 people on
HIV/AIDS. One of the key lessons is that young workers need HIV/AIDS education before they
migrate.205
MSM
The Humsafar Trust, which works with MSM in Mumbai, reports that MSM are generally
mobile in that they travel great distances to find other MSM and sex partners.206 Another
Mumbai-based project, ASHA, reports that within the MSM community, "sites, people, and
gatekeepers can change very rapidly." 207 An abstract presented in Barcelona, for example, found
that transgendered persons in Tamil Nadu have high levels of mobility, owing to, inter alia,
stigma, discrimination, and difficulty accessing housing and other basic needs.208
The first national BSS found that 57 percent of MSM respondents reported that they usually
traveled to other places; among them, 17 percent reported traveling at least every 7 to 14 days.
About 20 percent of respondents reported traveling at least once a month. These trips were
usually meant for socializing with relatives or friends (47 percent) or for pleasure (27 percent).
Respondents from Mumbai traveled more often compared to those from other sites (Delhi,
Calcutta, Chennai, and Bangalore).209 (See MSM section below.)
IDUs
The national BSS also found that among IDU respondents, there was wide variation in length of
stay in the city in which the interview occurred. The proportion of respondents who reported that
HIV/AIDS in India
58
they were living in the city since birth was as high as 89 percent in Chennai and as low as 37
percent in Mumbai. Most IDUs interviewed in Manipur (93 percent) and Chennai (81 percent)
reported that they were staying at their regular residence, whereas this figure was 26 percent in
Mumbai, 53 percent in Delhi, and 62 percent in Calcutta.210
Military
According to UNDP, in 2001, India had about 1.3 million military personnel.211 Designed
primarily to defend the country's frontiers, the army has become heavily committed to internal
security in Kashmir and in the northeast. Official data on HIV prevalence within the military are
not available. The U.S. National Intelligence Council believes that HIV/AIDS is unlikely to
undermine India's overall military capabilities because of the large pool of potential recruits.212
The NIC, however, has not released data on the costs to the Indian military to conduct
HIV/AIDS prevention and treatment programs. There is also the cost borne by ex-combatants,
their families, and they communities they return to when they fall ill because of AIDS.
Scheduled Tribes
There are 533 tribes in India. The areas inhabited by tribal populations constitute a significant
part of the underdeveloped areas of the country. Tribal populations primarily live in isolated
villages or hamlets.213 The main concentration of tribal peoples is in the central belt of India and
in the northeastern states. States and UTs in which the tribal population is greater than 50 percent
are Arunachal Pradesh, Meghalaya, Mizoram, Nagaland, Dadra & Nagar Haveli, and
Lakshadweep.214
The population of scheduled tribes (as a percent of national population and in absolute numbers)
has been increasing, from 19.1 million in 1951 to 38.0 million in 1971 and 67.8 million in
1991.215 According to India's 1991 census, scheduled tribes represented 8.1 percent of the total
population. 216
Assuming that the national percentage of the tribal population in 2001 was still 8.1 (though it has
likely risen), the 2001 tribal population was 83.2 million (using Census India 2001 national
population figure of 1.027 billion).217 Using a 1991 map of India’s tribal population from the
Ministry of Tribal Affairs in conjunction with provisional state-level population figures from the
2001 census yields the following rough data for the states identified in 2001 as having the
highest HIV prevalences. (Data for Bihar, Gujarat, and Rajasthan are also included, as abstracts
addressing tribal populations in these states were presented at the XIV International AIDS
Conference in Barcelona in July 2002 [see below for selected abstract summaries].)
Table 7. Size of Tribal Population in Six High-HIV-Prevalence States
State
Total Population,
2001 (millions)
Nagaland
1.99
Tribal Population as %
of Total State Population,
_________ 1991_________
87.7
Estimate of Tribal
Population, 2001
(millions)
1.75
HIV/AIDS in India
59
34.4
0.82
Manipur______
2.39
9.3
Maharashtra
96.75
9.00
4.77
75.73
Andhra Pradesh
6.3
2.27
Karnataka_____
52.73
4.3
0.62
Tamil Nadu
62.11
1.0
82.88
Bihar_________
7.7
6.38
50.60
7.54
Gujarat_______
14.9
56.47
Rajasthan_____
12.4
7.00
Sources: Indian Ministry of Tribal Affairs. Statewise Tribal Population Percentage in India (1991 Census).
<http://tribal.nic.in/img/IndiaMap.ipg> Accessed July 2003; Census of India. Census ofIndia 2001: Provisional
Population Totals. New Delhi: April 4, 2001 <http://www.censusindia.net/results/provindial.html >
The government has established health centers in tribal areas; however, it notes that medical
facilities are inadequate and underutilized. Indian's 1991 census found that the literacy rate
among tribal populations was 29.6 percent, far below the national figure (52.2 percent); the
female literacy rate was 18.2 percent (national figure: 39.2 percent). 218
According to a 1993-94 survey from the Ministry o Rural Development, over half of the rural
tribal population lives below the national poverty line. The per capita income of tribal peoples is
one of the lowest in the country.219
The Ministry of Tribal Affairs estimates that between independence and 1990, 8.54 million
people from scheduled tribes were displaced by development projects or industries (e.g.,
mining). This figure represents 55.2 percent of all Indians displaced for these reasons during that
time period. The ministry reports:
Those displaced have been forced to migrate to new areas and most often have
encroached on to forestlands and are, on record, considered illegal. It is a known fact that
displacement has led to far reaching negative social and economic consequences, not be
mentioned the simmering disturbances and extremism is most of the tribal pockets.
Economic planning cannot turn a blind eye to these consequences in the light of
displacement. While on the one side, tribal were alienated from their lands, there has not
been any remarkable progress on health, education or infrastructure development. It has
been a myth that industrialization would lead to a corresponding improvement in these
sectors among the local tribal. It has only proved that they have been further marginalized
from whatever rights and resources earlier enjoyed by them. There has been no attempt to
improve the skills of the tribal to compete with the mainstream societies in taking up any
responsible position in the industries set up in their areas.220
Another facet of mobility is labor migration. Many tribal men are mobile, seeking employment
in urban areas and moving regularly between cities and their home villages.221 Many are also
mobile through their service in the army.222
There are very few data on HIV/AIDS and India’s tribal populations. Below is a summary of the
abstracts presented in Barcelona in July 2002 that addressed the topic:
HIV/AIDS in India
60
■
Researchers from the Tribal Development Society in Kanchee District, Tamil Nadu, and the
South Nassau Communities Hospital in New York examined HIV risk among women of the
Irrula Tribes in Tamil Nadu. Ethnographic data were collected using key informant
interviews and focus group discussions. They found that none of the women was literate. Age
at first marriage was 13. Illness is always associated with the "evil eye, witchcraft, and devil
possession." Health is not a priority, and health-seeking behavior is supplanted by religious
belief, practice, and ritual. Tribal women prefer self-remedies and native medicines to
institutionalized medicine. Both men and women migrate for work and both report
extramarital relationships; having multiple sexual partners and leaving one partner and
marrying another is common. Men make sexual decisions. There was no awareness of
HIV/AIDS. None of the women had heard about condoms, and no one in the tribe used them.
Women did report STI symptoms.223
■
SVYM in Mysore and the University of South Florida in the U.S. conducted a household
survey within the 109 tribal colonies of the H.D. Kote District of Karnataka. They found that
22 percent of respondents had heard of HIV/AIDS, whereas only 10 percent had knowledge
of how it is transmitted. AIDS awareness among women (9 percent) was considerably lower
than that among men (18 percent). Only 5 percent of women knew how HIV/AIDS is
transmitted; the comparable figure for men was 17 percent. Only 2 percent of women knew a
method of preventing HIV; among men, this figure was 13 percent. 224
■
As part of the same study, the researchers used unstructured interviews and focus groups, to
gather information on sexual values, beliefs, and practices. Beliefs included "Surgical
sterilization prevents STIs" and "There is cure for every disease." (The abstract did not
include data on the prevalence of these beliefs; one infers that they were the prevailing
beliefs.) Lack of structured marriages (this term was also not defined in the abstract) and
what the researchers deemed tribal "permissiveness" regarding pre- and extramarital sexual
relationships exacerbate HIV vulnerability. The researchers noted a recent increase in
transactional sex, wherein tribal people were trading sex with urban dwellers in exchange for
material goods (presumably this dynamic was being experienced by tribal populations who
had migrated to urban areas and had returned [permanently or temporarily] to participate in
the study).225
■
In Chennai, the MGR Medical University conducted a cross-sectional, population-based
(n=158) study in a tribal community in south India. Among males ages 15-49, 72 percent
reported high-risk behavior. Over 60 percent of all respondents attended government health
centers for STI/RTI treatment. However, they had little knowledge of STIs, and treatment
compliance was poor.226
■
Since 1997, researchers from the BUM Maheswaran Center for Social Education and
Development in Madurai, Tamil Nadu, have been working on HIV/STI prevention with the
Western Ghats of Kodaikana, a tribal community living near popular hill tourist areas.
Members of the tribal community travel to the "buffer zone" with the nontribal community
every three months. Many spend this time drinking, smoking, and visiting sex workers.
Knowledge of STIs/HIV/AIDS is very low. Having multiple sex partners (other than a blood
relation) is widely accepted.227
HIV/AIDS in India
61
■
Project Concern has examined migration of tribal women from Chota Nagpur in Bihar to
urban centers in search of employment as domestic workers; there are an estimated 40,000 to
60,000 female migrant household laborers from Bihar in Delhi. These women's vulnerability
to HIV infection is related to lack of family support; poverty; little or no education; limited
access to information on sexual health; risk of coerced sex and/or other forms of violence; ’
lack of advocacy in legal and social welfare systems; and ineligibility for protection under
labor laws given their unskilled worker status. Project Concern used qualitative and
quantitative methods to examine these vulnerability factors and to identify the
HIV/AIDS/STI needs of migrant girls and women from Bihar working in Delhi as domestics.
They found that knowledge of HIV/AIDS and modes of transmission was inadequate. A
culture of silence about abuse exists, given lack of advocacy and labor rights, as well as
cultural norms.228
■
The Gujarat State AIDS Control Society has observed permanent and seasonal migration
patterns. Within the state's tribal communities, migration tends to be seasonal, with tribal
populations moving to urban areas in search of work. Their high rates of illiteracy and lack of
skills render them a cheap labor force. Within tribal communities, having multiple sex
partners is normal practice. Sexual health services in tribal areas are minimal. Moreover,
mobility renders follow-up for STI treatment difficult. In urban areas, they are often bonded
labor, rendering any access to health services difficult. GSACS found that tracking floating
populations and coordinating health services at both the workplace and permanent residence
are crucial.229
Intercountry Migration
Recent studies have estimated that over 100,000 Indians leave the country each year to work in
other countries; 80 percent of these workers are unskilled.230
According to the Indian government, there were over 1.5 million Indian migrant workers in the
Middle East in 1991. By 1995, this figure had increased to over 4 million. Indian men are hired
as temporary contract workers in construction, in addition to jobs as domestic workers,
engineers, accountants, and technicians. Most Indian female migrants in the Gulf states work as
domestics or nurses/nurses' aids.231 Hong Kong also has many Indian domestic workers. 232
Social and legal protections for Indians leaving the country for work abroad are poor. (Similarly,
there are few support systems for individuals who enter India as migrant workers. 233) Migrants
can experience physical as well as financial exploitation by illegal recruiting agencies, law
enforcement officials, border crossing officials, other intermediaries, employers in the host
country, and other migrants. 234 UNDP reports that Indian export labor has become "casualized"
and feminized, indicating a decline in protection of workers' rights and health. Undocumented
migrants, particularly women, are especially vulnerable to fraud and exploitation, including
sexual abuse; lack of freedom of movement; and poor access to sanitation, nutrition, and health
care. 235
HIV/AIDS in India
62
,1’”famife“<*
?e1C0Un,ry’ ‘re
'
Sm °”"S ,h,a*ri<led *heir behaViOrtaTc^X7VtdteMeed 6'0"’ 'b'
danfre
T) deSpair’ loneliness, racial and cultural discrimination, marginalization
drugs. Au’o^esri™Ztbta1S^ie“d^^^&'Se' inC'“din8 inJ'C,ing
of legal and human rights. For example,
V status, leads to anger, confusion and vulnerability of sexual partners.238
Refugees in India
definition of refugees.)
d, and China.
(See <hap://www.unlicr.cl1/> for UNHCR's
Indian Asylum Seekers
^XXeXlusMTZtoBd 3 ‘PPc “T
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in -dustria!
Genjany, Ireiand, My, Nethirlands, PoiaiX.oXedeX^Xd, ?“ U^ani
Human Trafficking
According to a 2003 report on trafficking from the U.S. State Department:
XSZS
S™etm- slaved
is a
dia or transited through India en route to Pakistan and the Middle East for
'
HIV/AIDS in India
63
purposes of sexual exploitation, domestic servitude, arid forced labor. Nepalese women and girls
are trafficked to India for commercial sexual exploitation.242
According to the 2003 State Department report, forced, bonded, or indentured child labor is
illegal in India, and penalties for trafficking are commensurate with penalties for rape or forcible
assault. Although the government of India does not yet fully comply with the minimum
standards for the elimination of trafficking, it is making significant efforts to do so despite
limited resources. Once-rare prosecution of traffickers, brothel owners, and others associated
with trafficking has increased significantly over the past year. Three special courts in New Delhi
have been designated to hear trafficking cases. The government has significantly increased the
number of arrests, prosecutions, and convictions of traffickers and brothel owners over the past
year, but backlogged courts slow criminal justice proceedings. There are reports of border guards
accepting bribes or ignoring trafficking. In addition, some law enforcement officials have been
implicated in alerting brothels to raids.243
The State Department report highlights India's significant efforts in trafficking prevention.
National and state governments are supporting projects to raise women's educational attainment
and provide them with skills and opportunities to generate income and thus reduce their
vulnerability to trafficking. The government is also conducting the world’s largest child labor
elimination program, which includes providing primary education for 250 million children. State
interventions, often undertaken in partnership with civil society, include:
■
"
•
supporting public awareness campaigns about pedophilia and sex tourism
conducting training programs for drivers and bus conductors to identify "girls in distress"
establishing village and community level “watchdog” committees to prevent trafficking
by monitoring the movements of women and children244
This last item, community-level monitoring, may inadvertently prevent women and children
from safe migration. For example, the Population Council has found that efforts to prevent
trafficking of Nepalese women and children into India often discourage migration altogether,
preventing women who want to travel or voluntarily seek safe employment elsewhere. 45 The
council also found that many Nepalese antitrafficking interventions are not sensitive to the
human rights of trafficked women and girls, in that fear-based HIV messages lead to increased
stigma for trafficked returnees, who are condemned by their communities for disgracing their
families as well as for bringing HIV/AIDS into their communities.246
India's Lawyers Collective HIV/AIDS Unit also notes that during police raids intended to rescue
child sex workers, some sex workers have been abused and subject to violence. Some have also
been subject to mandatory HIV testing.247 (See Sex Work section below.)
Health
Health Status
As mentioned above, India has made significant progress in the past several decades in
improving the health and well-being of its people. For example, between 1990 and 2000, the
percent of the population with access to an improved water source rose from 78 to 88 percent.
■
HIV/AIDS in India
64
Access to improved sanitation rose from 21 to 31 percent (however, this figure was 14 percent
for rural population in 1990, vs. 73 percent for urban populations).248 Over the past 40 years, life
expectancy has risen to 63 years, and infant mortality has fallen by over two-thirds.249
Despite these achievements, the country continues to bear a heavy burden of both communicable
and noncommunicable diseases. (See the accompanying table of key indicators.) There are
myriad challenges within the health sector, 0 including the generally poor quality of services
delivered by both the public and private sectors.251 A high proportion of the population continues
to suffer and die from preventable infections, pregnancy and childbirth-related complications,
and malnutrition. The large disparities across India place the burden of these conditions mostly
on the poor, women, and scheduled tribes (indigenous groups) and scheduled castes (previously
called ’’untouchables"). The poorest 20 percent of Indians, for example, have more than double
the mortality rates, malnutrition, and fertility of the richest quintile. 2 Moreover, in July 2003,
the World Bank noted that India’s "progress in health indicators has been slowing down
precipitously.”253
India’s physical environment is deteriorating in both urban and rural areas. The World Bank
estimates that annual environmental degradation in India represents 6 to 8 percent of GDP.
About 40 percent of this cost is related to the burden of disease resulting from unsafe water and
poor sanitation, and 35 percent from air pollution, including both indoor and urban air pollution.
The poor are particularly vulnerable. Over 20 percent of urban dwellers live in slums and are
grossly overexposed to air and water pollution. Conditions are particularly poor in India’s largest
cities. The elderly, children, and the poor suffer disproportionately from adverse health impacts
linked to pollution and overcrowding.254
India has the largest number of malnourished children in the world. About 50 percent of children
under four are malnourished in terms of weight-for-age; 30 percent of newborn children are
significantly underweight; and 60 percent of Indian women are anemic. The nationally set
average daily per capita consumption requirement is 2,400 kcal. However, in rural areas, average
daily per capita consumption is only 2,150 kcal, indicating a significant food gap at the
household level.255
Infrastructure
India’s state governments are primarily responsible for health care, although some national health
programs (e.g. HIV/AIDS, family welfare, malaria, leprosy, blindness, and TB) are supported by
central government funds. The World Bank and other donors are supporting decentralization of
these programs to states.256
The public health infrastructure is vast, comprising 600 district hospitals, 4,000 community
health centers, 25,000 primary health centers, 137,000 subcenters, and 160 medical colleges.257
Public health facilities suffer from poor management, low-quality service, and underfunding.258
In releasing a new health policy in 2002, the Indian Ministry of Health reported that low
investment in health had led to a poor-quality and uneven healthcare delivery system across the
country. In public health facilities, the availability of medicines is frequently negligible. The
HIV/AIDS in India
65
equipment in many public hospitals is often obsolete and unusable, and infrastructure is
dilapidated. Less than 20 percent of Indians seek outpatient services in the public sector, and less
than 45 percent use inpatient facilities in public hospitals.259
NFHS-2 found that, among ever-married women ages 15-49 residing in rural areas, 53 percent
live in a village with no health facility (primary health center, subcenter, hospital, dispensary, or
clinic). Fourteen percent of rural women must travel at least 5 km to reach the nearest health
facility. The median distance to a primary health center was 4.9 km and to a subcenter, 1.3 km.
The median distance to a dispensary or a clinic was 2.4 km and to a hospital, 6.7 km 260
Expenditures
See also the Economy section above.
In 1990, India's public spending on health was 0.9 percent of GDP, a figure that did not change
during the rest of the decade.261 In 2000, private expenditures on health accounted for 4.0 percent
of GDP, or 81.6 percent of all health spending.262
Preventive care is almost exclusively provided through the public sector: an estimated 90 percent
of immunizations and 60 percent of prenatal care is provided through the public sector.263 There
is large variance in health financing among Indian states, and the gap between rich and poor
states regarding public resources for health is increasing. Kerala, Punjab, and Tamil Nadu, for
example, have double the per capita public health spending of Bihar and Madhya Pradesh.264
Studies have found that states with better equality in their public spending have better health
status outcomes.265
NFHS-2 found that 65 percent of Indian households go to private hospitals/clinics or doctors for
treatment when a family member falls ill. Only 29 percent normally use the public health sector.
Even among poor households, only 34 percent normally use the public health sector when family
members become ill.266 A June 2001 report by the World Bank found that for 80 percent of
Indians, the private sector is the main and, in some cases, only provider of health services. The
report also documented the generally poor quality of services delivered by both the public and
private sectors.267
States differ a great deal in the extent to which their populations use private services as well as in
the level of poverty and type of service provided. Poorer households purchase less curative
health care from the private sector than do richer households. Partly because of inability to pay
and the lack of risk pooling, the poor are much less likely to be hospitalized. Across India, those
above the poverty line have more than double the hospitalization rates of the poor.268
Only 10 percent of Indians have some form of insurance, most of which are inadequate.
Hospitalized Indians spend 58 percent of their total annual expenditures on health care. Over 40
percent of those hospitalized borrow money or sell assets to cover expenses. The World Bank
conservatively estimates that one-fourth of hospitalized Indians were not poor when they entered
the hospital but became so because of hospital expenses; the existence and scale of this
phenomenon vary greatly by state.269
HIV/AIDS in India
66
The World Bank argues that the private health sector in India is unlikely to substantially improve
the health and nutritional status of the poor. The private sector remains virtually unregulated and
has highly variable quality of care.270 (See also TB section below.) However, the government's
response to HIV/AIDS, at least with regard to ART, is predicated on strong partnerships with the
private sector (see Response section).
Tuberculosis
According to WHO, India continues to have the world’s highest burden of TB. Each year, there
are an estimated 2 million new TB cases in India, representing about one-third of the global TB
burden. TB remains the country’s leading cause of death; annually, about half a million Indians
die because of TB.271
WHO estimates that 4.0 percent of adult (15-49) TB cases were HIV-positive during 2001. An
estimated 3.4 percent of new cases that year were multidrug-resistant.272
0*7*1
0*7/1
TB is the most common opportunistic infection in India. ,
In January 2003, researchers
from YRG Care and the Dr. ALM Post Graduate Institute of Basic Medical Sciences, University
of Madras, in Chennai reported the results of a retrospective analysis of 594 AIDS patients (72.9
percent male; baseline CD4 cell count, 216 cells/microL) receiving care at YRG. The most
common OI was pulmonary tuberculosis (49 percent; median duration of survival, 45 months). 275
India has had a national TB control program since 1962.276 In 1993, the government designed the
Revised National TB Control Program (RNTCP). In 1997, DOTS was launched. The treatment
success rate for patients registered in 2000 was 84 percent. According to WHO, at the end of
2002, about 550 million people, or 55 percent of India's population, had access to DOTS under
the RNTCP.277
In 2003, RNTCP reported that during the first quarter of that year, DOTS coverage increased to
665 million population. (Using India's mid-2003 population of 1.069 billion278 yields DOTS
coverage by March 2003 of 62.2 percent.) RNTCP also reported that the number of districts
(implementing units) had increased from 287 to 363; in addition, 13 more districts representing a
population of 31.7 million had been appraised and were ready for RNTCP service delivery. Over
60,000 patients were being placed on treatment each month.279
In 2001, a joint action plan on HIV/AIDS and TB was created, though WHO notes that concrete
strategies to link the two do not yet exist. WHO highlights other constraints in the TB system,
including:
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■
■
■
■
lack of confidence in government TB services due to poor services in the past
vacancies of key staff, especially laboratory technicians
poor quality services and poor results in the private sector
lack of full involvement of medical colleges
poor drug distribution to local level
ineffective lab quality control
HIV/AIDS in India
■
67
lack of local electrical supply280
The current plan for the RNTCP covers 2001-2004 and aims to expand DOTS coverage to over
80 percent of the country by 2004. Constraints to achieving this target include:
■
■
■
uncertain funding from 2005 onward
challenge of concurrently maintaining the quality of TB services and rapidly expanding
coverage
6
lack of TB awareness in some communities
decentralization without adequate local management, supervision, and monitoring281
TsVand HIV/AIDS)^108 AUianCe “India haS als° identifled constraints related to accessing
HIV/AIDS*™^Tfi’leading t0 misunderstanding and confusion at community level about
"
■
■
stigma and discrimination that surround both HIV/AIDS and TB
lack of access to affordable TB screening and treatment
poor referral and follow-up systems282
Dr. Mana Ekstrand of the University of California San Francisco notes that studies conducted
over the past 20 years have identified private practitioners as one of the greatest obstacles to TB
control m India ,
,
,
Private doctors with varying types of training and degrees often
violate treatment guidelines by failing to use sputum testing and by prescribing the wrong drugs
and inappropriate doses. Many private providers have been found to undertreat TB, and studies
^i? 287°U28d that the maJ°rity of sputum-positive patients in private care are not being treated for
TB. ,
Several studies289 290 291
292 293 294 295
several studies ,,,,,,
report that ™
TB patients rarely go immediately to
government hospitals, due to their reputation as having long lines, unfriendly treatment, and
inferior drugs. Instead, many patients initially seek care by going to private providers, to
"quacks" in the street, or directly to pharmacists to obtain their medications. The TB literature
also shows that there is a great deal of "provider switching," with patients only going to
government hospitals for care once their funds are depleted. Ogden et al. reviewed these factors,
concluding that to be successful, TB control programs need to address the social dimensions of’
the disease, rather than focusing simply on patient factors influencing adherence.296
Although most TB patients know that TB care requires sustained regular treatment, they
frequently admit to interrupting their treatment as soon as they gain symptomatic relief. Patient
adherence rates are typically reported as being between 50 and 60 percent.297 , 298 , 299 TB
patients are also likely to discontinue treatment if they have low incomes and little education. As
the treatment progresses, social commitments and work often become more important and
displace the burden of treatment adherence.
The stigma of a TB diagnosis has many consequences,’ including social stigma. Many believe it
to be a hereditary disease, making it more difficult to get married, both for TB patients and for
HIV/AIDS in India
68
their family members.300 The situation for female TB patients is typically worse than for men,
especially if they are married. Women tend to neglect their health in favor of doing household
chores and often delay treatment. They report having little, if any, control over household
finances and fear that their husbands will divorce them if they disclose their diagnosis.301, 302
Similar bairiers have been found in research examining adherence to leprosy regimens in
inoia. ,
,
,
,
Only a traction of leprosy patients are estimated to be in treatment,
due to the social stigma of the disease,308 and among those being treated, adherence is typically
estimated at 50 percent. In one study ,309 patients who dropped out of treatment attributed this to
inconvenient clinic hours, lack of regimen knowledge, medication side effects, and the social
stigma of leprosy. Poor clinic attendance has also been found among leprosy patients who
believe in a traditional (humeral) cause of illness,310 who experience adverse side effects,311 and
who report conflicting family and work commitments.312
HIV shares many of the features of leprosy and TB, including being an infectious, stigmatized
disease with a medication regimen that can have severe side effects and that requires a long
period of adherence. Many of the adherence barriers seen with TB and leprosy are thus likely to
apply to HAART. For example, the phenomenon of "provider switching" wherein patients seek
care at government hospitals only when their funds for private care are depleted, has already
been observed among PWHA in New Delhi.313 In addition, providers have much less experience
treating HIV than TB and monitoring for HAART toxicity and efficacy is more expensive than
TB sputum tests. Patient demands are also greater for HIV treatment regimens; the drug regimen
is more complicated and more expensive, and it may have to be followed for life, rather than for
six to eight months. Further, an HIV diagnosis carries an even greater stigma than TB in this
setting. Thus, judging from the experience of TB and leprosy treatment in India, and from the
general Indian adherence literature,314 significant adherence problems with ART can be
anticipated. Addressing these problems requires a careful examination of both provider and
patient factors associated with antiretroviral medication adherence.
Other Health Issues
Malaria is another critical health concern in India, with 2 million to 2.5 million new cases each
year. Other major health issues in India include polio, measles, diarrheal disease, encephalitis,
dengue fever, diphtheria, leishmaniasis, poliomyelitis, Guinea Worm disease, leprosy, and
lymphatic filariasis.
Sexual and Reproductive Health
UNFPA ranks India a category 'A' country, meaning that it is furthest from achieving the sexual
and reproductive health and rights goals of the International Conference on Population and
Development (ICPD), held in Cairo in 1994. Group A countries have the greatest need for
external assistance and the lowest capabilities for mobilizing domestic resources to close this
gap.316
The accompanying table provides key S&RH indicators. Reproductive tract infections are
widespread among young women.317 Maternal mortality is high, with most maternal deaths the
HIV/AIDS in India
69
result of infection, hemorrhage, eclampsia, obstructed labor, abortion, or anemia. Between 50
and 90 percent of all pregnant women in India experience anemia. Lack of spacing between
children—37 percent of births occur within two years of the latest birth—also exacerbates
mortality rates. Thirty-seven percent of pregnant women in India receive no prenatal care during
their pregnancies. Women cite the lack of nearby and adequate health care facilities as one of the
main reasons that they did not seek/receive antenatal care. Lack of appropriate care and referrals
during childbirth are linked to maternal mortality.318
Population
India's family planning program was launched in 1952. Since the 1960s, India's total fertility rate
(average number of children a woman would have assuming that current age-specific birth rates
remain constant throughout her childbearing years, usually considered to be ages 15 to 49) has
declined from over 6 to 2.97, while the contraceptive prevalence rate (modem methods) has
increased from less than 10 per cent to 43 percent.319 However, the national TFR masks wide
state-level differences. Comparatively richer states such as Goa and Kerala have attained below,
replacement level fertility; Karnataka, Himachal Pradesh, Tamil Nadu, and Punjab are at or close
to replacement level fertility. By contrast, the TFR is 3.3 or above in the poorer states of
Meghalaya, Uttar Pradesh, Rajasthan, Nagaland, Bihar, and Madhya Pradesh. Between one-third
and one-half of all births in these latter states are fourth or higher-order births, compared with
only 7 to 9 percent of births in Kerala, Goa, and Tamil Nadu.320
Rural women and women from scheduled tribes and castes have somewhat higher fertility than
other women. Fertility is particularly high for illiterate women, poor women, and Muslim
women. Over half of women ages 20-49 had their first birth before reaching age 20, and women
ages 15-19 account for almost one-fifth of total fertility.321
Overall, sterilization accounts for 75 percent of total contraceptive use. Female sterilization is far
more common than vasectomies; the NFHS-2 found that among currently married women, 34
percent are sterilized, whereas only 2 percent of women report that their husbands are sterilized.
Three percent of women use the condom as a contraceptive; 2 percent use the pill and the same
percentage uses IUDs. Contraceptive prevalence varies widely among socioeconomic groups.
Muslim women, women from scheduled tribes, and poor women are 37 to 40 percent less likely
than other women to use contraception.322 Unmet need for family planning varies from 7 to 9
percent of currently married women in Punjab, Haryana, Andhra Pradesh, Gujarat, and Himachal
Pradesh to 25 to 36 percent in Meghalaya, Nagaland, Arunachal Pradesh, Uttar Pradesh and
Bihar.323
Both national and state-level population policies continue to emphasize the achievement of
replacement fertility as their main objective. Historically, the National Family Welfare Program
has focused narrowly on population control, resulting in a bias toward sterilization over spacing
methods for contraception. Lacking choices, women who wanted to space births but not end
childbearing began to rely heavily on abortion as a means of birth spacing. Reliance on abortion
for birth spacing is perpetuated by current policies, as a number of states continue to emphasize
both a two-child norm and reliance on female sterilization as the preferred means of attaining
these goals.324
HIV/AIDS in India
70
Although the Medical Termination of Pregnancy Act of 1971 legalized abortion, access to safe
abortion remained low, and the number of illegal and unsafe abortions high. In 2002, the Indian
Parliament amended the 1971 Medical Termination of Pregnancy Act to make legal abortion
more widely accessible. (For a recent, detailed discussion of sex determination and sex
selective abortion, see Rupsa Mallik. India: Recent Developments Affecting Women's
Reproductive Rights. Takoma Park, Md.: Center for Health and Gender Equity, December 2002
<www.genderhealth.org>)
Sexually Transmitted Infections
Several studies indicate that herpes simplex virus-2 (HSV-2) may be fueling the HIV epidemic in
India. Researchers from Sion LTMG Hospital and Medical School, Mumbai District AIDS
Control Society, Center for AIDS Research & Training, and UCSF found that men attending
public STI clinics in Mumbai had a high prevalence of HIV, associated with HSV-2 infection
and visiting a female SW. Enrolling consecutive patients attending two municipal STI clinics in
Mumbai, they found that 54 percent had visited a in the last three months, 47 percent were
married, 24 percent had some MSM activity (receptive or insertive anal sex) in the past. Among
married men, 46 percent had visited a SW in the last three months and 12 percent had had MSM
activity. Among all men, 20 percent were HIV-positive, 42 percent had HSV-2, 11 percent had
syphilis, 6 percent tested positive for hepatitis B surface antigen, 4 percent had chlamydia, and
15 percent gonorrhea. HIV was significantly associated (p<.05) with ages 31-40, exposure to
SW, urethral discharge, HSV-2, and syphilis. Visiting.a SW in the last three months was
associated (p<.05) with HSV-2, active genital ulcers, and urethral discharge. Recent MSM
activity was not associated with increased HIV or STI risk.326
A study by YRG Care and Johns Hopkins involved 1,631 adults ages 18-40 living in slum
communities in Chennai. The researchers found that HSV-2-positive men were seven times as
likely to be HIV-positive (AOR= 7.44, 0.97, 57.06) and over four times as likely to have
hepatitis C (AOR— 4.53, 1.28, 16.01) as HSV-2-negative men. HSV-2 was not associated with
HIV or hepatitis C in women. However, controlling for number of lifetime sex partners, women
reporting genital ulcers were over three times as likely to have hepatitis C (AOR= 3.54, 0.99,
12.68) compared with those without genital ulcers. MSM (n=44) and male IDUs (n=6)were at
high risk of HIV (MSM: OR= 8.55, 95% CI: 1.52, 48.00; IDU: OR=59.83, 5.08, 705.48) and
hepatitis C (MSM: OR= 4.32, 1.18, 15.95; IDU: OR= 54.05, 11.70, 249.68).327
In Pune, Johns Hopkins and the National AIDS Research Institute found that recent HSV-2
infection was a major independent risk factor for acquisition of HIV infection among STI
patients. They used a retrospective cohort study of 2,732 HIV-1-seronegative patients attending
three STI and one gynecology clinic, continuously enrolled from 1993 to 2000. Forty-three
percent of participants were infected with HSV-2 at the baseline visit. Among those initially
HSV-2-seronegative, HSV-2 incidence was 11.4/100py (95% CI 9.9-13.0). Based on a median
follow-up time of 11 months, the incidence of HIV-1 was 5.8/100py (95%CI 5.0-6.6). The
adjusted relative risk of HIV acquisition associated with chronic (prevalent) HSV-2 infection
was 1.69 (95%CI 1.23-2.33; p=0.001) and 1.81 (95%CI 1.09-3.03; p=.02) with remote primary
'
HIV/AIDS in India
71
HSV-2 infection. Recent HSV-2 infection was independently associated with a 3.64-fold
increased risk of primary HIV infection (95%CI 1.72-7.70; p<.001).328
Hopkins and the National AIDS Research Institute found that between 1993 and 2000, there was
a significant decrease in the clinical diagnosis of all STIs among patients presenting to the
government STI clinics in Pune. The researchers note that this decline could be the result of
increased STI/HIV awareness and risk reduction, including increased condom use. However, it is
also possible that individuals at highest risk for STIs have shifted their clinical care to the private
sector.329
Stigma and Discrimination
See also the Household Impact section below.
HIV/AIDS-related stigma in India is severe and contributes to the suffering of those infected as
well as their loved ones. Stigma also interferes with decisionmaking on HIV counseling and
testing, disclosing one's HIV status, and seeking and remaining in treatment. Members of
marginalized groups often experience dual stigma, forcing them to hide their lifestyles and
rendering it difficult to access HIV/AIDS programs.
As in many other countries, reported statistics on HIV infection in India suggest that the
epidemic at least in its early stages—has disproportionately affected poor, marginalized
groups, including female sex workers, truck drivers, migrant workers, MSM, and IDUs.
Consequently, AIDS is often perceived as a disease of "others," of people living on the margins
of society, whose lifestyles are considered "perverted" and "sinful." These perceptions foster the
attachment of blame to PWHA, which is an important component of stigma.
Early descriptions of HIV epidemiology created a general perception that HIV infection was
largely restricted to sex workers, truckers, and IDUs. The rest of the population was, and in
many cases, still is, in denial, despite that infection rates among the general population are
rising.330
Dr. Shalini Bharat of the Tata Institute of Social Sciences in Mumbai led a study on HIV/AIDSrelated discrimination, stigma, and denial. Her team collected data in Mumbai and Bangalore
using key informant interviews, in-depth individual interviews, and focus group discussions. The
main overt and covert forms of discrimination experienced by respondents were:
Hospitals
■
■
■
•
*
■
refusal to provide treatment for HIV/AIDS-related illness
refusal to admit for hospital care/treatment
refusal to operate or assist in clinical procedures
restricted access to facilities like toilets and common eating and drinking utensils
physical isolation in the ward (e.g. separate arrangements for a bed outside the ward in a
gallery or corridor)
cessation of ongoing treatment
HIV/AIDS in India
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■
■
■
■
■
■
■
■
■
■
■
■
72
early discharge from hospital
mandatory testing for HIV before surgery and during pregnancy
restrictions on movement around the ward or room
unnecessary use of protective gear (gowns, masks, etc.) by health care staff
refusal to lift or touch the dead body of an HIV-positive person
use of plastic sheeting to wrap the dead body
reluctance to provide transport for the body
delays in treatment; slow service (e.g. made to wait in queues, asked to come again)
excuses or explanations given for non-admission (but admission not directly refused)
shunting patient between wards/doctors/hospitals
keeping patient under observation without any treatment plan
postponed treatment or operations
unnecessarily repeated HIV tests
conditional treatment (e.g. only on the condition that the patient will come for follow up or
join a drug trial program).
Home and Community
■
■
■
■
■
■
■
■
■
severed relationships, desertion, separation
denial of share of property or access to finance
blocked access to spouse, children, or other relatives
physical isolation at home (e.g. separate sleeping arrangements)
blocked entry to common areas or facilities (toilet, etc.)
blocked entry to common places like village or a neighborhood area
denial of death rituals
labeling and name-calling
disparaging remarks about the HIV-positive family member (e.g. “he is paying for past sins”)
"guilt tripping” for burdening the family economy and for lowering family prestige
Workplace
■
■
■
■
■
■
removal from j ob
forced resignation
withdrawal of health/insurance benefits
poor access to shared facilities
social distance
labeling and name calling331
People living with HIV/AIDS expressed fear of:
■
■
■
■
■
AIDS stigma (of being identified with “deviant,” “]morally sinful” behavior, mainly sexual
promiscuity and visiting sex workers)
loss of reputation in the family and society
damaging the family’s social reputation
HIV serostatus’s being revealed and being identified as sexually deviant
social discrimination and isolation, of being avoided or shunned by others
HIV/AIDS in India
73
being judged and categorized as a member of a “deviant” group such as promiscuous people
and gay men
■ death and of dying early
* dying uncared for, and being denied last rites
■ social ridicule
" various illnesses and debilitating ill-health, of painful conditions, of not receiving medical
attention, and of being denied admission to hospital
* being deserted, of loss of significant relationships, and of loss of trust and confidence
■ losing one’s job or source of income
■ passing the infection to others, whether spouse, children, or other family members332
In both study locations, stigma and discrimination were most often encountered in the health care
setting and, to a lesser but still significant extent, in family and community contexts.
Discrimination was also reported in schools; children of HIV-positive parents, regardless of their
own serostatus, were often denied the right to go to school or were segregated from other
children. Life insurance companies were not trusted by people with HIV, despite assurances that
benefits would be paid if the policyholder had tested positive after taking out a policy. Concern
was expressed by people with HIV that they faced harsher treatment from insurers than did
people with other serious health conditions.333
In a study set in New Delhi, researchers from SHARAN and the Tata Institute of Social Sciences
found that stigma and discrimination against people living with HIV/AIDS in hospitals and
clinics discourages many from seeking care. They found many of the same scenarios as
described in the Bharat study above, including denial of and delayed treatment, segregation and
isolation from other patients, and early discharge (in both public and private facilities). Other
barriers to care include the misconception that AIDS is untreatable, the lure of witch doctors who
claim to have a cure, and lack of awareness on the part of PWHA about their own needs and
rights. Study participants responded that they use several strategies to access care without
incurring negative repercussions, including concealing their HIV status as long as possible,
seeking care outside their own community to protect anonymity, and patronizing local AIDS
service organizations that provide nondiscriminatory care. Those who can afford to visit private
clinicians do so to avoid long queues in government hospitals and to receive timely care. As the
costs for ongoing care accumulate, PWHA eventually turn to the public sector for free or
subsidized services.334
Bharat also found that the treatment of the bodies of people who had died of AIDS-related
illnesses was also a serious concern to HIV-positive respondents. The practice in Mumbai of
placing such bodies in black plastic bags was regarded as an affront to human dignity and an
effective breach of confidentiality, rendering it very difficult to access good undertaker and
funeral services. Concern was also expressed in both sites that traditional rites were no longer
being administered to people who had died of AIDS-related conditions. Although instances of
HIV/AIDS-related discrimination were documented at work, in this study the workplace did not
emerge as a major setting for negative experiences for'HIV-positive people. This may be related
to lack of disclosure as well as the fact that many industries and businesses are in denial about
the spread of the epidemic and its potential impact.335
HIV/AIDS in India
74
At a February 2002 workshop held by the International HIV/AIDS Alliance-India, participants
noted that although many NGOs, CBOs, and PWHA have some knowledge of AIDS and OIs,
their information sometimes contains major inaccuracies. The Alliance’s assessment of
HIV/AIDS-related treatment in India found that secrecy and ostracism were major barriers to
safe and effective treatment336 (see the Stigma section for more detailed discussion).
Gender and HIV/AIDS Stigma
See also the Gender section.
.
Bharat’s study provided evidence that AIDS stigma and discrimination in India are often a
gendered phenomenon. Women were often blamed by their parents-in-law for infecting their
husbands, or for not “controlling” their partners’ urges to have sex with other women. In
addition, HIV-positive women were more likely to take care of their husbands, neglecting their
own health. After having been the primary caregivers for their husbands, many women were
asked to leave the house of their in-laws after the husband died.337 Anecdotal reports from the
FXB India Society in West Bengal indicate that after a husband's AIDS death, widows are being
forced from their in-laws' home and sent back to their parents, where they also face rejection.338
Bharat found that women were less likely to seek testing, and less able to afford treatment, than
were the men in her study. The quality of care provided to women with HIV/AIDS in the family
was significantly poorer than the care provided to men. Issues such as inheritance, housing, and
caregiving were identified as highly problematic for women. Although a small number of cases
were cited in which women had abandoned their HIV-positive husbands, more common was the
neglect and maltreatment of HIV-positive women by husbands and in-laws.339 The Positive
Women Network in Chennai reports that HIV/AIDS-related stigma and discrimination have a
greater impact on Indian women than on men.340
A study undertaken by Ipas, a reproductive health NG0 based in Chapel Hill, has also
documented the gendered nature of HIV/AIDS stigma and discrimination in India.341 In an Ipas
study of reproductive choice and HIV/AIDS, one informant in India noted that some providers
refuse to insert IUDs for women with HFV because they do not want to come into contact with
their vaginal fluids. It can also be very difficult for HIV-positive not to breastfeed, given that this
departure from standard practice can be interpreted to signify that a woman is HIV-positive and
that many women do not have access to breast milk substitutes.342 A study by researchers from
the Dr. MGR Medical University and National Institute of Epidemiology, both in Chennai,
involved 50 HIV-positive mothers ages 19-30, all from lower socioeconomic groups. Of them,
96 percent were aware that breast milk transmits HIV. Despite knowing the risk of transmission,
74 percent of the women breastfed their babies. Of those that breastfed, 16 percent cited family
stigma as the reason, while 18 percent cited lack of money to purchase breast milk substitutes.343
(According to the NFHS-2, although breastfeeding is nearly universal in India, few children
begin breastfeeding immediately after birth. Fifty-five percent of children under four months of
age are exclusively breastfed. The median duration of breastfeeding is 25 months, and the
median duration of exclusive breastfeeding is two months.344)
HIV/AIDS in India
75
The Ipas study highlighted that in India, pregnant women with HIV have reported being
pressured by health care providers to terminate their pregnancies. A health worker may not
consider his/her advice to be coercive, but it may be perceived that way, especially by women
who are accustomed to relying on health workers’ expertise and not accustomed to challenging
persons in positions of authority.345
Studies have also detailed how in addition to female sex workers, MSM and transgenders with
HIV/AIDS experience double discrimination. People in these marginalized groups are
stigmatized not only on the grounds of HIV status but also for being members of a socially
denigrated group.346 (See also the MSM and Sex Work sections below.)
Government, media, and research responses to HIV/AIDS in India have focused on the role of
women engaged in sex work in the spread of the epidemic. Targeted interventions, particularly
focusing on sex workers, have been the cornerstone of the Indian government’s HIV/AIDS
program. Representations of AIDS as an “immoral” disease, associated with immoral behavior
such as sex work, have created a backlash, particularly against female sex workers. Several
media reports have described violence against female sex workers or women purported to be sex
workers. (See also the Sex Work and Violence sections.)
(The Indian Council of Medical Research, India’s National AIDS Research Institute, and Yale
University's Center for Interdisciplinary Research on AIDS are undertaking a year-long study on
HIV/AIDS-related stigma in Indian hospitals
<http://cira.med.yale.edu/research/indiastigma.html> The study, entitled "Understanding HIVRelevant Stigma in India," aims to determine how stigma affects patient care and to "lessen
unconscious biases" among doctors toward HIV-positive patients. Researchers plan to interview
patients and health care providers in Pune, a location selected because of its "increasing" HIV
infection rate and the availability of trained researchers. When findings are available, they will
be integrated into this report.)
Gender
Gender is integrated into all the sections of this paper. The text below seeks to provide a very
broad overview of the topic, but other sections should be consulted as well, particularly
Epidemiology, Stigma, Health, Violence, IDU, and Sex Work.
Dr. Suniti Solomon, who diagnosed the first case of HIV in India and is the director of the YRG
Center for AIDS Research and Education in Chennai, analyzes the social construct of gender in
India, which has evolved over several hundred years and renders women highly vulnerable to
acquiring HIV and other STIs. 348 She notes that in addition to biological vulnerability:
The lack of opportunities for young women to receive sex education and HIV
information leads them to accumulate unverifiable myths. Social norms only encourage
“innocent” women, e.g., who is sexually naive until marriage, does not seek pleasure
from sex, one who would willingly and actively participate in sex only for the pleasure of
her husband. Women’s economic independence on men causes poor health-seeking
behaviors. Reproductive tract infections are not promptly treated increasing their
HIV/AIDS in India
76
susceptibility to HIV. Women with poor social and job skills feel inclined to offer sexual
services or to offer sex in return for social support. These women are more likely to stay
within a marriage no matter how vulnerable they are to infection. Motherhood, no doubt
noble, also enslaves women. Fertility pressures force women to abandon caution when
having sex with a known HIV-infected partner. Marriages are saved at the cost of HIV.
Women are taught to accommodate and be resilient in the face of violence. They pride in
being able to live in the midst of violence. Violence directly enhances one’s vulnerability
to HIV. Submission to violence encourages men to engage in irrational and unchallenged
behaviors such as having concurrent multiple partners. The impact of HIV on a woman is
much greater than that on men. In most societies, women play the nurturing role, in
predominant cases, naturally and voluntarily. However, when she is HIV infected, which
may imply an infected partner, her burden doubles.349
Dr. Gautam Bhan of the Institute of Development Studies at the University of Sussex notes that:
On the surface, one sees increasing international exposure, urbanization and a growing
industrial sector, rising male and female literacy, and relatively low inflation—aggregate
indicators that tell stories of progress and development, but also hide volumes behind
their numbers....Many women have risen to positions of power within the government at
the center and state levels; others head businesses, hold high-salary jobs, outperform boys
in school examinations and are, generally, more visible than they have been at anytime
outside the freedom struggle. Yet, seeing the Indian scenario a decade after reforms, it
seems that for every woman that gains in power, several more silently recede further into
the depths of poverty. Notions of women’s empowerment come into question when
female members of the ruling Hindu right government urge Indian women to return to
their home and fulfill their roles as wives, mothers and nothing else. Increasing economic
inequities, the feminization of poverty, and the changing role of the State within a liberal
economy, in addition to changing notions of caste, religion, and social mores, have
individual and combined effects on understandings of gender in India today.350
Early Marriage
NFHS-2 found the proportion of women who marry below the age of 15 is rapidly declining, and
the practice of very early marriage (before age 13) has almost disappeared in urban areas and
become quite rare in rural areas. However, the majority of ever-married Indian women ages 20—
49 were married before they reached the legal minimum age at marriage of 18 years, as set by
the Child Marriage Restraint Act of 1978. About half of women ages 25—49 married before age
15 in Madhya Pradesh, Bihar, Uttar Pradesh, Andhra Pradesh, and Rajasthan, and about fourfifths of women in these states married before reaching the legal minimum age at marriage of 18
years. By contrast, the median age at first marriage is 22 to 23 years in Goa, Mizoram, and
Manipur, and 20 years in Kerala, Nagaland, Punjab, and Sikkim. On average, Indian women are
five years younger than their husbands.351
Female-to-Male Sex Ratio
HIV/AIDS in India
77
Of serious concern is the overall female-to-male sex ratio of the population. During the 20th
century, sex ratios fell consistently, except for a very slight increase in the 1990s. In 1901, the
ratio was 972 females per 1,000 males; according to the 1991 census, it had declined to 927
females per 1,000 males.352 According to the 2001 census, the ratio had risen slightly to 933,
though still far below the 1901 figure.353 Nobel economist Amartya Sen attributes India’s sex
imbalance to “the comparative neglect of female health and nutrition, especially—but not
exclusively—during childhood.”354
Women are often not in positions to influence how earned income is spent within the household.
Other factors include increasing cases of sex-selective abortions (illegal but widespread); female
infanticide; violence against women (see below); suttee (wherein a widow is burned to death on
her husband’s cremation pyre, an illegal act); dowry murders (wherein a woman is killed due to
insufficient gifts/money given by her parents at the time of her wedding); and discrimination in
access to health care, nutrition, and employment opportunities.355
(For more information on sex-selective abortions, see Rupsa Mallik. India: Recent Developments
Affecting Women's Reproductive Rights. Takoma Park, Md.: Center for Health and Gender
Equity, December 2002 <www.genderhealth.org>)
Preference for Sons
Das Gupta et al. highlight that kinship systems in India:
... generate a critical dichotomy between the value of a girl to her parents and her value
to her husband's family. As long.as the custom persists for women and their future
productivity to be totally absorbed by their in-laws, parents are likely to perceive
daughters as a drain and prefer to raise sons. Women can contribute little to their parents'
welfare, so even when levels of women's education and formal sector labor force
participation increase, the fruits of these go to her husband's home. Even though women
can gain considerable power in the household in their old age, this depends on having
sons who support their mother's voice in the household at the expense of their own
wives....The fact that sons are the main source of old age support is clearly culturally
determined, as there is no intrinsic reason why parents cannot seek such support from
their daughters as they do elsewhere in Asia. Nor can adequate pensions and savings
offer peace of mind for one's old age, as long as people believe that they will be 'hungry
ghosts' in the afterlife unless sons provide the necessary rituals.356
Despite socioeconomic changes, preference for sons continues in India. 357 The NFHS-2 found
that nationally, 33 percent of ever-married women want more sons than daughters, but only 2
percent want more daughters than sons. Son preference tends to be stronger in the northern part
of the country, especially in Uttar Pradesh, Rajasthan, Bihar, Haryana, Madhya Pradesh, Orissa,
and Arunachal Pradesh. Weakest son preference is found in Meghalaya, Mizoram, Tamil Nadu,
Kerala, Karnataka, and Goa.358
One reason for this scenario is that a son gives a woman standing in the household and
community. As a young woman, she has limited bargaining power vis-a-vis her mother-in-law
.
HIV/AIDS in India
78
and other household members. As an old woman, she is vulnerable without a son to offer his
protection. Although it is unusual for men to take a second wife if their wife does not have a son,
whenh does occur, the first wife’s position in the household is relegated to that of domestic
Education
There are acute gender disparities in literacy and education, as shown in the accompanying
indicator table. Women's literacy and educational attainment also vary significantly by state. For
example,NFHS-2 found that 58 percent of ever-married women ages 15—49 are illiterate, a
decline from 63 percent at the time of NFHS-1. The literacy rate for ever-married women is
highest in Mizoram (90 percent), closely followed by Kerala (87 percent); it is lowest in Bihar
(23 percent), Rajasthan (25 percent), and Uttar Pradesh (30 percent). The percentage of women,
who have completed high school ranges from 7 percent in Rajasthan to 44 percent in Delhi.
Other states where the percentage of women who have completed high school is relatively high
(30 percent or higher) are Kerala, Goa, and Punjab. In Orissa, Bihar, Meghalaya, Madhya
Pradesh Arunachal Pradesh, and Assam, less than 10 percent of women have completed high
school.36
Women's lower educational levels are related to lower formal labor force participation and
decreased earnings and thus lessened economic autonomy. This situation may increase women's
economic dependence on men and inability to refuse sex or insist on condom use—factors that
can increase vulnerability to HIV.361 Moreover, compared with boys, girls are more often kept at
home when household income and/or labor supply falls (an increasing phenomenon given high
AIDS mortality) (see Household section below).
Employment
The NFHS-2 found that 39 percent of ever-married Indian women ages 15-49 do "work other
than housework and that over two-thirds of these women work for cash. Women’s work
participation rates vary from 9 percent in Punjab and 13 percent in Haryana to 60-70 percent in
Manipur, Nagaland, and Arunachal Pradesh. In rural areas, 76 percent of working women work
in agriculture. In urban areas, 27 percent of working women are production workers, 17 percent
are professionals, 15 percent are agricultural workers, and 13 percent are in sales and service
occupations.362
A significant feature of women’s work participation in India is their substantial contribution to
family earnings. NFHS-2 found that about 18 percent of urban as well as rural women who
worked for money at any time in the 12 months preceding the survey reported that their family
was entirely dependent on their earnings. Another 30 percent in urban areas and 24 percent in
rural areas reported that they contributed half or more (but not all) of total family earnings.
Twelve percent of women in urban areas and 9 percent in rural areas reported that they
contributed almost nothing to total family earnings. NFHS-2 also found that 10.3 percent of all
Indian households are headed by women. In urban areas, 11.1 percent of households are headed
by women; in rural areas, this figure is 10 percent.363
Decisionmaking
HIV/AIDS in India
79
NFHS-2 found that 48 percent of ever-married women are not involved in making decisions
about their own health care. There are large variations among states: over 75 percent of women
in Himachal Pradesh, Meghalaya, and Punjab are involved in decisions about their own health
care, compared with about 40 percent in Madhya Pradesh, Orissa, and Rajasthan. Nationally,
only 41 percent of women who earn cash decide independently how to spend the money that they
earn.364
Land Tenure
A 1999 World Bank study states that Indian women's legal rights have generally not been
implemented.365 The study goes on to focus on significant gender biases in land tenure. Women
have legal rights to inherit and own land; this is particularly true for Hindu women, following the
introduction of the Hindu Succession Act in 1956, which stipulates that the daughter(s), widow,
and mother of a Hindu man who died intestate inherit property equally with his sons. In practice,
however, significant and persistent gaps remain between women's legal rights and their actual
ownership of land, and between the limited ownership rights women do enjoy and their effective
control over land. (Agricultural land subject to tenancy is exempt from the Hindu Succession Act
and is governed by state-level acts. With regard to land ceiling acts, additional land may be kept
in the case of adult sons but not adult daughters. In assessing a family's landholdings, holdings of
both spouses are considered, but those of women are often arbitrarily declared "surplus," whereas
men's holdings remain untouched.)366
Women’s legal land rights conflict with deep-rooted social norms and customs and are rarely
recognized as legitimate in practice. Social stigma, seclusion, and other sanctions pressure
women to forfeit their legal rights in favor of their brothers. Consequently, in the event of
widowhood or marital breakup, women are dependent on their brothers for socioeconomic
support. The social obstacles to women's ability to exercise their legal rights are strongest in
north India (e.g., Rajasthan, Uttar Pradesh) and weakest in the southern states. And even when
women do hold land in their name, they may not be able to exert effective control over it, unable
to determine how it should be used, leased, or mortgaged.367
Women’s lack of control over independent sources of income affects their vulnerability to
acquiring HIV as well as ability to access AIDS care; it also affects the vulnerability of their
children. This scenario also holds for women in better-off and higher-caste households.368
Violence
See also the Govemance/Violence section above.
NFHS-2 found that 20 percent of ever-married women have experienced beatings or physical
mistreatment since age 15 and at least one in nine experienced such violence in the 12 months
preceding the survey. Most of these women have been beaten or physically mistreated by their
husbands. Domestic violence against women is more prevalent (27 to 29 percent) among women
working for cash; poor women; scheduled-caste women; and widowed, divorced, or deserted
women.
HIV/AIDS in India
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NFHS-2 asked respondents whether they thought that a husband is justified in beating his wife
for each of the following reasons: if he suspects her of being unfaithful; if her natal family does
not give expected money, jewelry, or other items; if she shows disrespect for her in-laws; if she
goes out without telling him; if she neglects the house or children; or if she does not cook food
properly. Among ever-married women, 56 percent accept at least one reason as a justification for
wife beating. A higher proportion of rural women (60 percent) than urban women (47 percent)
agree with at least one reason, and rural women are also more likely than urban women to agree
with each specific reason. Agreement with at least one reason and with each of the different
reasons for wife beating declines sharply with education. Women belonging to scheduled tribes,
scheduled castes, or other backward classes (58 to 63 percent) are more tolerant of wife beating
than are women not belonging to a scheduled caste, scheduled tribe, or other backward class (49
percent).369
The National Crimes Record Bureau of India's Ministry of Home Affairs indicates that there was
a 71.5 percent increase in reported cases of torture and dowry deaths from 1991 to 1995 (which
may reflect increased/improved reporting). In 1995, torture of women constituted 29.2 percent of
all reported crimes against women. In another study, 18 to 45 percent of married men in five
districts of Uttar Pradesh acknowledged that they physically abused their wives. A 1989 study of
dowry abuse indicated that one out of every four dowry victims was driven to suicide.370 (The
International Center for Research on Women has published numerous case studies on domestic
violence in India: http://www.icrw.org/publications violence.htm)
As part of a multisite international behavioral HIV intervention trial, YRG Care, Johns Hopkins,
and UNC conducted in-depth interviews with men and women in two randomly selected slums in
Chennai. Participants noted that husbands hold decisionmaking power in economic, social, and
sexual spheres. Gender norms often sanction husbands’ violence. As women try to minimize
exposure to violence, their ability to insist on monogamy, negotiate condom use, or refuse sex is
limited. Clear patterns of violence were present; respondents reported that husbands regularly
beat wives in most marriages. Women described being slapped, kicked, having their head hit
against the floor, and being burned with lit cigarettes; some were struck with objects such as
ladles or stones. Slapping or hitting the face was the most frequent type of violence, with
physical sequelae such as recurring headaches and blurred vision reported. Disobeying husbands
or elders, neglecting household chores, refusing sex, and suspected infidelity often triggered
violence. Drinking often preceded explosive outbreaks of violence. Some women modified their
behavior to avoid physical violence by engaging in silent passivity during verbal arguments and
acquiescing to unwanted sex. Although most respondents believed wife beating was the norm,
the acceptable intensity of violence varied by gender.371
Accessing HIV Care and Treatment
A study by the S. Singh Postgraduate Institute of Medical Education and Research found that
among 252 HIV-infected participants, an HIV-positive spouse was the only risk factor for
acquiring HIV in 82.25 percent of women, compared to only 2.55 percent of men. Among all
women, 75 percent were ’’completely unaware” of the risk to themselves from their husband,
HIV/AIDS in India
81
only 19.4 percent had received primary education, 75 percent had never heard of HIV before
being tested, 25 percent women were widows whose spouses had died because of AIDS.372
Prior to HIV/AIDS, there were already strong gender biases in access to health care.373 A small
study by CHANGE and UNC in rural Gujarat found that women rank older male household
members' health as the highest priority. Despite pain or discomfort, women cany out their work
responsibilities.374
The International Alliance for HIV/AIDS has found that when both a husband and wife are
infected with HIV/AIDS, men routinely receive care and treatment ahead of their wives. 375 Lack
of money and distance to treatment are also constraints. 376 The Lawyers Collective HIV/AIDS
Unit, the leading organization analyzing HIV/AIDS and human rights in India, has reported on
how HIV/AIDS is exacerbating gender inequalities and how Indian laws perpetuate gender
inequality and are ill equipped to resolve the varied difficulties faced by women with HIV/AIDS.
In a study of 70 cases involving women living with HIV/AIDS between 1998 and 2001, it found
that most women were between 18 and 30 years of age and that over 50 percent were widows,
economically dependent and unemployed. Among the most critical issues was women's struggle
to obtain maintenance from husbands or in-laws; other major issues included property rights,
custody of children, discrimination in health care, consent and confidentiality, and harassment.377
See also the Household Impact section.
Widows
According to NFHS-2, 9.0 percent of Indian women are widows (9.2 percent of urban women
and 9.0 percent of rural women). Among women age 50 and above, 43.4 percent are widows
(among urban women age 50 and above, 45.2 percent are widows; for rural women in the same
age group, 42.8 percent are widows).378
Dr. Martha Chen of Harvard cites the following reasons as contributing to the high number of
widows in India: husbands are, on average, five years older than wives, and widow remarriage is
infrequent. 7 After the death of a spouse, women are often forced to adhere to strict codes of ■
dress, demeanor, and diet throughout their lives, far beyond the actual mourning period. For
widows without relatives on whom to rely, social norms restrict their right to property and
employment outside the home because of their gender, but restrict remarriage. Widowed men in
India are not subject to the same restrictions: they can own property, are allowed to work outside
the home, and have greater freedom to remarry.380
Widows are expected to remain in the husband’s village, where they face social isolation,
intensified if the husband has died because of AIDS (and the widow herself is infected). Most
widows receive little economic support from their families or communities. Most live with
unmarried children or as dependents on adult sons. Their legal rights, particularly in terms of
property and inheritance rights, are often violated.381 The NFHS-2 found that widows (in
addition to women who were divorced, separated, or deserted) were more likely than currently
married women to have been beaten by their in-laws.382
HIV/A1DS in India
82
Recent news articles have highlighted how widows with HIV/AIDS have been stigmatized and
abandoned by their in-laws and communities. Moreover, their children have been denied access
to school, on the premise that they will infect other children.383 (See the Stigma and Household
sections.) Destitution combined with a lack of education could render children not already
infected more vulnerable to acquiring HIV.
In a review of NACO, CHANGE found that NACO's vertical structure has led to lack of
integration and coordination with sexual & reproductive health, child health, and family planning
programs. NACO's focus on individual behavior change strategies for "high-risk" groups ignores
the vulnerability of monogamous women. CHANGE recommends that NACO addresses
women's simultaneous need for protection from unwanted pregnancy and HIV/STI infection by
integrating HIV/AIDS and sexual & reproductive health programs, as well as by introducing dual
protection strategies. It also points to the Sonagachi Project (see Sex Work section), among
others, as a model of collective active that enables women to negotiate condom use and access
integrated reproductive health, legal, and social services. 384
Awareness and Knowledge of HIV/AIDS
To gauge population knowledge about HIV/AIDS, NACO undertook the National Baseline
Behavioral Surveillance Survey (BSS) from April through September 2001. Three groups were
surveyed: general population, sex workers and their clients, and MSM and IDU.
Methodology
General Population
States and union territories were categorized into 22 sampling units. There were 3,832
respondents ages 15-49 years (1,916 male and 1,916 female) in each sampling unit, with an equal
number from urban and rural areas. A three-stage cluster-sampling format was used for
identification of the sample. A total of 84,182 respondents were contacted across the country
during the baseline survey. Of them, 49.9 percent were residing in urban areas, 50.5 percent were
females. The median age of respondents was 29 years for females and 30 years for males for the
entire sample. About 75 percent of respondents were currently married (ranging from a low of
56.2 percent in Goa to a high of 80.4 percent in Bihar). Average literacy level of sampled
respondents was 75.1 percent (ranging from a low of 33.1 percent among rural females from
Madhya Pradesh to a high of 99.3 percent among urban males in Kerala). Among male
respondents, 18.4 percent were unemployed (includes respondents currently studying). Among
women, 65.9 percent were housewives, and an additional 13.4 percent were unemployed
(includes students).385
Sex Workers and Their Clients
32 states and UTs were categorized into 21 sampling units. A total of 5,648 clients of sex
workers and 5,572 female sex workers were interviewed across all the sampling units. For each
sampling unit, SWs were selected from the predominant type of sex work that was prevalent in
that sampling unit. In addition, control groups of SWs were surveyed in Delhi, Mumbai,
HIV/AIDS in India
83
Calcutta, and Andhra Pradesh, covering 1,087 respondents. These control groups were included
to assess any significant differences between brothel and non-brothel-based SWs in these
geographic locations. A four-stage cluster sampling design was adopted for selecting respondents
among brothel-based SWs and a three-stage cluster sampling design was adopted for nonbrothel-based SWs and clients of sex workers.386
MSM and IDU
Among MSM, the survey was carried out across in Delhi, Calcutta, Mumbai, Chennai, and
Bangalore. (The operational definition of MSM was manual, oral, or anal sex with other men in
the past six months.) Among IDUs, it was carried out in Delhi, Calcutta, Mumbai, Chennai, and
Manipur. A total of 1,387 MSM and 1,355 IDUs were interviewed across all sampling units. A
two-stage cluster sampling design was adopted for selecting both MSM and IDU respondents; in
Manipur, a three-stage cluster sampling design was adopted for selecting respondents among
IDUs.
Overall, 42 percent of MSM respondents were ages 19-25, and 39 percent were ages 26-35. Less
than 5 percent were below age 19. The mean age of all respondents was 28. About 9 percent of
sampled respondents were illiterate. Nearly 11 percent studied up to the primary level. About 19
percent had completed secondary education. At the aggregate level, there were more respondents
engaged in service (21 percent), self-employment (13 percent), and petty business/ small shop
owner (13 percent) than other primary occupations. Seven percent were students, and 13 percent
were unemployed. About one-third of respondents had ever been married to a female partner.
About two-thirds (64 percent) of respondents were not currently married nor living with any
female partner. About one-fourth (26 percent) were currently married and living with their wives
(female).387
Among IDU respondents, about 75 percent were between ages 19 and 35. The median age of
respondents was 30. There was a wide variation in educational level of respondents across the
five sites. The proportion of illiterate respondents was significantly higher in Calcutta (56
percent), Mumbai (42 percent), and Delhi (39 percent) compared with Chennai (15 percent) and
Manipur (11 percent). Overall, 41.2 percent of respondents reported that they had ever been
married. Nearly three-fifths of repsondents reported that they were not married and not living
with any sexual partner. About 27 percent of respondents were currently married and living with
their spouses. Overall, about one-quarter of respondents were nonagricultural or casual laborers.
About 20 percent were unemployed or retired, 13 percent petty business/small shop owners, 8
percent transport workers, and 6 percent students. 388 (See also the Alcohol and Drug Use section
below.)
Overall Awareness
The BSS asked respondents if they had heard of HIV/AIDS. No description of the disease or its
symptoms was provided. So defined, overall, awareness of HIV/AIDS in India is 76 percent,
though variance among states is significant: 99 percent of respondents in Kerala reported that
they had heard of HIV/AIDS, as had 96 percent in Andhra Pradesh. However, only 40 percent of
respondents in Bihar and 51 percent in Uttar Pradesh Were aware of HIV/AIDS. There were also
HIV/AIDS in India
84
major urban-rural differentials: 89 percent of urban BSS respondents were aware of HIV/AIDS,
versus only 72 percent in rural areas.389 (Moreover, the urban figure may mask lower HIV/AIDS
awareness in urban slum areas. Among other factors, slums often have a large number of recent
migrants from rural areas.390 , 391) (See figure 1.)
Gender differences are also striking: overall 82 percent of men surveyed were aware of
HIV/AIDS, whereas among women, this figure was 70 percent. Across states, there was no
exception to the finding of greater AIDS awareness among men than among women. The
difference was most striking in Bihar, where 54 percent of men but only 27 percent of women,
about half the rate in men, reported awareness.392
(The NHFS-2, conducted in 1998-99, found that 60 percent of ever-married Indian women had
not heard of AIDS. Awareness of AIDS was particularly low among women not regularly
exposed to media, women from scheduled tribes, illiterate women, women living in households
with a low standard of living, and rural women.393)
The BSS found that awareness among SWs, MSM, and IDUs is much higher than in the general
population. Overall, 94 percent of SWs reported that they had heard of HIV/AIDS. State-level
results varied from a high of 99 percent in Tamil Nadu to a low of 88 percent in Karnataka.394
Among MSM, 97 percent reported awareness of the disease, with relatively little variation
among large cities: 99 percent of MSM in Mumbai (Maharashtra), 98 percent in Chennai (Tamil
Nadu), 96 percent in Bangalore (Karnataka), and 94 percent in Calcutta (West Bengal) reported
that they had heard of HIV/AIDS. Finally, overall knowledge of HIV/AIDS among IDUs in
India is 97 percent, with 100 percent reporting knowledge in Manipur, 98 percent in Chennai 96
percent in Calcutta, and 95 percent in Mumbai.395
Figure 1. BSS: General Population: Awareness of HIV/AIDS
TABLE3.4 PROPORTION OF RESPONDENTS WHO HAD EVER HEARD OF HIV/AIDS
SI. State Sampling Units
No.
Rural
Urban
Combined*
M
F
T
M
F
T
M
F
T
1.
Andhra Pradesh
95.8
97.0
96.4
94.9
97.6
96.2
95.1
97.4
96.3
2.
Assam
91.5
85.6
88.5
72.4
57.7
65.1
74.5
60.8
67.7
3.
Bihar
84.3
62.8
73.6
49.1
21.5
35.3
53.7
26.9
40.3
4.
Delhi
90.3
86.3
88.3
93.3
81.9
87.4
90.6
85.9
88.2
5.
Goa+
99.0
94.6
96.8
95.6
87.2
91.4
97.0
90.2
93.6
6.
Gujarati
86.8
61.6
74.2
67.6
25.0
46.1
74.3
37.5
55.7
7.
Haryana
92.5
85.2
88.8
83.6
64.7
74.2
85.8
69.8
77.8
8.
Himachal Pradesh
97.1
96.7
96.9
90.9
88.9
89.9
91.5
89.6
90.5
9.
Jammu and Kashmir
99.3
93.9
96.6
83.9
69.7
76.8
87.6
75.4
81.5
10. Karnataka
95.1
88.0
91.6
86.5
74.8
80.7
89.1
78.9
84.0
11. Kerala+
99.5
98.6
99.0
99.1
98.7
98.9
99.2
98.7
98.9
12. Madhya Pradesh
92.5
78.2
85.4
61.9
32.3
47.0
69.0
42.9
55.9
13. Maharashtra
96.0
90.2
93.1
80.6
69.2
74.9
86.6
77.3
81.9
14. Manipur
98.5
98.6
98.6
96.6
89.5
93.1
97.1
92.0
94.6
15. Orissa
91.5
81.4
86.5
73.0
55.1
64.1
75.4
58.6
67.1
16. Other North East States
93.8
86.9
90.3
77.6
66.7
72.2
80.7
70.6
75.6
17. Punjab*
98.2
90.9
94.6
94.9
86.6
90.8
96.0
88.0
92.0
18. Rajasthan
90.0
77.5
83.6
70.0
45.0
57.3
74.6
52.5
63.3
19. Sikkim
93.4
91.1
92.3
70.5
68.8
69.6
72.6
70.8
71.7
20. Tamil Nadu+
96.1
94.3
95.2
88.3
83.7
86.0
91.0
87.4
89.2
21. Uttar Pradesh
79.6
64.1
71.7
63.8
27.6
45.4
66.9
34.9
50.6
22. West Bengali
89.1
80.2
84.6
57.6
38.6
48.1
66.2
50.1
58.2
93.2
85.7
89.4
79.5
65.2
72.3
82.4
70.0
76.1
All India
Mean
Source: NACO. National Baseline General Population Behavioural Surveillance Survey: 2001. New Delhi.
<http://www.naco.nic.in/nacp/publctn.htm>
Misperceptions
The BSS also aimed to gauge the prevalence of misperceptions about how HIV is transmitted.
Respondents were asked whether (1) HIV can be transmitted by mosquito bites, (2) HIV can be
transmitted by sharing a meal with an infected person, or (3) a healthy looking person can have
HIV. Overall, only 21 percent of respondents responded correctly to all three questions (i.e.,
having no incorrect knowledge"), revealing a high level of misperception about HIV
transmission (see figure 2).396
Figure 2. BSS: General Population: Correct Knowledge of HIV Transmission
TABLE 3.14
9.^R.E^TS having no incorrect knowledge on
TRANSMISSION OF HIV/AIDS
SI. State Sampling Units!
No.
(Ail figures aro in percentage)
Urban
Rural
Combined*
M
F
T
M
F
T
M
F
T
27.8
29.9
26.6
28.2
7.5
8.8
1.
Andhra Pradesh
33.1
25.7
29.4
28.8
26.9
2.
Assam
18.5
15.8
17.2
9.0
6.5
7.7
10.0
3.
Bihar
19.0
15.5
17.3
7.4
4.1
5.7
8.9
5.6
7.2
4.
Delhi
29.1
19.1
24.0
25.4
13.8
19.4
28.7
18.5
23.5
5.
Goa+
30.4
37.3
33.8
28.0
24.9
26.5
29.0
30.1
29.5
6.
Gujarat+
21.8
16.1
18.8
11.8
4.5
8.1
15.2
8.5
11.8
7.
Haryana
30.6
27.1
28.8
19.2
14.9
17.1
22.0
17.9
20.0
8.
Himachal Pradesh
37.9
66.3
52.0
21.4
42.5
ITo
22.8
44.6
33.7
9.
Jammu and Kashmir
42.6
56.9
49.7
19.4
9.1
■14.2
24.9
20.4
22.7
10. Karnataka
9.6
7.1
8.3
6.4
5.9
6.2
7.3
6.3
6.8
11. Kerala+
49.7
41.0
44.4
49.0
46.3
47.5
49.2
44.8
46.6
12. Madhya Pradesh
18.2
17.8
18.0
8.2
5.0
6.6
10.5
7.9
9.2
13. Maharashtra
42.7
40.3
41.5
32.0
20.0
26.0
36.2
27.8
32.0
14. Manipur
72.9
52.5
62.7
35.8
22.6
29.2
45.9
30.8
38.4
15. Orissa
21.2
20.4
20.8
10.2
5.6
7.9
11.7
7.6
9.7
16. Other North East States
39.1
38.8
38.9
30.2
31.5
30.8
31.9
32.8
32.4
17. Punjab+
41.3
42.4
41.8
30.2
34.7
32.4
33.7
37.1
35.4
18. Rajasthan
24.3
25.1
24.7
18.4
14.3
16.3
19.8
16.8
18.2
19. Sikkim
36.0
20.3
28.2
17.8
13.2
15.5
19.5
13.9
16.7
20. Tamil Nadu+
27.2
12.0
19.6
16.3
5.9
11.1
20.0
8.0
14.0
21. Uttar Pradesh
17.6
14.8
16.2
9.3
4.3
6.7
10.9
6.4
8.6
22. West Bengal*
26.0
26.6
26.3
12.3
8.6
10.5
16.1
13.6
14.8
21.3
All India
Mean
31.2
29.1
30.1
20.1
16.8
18.4
22.7
19.9
Standard Deviation
13.8
15.8
13.9
11.1
12.9
11.5
11.7
12.7
11.7
Median
29.8
25.4
27.3
18.8
13.5
15.9
21.0
17.4
19.1
Range
* Weighted fibres
9.6-72.9 7.1-66.3 8.3-62.7 6.4-49.0 4.1-46.3 5.7-47.5 7.3-49.2 5.6-44.8 7.2-46.6
Base: All Respondents
Source-. NACO. National Baseline General Population Behavioural Surveillance Survey: 2001. New Delhi.
<http://www.naco.nic.in/nacp/publctn.htm >
Among higher-risk groups, misperceptions were far less prevalent. Over 84 percent of MSM are
aware that HIV is not transmitted by sharing a meal with an infected person, and variation
ranged from a low of 70 percent in Calcutta to a high of 91 percent in Chennai. In addition, 78
percent of MSM are aware that HIV cannot be transmitted by mosquitoes, ranging from 55
percent in Calcutta to nearly 90 percent in Bangalore and Chennai. Overall, 71 percent are aware
that a healthy person may have HIV, and variation ranged from 55 percent in Bangalore to 89
percent in Mumbai (see figure 3).397
Figure 3. BSS: MSM: Correct Knowledge of HIV Transmission
TABLE 3.12 Correct Beliefs about HIV transmission
City
Aware that HIV is not transmitted through
Sharing a meal
Mosquito Bite
(All figures are in percentages)
Aware that a healthy
Respondents
person may be suffering correctly identifying
from HIV
all three issues
Bangalore
88.5
88.5
55.2
46.3
Chennai
90.8
89.7
75.7
69.1
Delhi
84.3
81.3
70.2
54.2
Kolkata
"tTo
Mumbai
86.6
547
757
88.8
"637
Total
84.1
78.0
70.7
53.6
63.0
Base: All tvstondents
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http://www.naco.nic.in./nacp-'nublctn.htm>
Among IDUs, 69 percent are aware that HIV is not transmitted by sharing a meal, and 67 percent
are aware that the virus cannot be spread through mosquito bites. Again, a high level of variation
is seen at the local level; 52 percent in Calcutta, 60 percent in Mumbai, and 91 percent in
Manipur hold correct beliefs about sharing a meal and HIV transmission, while 53 percent in
Calcutta, 49 percent in Mumbai, and 91 percent in Chennai hold correct beliefs regarding
mosquito bites and HIV. Awareness that a healthy person can have HIV is slightly higher, with
71 percent holding correct beliefs (variation ranged from 54 percent in Delhi to 83 percent in
Mumbai) (see figure 4).398
Figure 4. BSS: IDUs: Correct Knowledge of HIV Transmission
TABLE 4.27 [Correct Beliefs about HIV transmission
City/State
Proportion aware that HIV is
not transmitted through
Sharing a meal
Mosquito bites
(All ftgums are in percentages)
Proportion aware that a
healthy looking person
may be suffering
from HIV
Proportion of respondents
correctly identifying
all three issues
75.6
61.9
Chennai
81.5
91.1
Delhi
547
507
53.6
24.8
Kolkata
sTT
537
68.3
29.6
Manipur
90.7
87.8
71.4
60.8
Mumbai
60.0
48.9
• 83 3
31.1
Total
68.9
67.3
70.5
42.5
Base: All respondents
Source-. NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http://www.naco.nic.in/nacp/publctn.htm>
Finally, among sex workers, 63 percent are aware that HIV is not transmitted by sharing a meal.
Nearly 66 percent of all respondents are aware that mosquito bites are not responsible for HIV
transmission. A smaller proportion (58 percent) are aware that a healthy looking person may
have HIV; further, among brothel-based SWs, 63 percent knew that a health looking person
could have HIV, whereas this figure was 55 percent among non-brothel-based SWs (see figure
5).
Figure 5. BSS: SWs: Correct Knowledge of HIV Transmission
TABL£ 3.10 [CORRECT BELIEFS ABOUT HIV TRANSMISSION
SI.
State/State Group
No.
1.
Proportion Aware that HIV is
not transmitted through
Sharing a meal
with infected person
From mosquito
bites
(All figures arr :n pprcoinaqes'i
Proportion Aware
Proportion of
that a healthy looking
Respondents
person could be
correctly
suffering from
identifying all
________ HIV________three issues
Andhra Pradesh
69.4
64.2
Assam
65.5
57.9
~~
Bihar+
_______ 53.4_______
71.9
~
_______ 63.2________
25.7
4.
Delhi
_______ 73.3_______
72.6
_______ 55.6________
33,1
5.
Goa
_______ 85.9_______
76.0
_______ 54.8________
38.5
6.
7.
Gujarat
______ 57.9_______
69.0
_______ 51,7________
19.4
Haryana
_______ 39.3_______
50.9
_______ 31.8________
12.2
8.
Himachal Pradesh
______ 49.0_______
39.9
_______ 26.2________
7.7
9.
Jammu & Kashmir
32.4
21.1 ,
10.
Karnataka
_______54.5_______
77,0
50,6
21.7
11.
Kerala
______ 60.7_______
70.4
71.2
41.5
12.
Madhya Pradesh +
_______ 37,1________
52.3
51.2
12.0
Maharashtra
68.0
71.9
64.3
37.2
Manipur
______ 78.9_______
87.7
67.7
47,6
Orissa
______ 54.2_______
61.8
83.3
32.0
54.8
70.3
72.4
31.6
46.3
18.0
Other NE States+
Punjab+
18.
Rajasthan
19.
20~
Tamil Nadu+
21.
_______ 64.2________
67.6 _______76.5
______ 43.8________
~
43.4
~
~
67.8
3T2
32.2
80.7 ________
73.2
36.6
22.5
______ 83.5_______
93.3
71.2
60.6
Uttar Pradesh+
62.5_______
75.1
64.0
28.6
West Bengal
64.3_______
MJ
71.1
32.3
Brothel Based
63.9_______
63.4
29,8
Non Brothel Based
63.0
66,0
65.7
54.5
28.5
All India
63.4
65.8
58.1
29.0
Base: All Respondents
Sowrce: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2001: Part
7. New Delhi <http://www.naco.nic.in/nacp/publctn.htm>
Perception of Risk
Higher-risk groups were also asked whether they perceived themselves to be at high risk of
contracting HIV. Overall, 27 percent of MSM perceive themselves to be at very high risk of
acquiring HIV, whereas 29 percent reported moderate risk, 27 percent reported low risk, and 18
percent reported no risk at all of becoming infected with HIV. In terms of variation by city, 44
percent of MSM in Chennai and 40 percent in Mumbai perceive themselves to be at very high
risk of contracting HIV, whereas only 14 percent in Delhi and 16 percent in Calcutta perceive
themselves to be at very high risk (see figure 6).400
Figure 6. BSS: MSM: Risk Perception
TABLE 3.34 [Risk perception of getting infected with HIV/AIDS
City
(All figures are in percentages)
Very high
Moderate
Low
No chance
Bangalore
20.7
21.5
27.0
30.7
Chennai
44.1
29.8
17.6
8.5
Delhi
14
40J
26.4
19.4
Kolkata
15.6
~4
42.6
24.4
Mumbai
40.2
32.2
21.0
6.5
Total
26.7
28.5
26.9
17.9
Bait: AS Rk.'$pcnd&;ts
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http://www.nacd.nic.in/nacp/publctn.htm >
Among IDUs, 35 percent perceive themselves to be at very high risk of contracting HIV, 20
percent perceive themselves to be at moderate risk, 27 percent perceive a low risk, and 17
percent perceive no risk at all. There are large variations by city; 72 percent of IDUs in Mumbai
perceive themselves to be at very high risk of acquiring HIV, whereas 38 percent in Chennai, 24
percent in Manipur, and a very low 4 percent in Calcutta perceive themselves to be at very high’
risk (figure 7).401
Figure 7. BSS: IDUs: Risk Perception
TABLE 4.40 Perception regarding Risk of Contracting HIV/AIDS
Very high
City/State
Moderate
(All figures are in percentages)
Low
No chance
Chennai
38.1
19.6
27
14.8
Delhi
30J
14.6
39.1
iu
Kolkata
4.3
17.8
26.5
47
Manipur
____
24.1
26X)
33.1
15.8
Mumbai
____
72.2
20.0
6.3
1.1
34.5
19.9
26.6
Total
Base: AS Respoj;defits
17
'
~
'
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http.7/www.naco.nic.in/nacp/publctn.htm >
Nationally, a strikingly low 17 percent of sex workers perceive themselves to be at very high risk
of contracting HIV/AIDS. Approximately 26 percent reported a moderate chance of infection, 31
percent a low chance, and 17 percent no chance of acquiring HIV. Wide variation is seen at the
state level. Moreover, whereas 21 percent of brothel-based SWs perceived themselves at very
high risk of HIV, only 14 percent of non-brothel-based SWs reported this level of perceived risk
(figure 8).402
Figure 8. BSS: SWs: Risk Perception
TABLE 3.27 [PERCEPTION REGARDING RISK OF CONTRACTING HIV/AIDS
SI.
State/State Group
Very high
Moderate
Low
1.
Andhra Pradesh
10.0
2.
Assam
3.
4.
(AH figures are tnporcofuages)
No chance
29.4
45.5
33.7
21.5
34.4
5.2
Bihar+
16.7
To?
31.6
19.4
14.1
Delhi
10.4
32.7
33.1
Goa
TT
23.3
38.1
287
Gujarat
9.4
20.1
38.5
18.1
Haryana
5.9
28?
29.6
10.0
8.
Himachal Pradesh
0.4
6.6
36.2
41.3
9.
Jammu & Kashmir
10.5
8.8
28.9
29.8
10.
Karnataka
28,1
24.7
29.2
12.4
6.
11.
Kerala
13.0
33.7
39.3
12.2
12.
Madhya Pradesh +
427
110
21.0
13.0
13.
Maharashtra
26.0
25.7
26.8
19.0
14.
Manipur
23.2
39.7
15.
Orissa
26.5
15.4
32.2
23.9
21.3
4.1
Other NE States+
16.9
36.0
22.1
13.6
17.
Punjab+
4.9
"257
33.7
19.9
18.
Rajasthan
4.4
77
34.7
21.8
18.5
Tamil Nadu+
19.7
49.4
27
Uttar Pradesh+
28.2
11.4
23.8
25.6
30.4
21.
West Bengal
11.7
42.2
23.1
28.4
27.0
28.4
18.4
20.5
32.1
15.3
26J
30.7
17.3
Brothel Based
Non Brothel Based
All India_____________
21.2
14.0
16.8
7.1
Base: Al! Respondents
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2001: Part
7. New Delhi <http://www.naco.nic.in/nacp/publctn.htm >
Sexual Behavior
The general population BSS found that nearly 7 percent of adults surveyed reported having sex
with a nonregular partner in the last 12 months. (A nonregular partner was defined as one to
whom the respondent was not married or with whom the respondent had never lived and with
whom the respondent did not pay for sexual intercourse.) Again, results vary substantially by
state. Although a small percentage in West Bengal, Tamil Nadu, and Karnataka reported having
sex with a nonregular partner (2, 3, and 4 percent respectively), 11 percent in Maharashtra and
13 percent in Andhra Pradesh reported sex with a nonregular partner. Sex with a nonregular
partner is somewhat higher in urban areas, where 7 percent reported having sex with a
nonregular partner in the last 12 months, versus 6 percent in rural areas (figure 9).403
The difference between men and women, however, is striking: 12 percent of men versus only 2
percent of women report having had sex with a nonregular partner. There is little difference in
this gender variation in rural versus urban areas. The percentage of urban males reporting a
nonregular partner in the last 12 months ranges from a low of 3 percent in Manipur to a high of
23 percent in Maharashtra.404
Figure 9. BSS: General Population: Sex with Nonregular Partner
TABLE 327
SI.
NO.
PROPORTION OF RESPONDENTS WHO REPORTED HAVING SEX WITH ANY
NON-REGULAR PARTNER IN LAST 12 MONTHS
(All Tigures are in percentage)
State Sampling Units
Urban
Rural
Combined*
M
F
T
12.1
M
F
T
M
77
14.6
19.2
F
T
77
1.
Andhra Pradesh
16.2
8.0
2.
Assam
4.9
0.8
2.6
10.3
1.9
5.7
9.8
1.8
5.4
3?
Bihar
13.6
77
77
717
4.1
77
11.5
4.2
7.6
4.
Delhi
7.7
0.5
3.9
9.5
0.0
4.3
7.9
0.4
3.9
5.
Goa +
18.9
TT
9.8
14.0
1.0
LO
16.1
77
77
6.
Gujarat +
19.9
18.1
0.8
9.1
7.
Haryana
8.
Himachal Pradesh
9.
0.5
9.7
17.2
0.9
8.7
Ts
4.7
Tt"
1.6
4.9
77
4.8
4.3
0.3
2.1
6.1
0.5
3.2
6.0
0.5
3.1
Jammu & Kashmir
6.7
0.5
3.4
n?3
3.2
8.3
127
2.6
7.2
10.
Karnataka
5.4
1.6
3.3
8.9
1.1
4.7
7.9
1.3
4.2
11.
Kerala +
10.6
T7
4.8
10.9
3.2
6.1
10.8
2.9
5.7
12.
Maharashtra
23.4
14.6
19.0
9.8
2.6
6.2
15.0
7.3
11.1
13.
Manipur
2.5
1.1
1.8
5.6
0.4
2.9
TF Madhya Pradesh
4.8
0.6
2.6
227
1.0
To~8
Tls
Tn
8.7
To
FT
77
6.6
0.1
3.0
5.0
0.4
2.6
5.2
0.4
2.6
18.5
77
10.2
15.5
2.3
8.6
16.0
77
77
11.5
15.
Orissa
ie" Other North East States
Punjab +
13.2
1.7
7.1
10.8
1.1
5.6
nF Rajasthan
5.7
77
2.8
4.4
0.6
77
1.4
7.5
17.
1.3
6.1
0.6
2.5
13.7
1.5
7.6
19.
Sikkim
15.9
1.9
8.8
13.5
20.
Tamil Nadu +
TF
0.9
3.7
"FT
0.6
TT
6.6
0.7
77
21.
Uttar Pradesh
6.2
0.5
3.1
8.8
0.4
4.2
8.3
0.4
4.0
22? West Bengal +
5.6
1.0
3.0
3.2
0.9
1.9
3.8
1.0
2.2
12.6
2.3
7.0
11.4
1.8
6.3
11.8
2.0
6.6
All India
Mean
Source: NACO. National Baseline General Population Behavioural Surveillance Survey: 2001. New Delhi.
<http://www.naco.nic.in/nacp/publctn.htm >
Of the subsection of the general population that reported sex with a nonregular partner in the past
12 months, the BSS survey asked respondents whether they use condoms consistently with all
nonregular partners. Overall, 32 percent reported consistent condom use with all nonregular
partners. However, consistent condom use varied widely by state; although 60 percent of those in
Maharasthra reported consistent condom use with a nonregular partner, only 25 percent in
Andhra Pradesh reported such use.405
Among MSM who had commercial sex in the month prior to the survey, 13 percent reported
consistent condom use with commercial male partners. (A commercial partner was defined as
one with whom the respondent had sex in exchange for money.) This contrasts dramatically with
the 30 percent of MSM reporting consistent condom with a noncommercial male partner in the
month prior to the survey. At the state level, 33 percent of those in Mumbai who had commercial
sex reported using condoms consistently, whereas a low 8 percent in Calcutta and 9 percent in
Bangalore reported using condoms consistently with commercial partners. Among MSM who
had sex with a noncommercial partner in the month prior to the survey, wide variation also
occurred at the local level; 56 percent in Mumbai reported consistent condom use with
noncommercial partners, whereas 11 percent in Delhi and 20 percent in both Calcutta and
Chennai reported consistent condom use (figure IO).406
Figure 10. BSS: MSM: Consistent Condom Use with Nonregular and Commercial Partners
TABLE 3.29 Consistent Condom Use with Commercial/Non-Commercial Male Partners in
Last One Month(All figures are in percentages)
City
Consistent condom use with
commercial male partners*
Consistent condom use with
non-commercial male partners **
Bangalore
8.9
43.7
Chennai
15.6
19.2
Delhi
13.9
11.3
Kolkata
7.5
20.5
Mumbai
33.3
56.4
Total
12.6
30.3
’ B&e: Jhose wfw lad sex
any ccmmeraal male partner in last 1 month
’ ’ Base: Tltese who had sex with any non-comm&tal male partner ffi last 1 month
Source'. NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http://www.naco.nic.in/nacp/publctn.htm >
Among IDUs, the BSS found that 10 percent had sex with any nonregular partner in the last 12
months, with the highest percentages in Delhi (18 percent) and Manipur (14 percent). Overall, 16
percent had sex with any commercial partner in the last 12 months, ranging from 8 percent in
Mumbai to 25 percent in Delhi.407 However, a study in Delhi found a much greater level of
high-risk sexual behavior among drug users (both injecting and noninjecting). Seventy drug
users were compared with 128 non-drug users, randomly selected from the same community and
matched by age and economic status. Seventy-eight percent of sexually active drug users had
multiple sex partners, and drug users were 6.7 times more likely to visit commercial sex
workers 408 A study in Chennai of 350 male, long-term IDUs found that 28.9 percent were HIV
positive. Seventy-one percent shared injecting equipment, and 51 percent visited sex workers
"frequently.” In the sample, 63 percent were married. HIV-positive IDUs had a significantly long
duration of injection use (p<0.05), more frequent history of sex with sex workers (p <0.01), and
more concurrent use of alcohol (p <0.01).409 (Note that in this sample, 77 percent of participants
were employed, and 56 percent had attained secondary level education.)
Among IDUs who reported sex with any nonregular partner in the 12 months prior to the survey,
12 percent reported using condoms consistently with these partners. Thirty-two percent reported
consistent condom use with commercial partners, and only 6 percent reported consistent condom
use with regular partners (figure 11).410
Figure 11. BSS: IDUs: Consistent Condom Use with Nonregular Partner
TABLE 4.36 {Consistent Condom Use with Commercial/ Non-Regular/ Regular Partners
in Last Twelve Months
(All figtims are in percentages)
City/State
Consistent condom use with
commercial partners *
Consistent condom use with
non regular partners**
Chennai
3L5
iTs
Consistent condom use with
regular partners***
8^0
Delhi
17.4
8.3
4.8
Kolkata
40.0
20
L8
Manipur
14.3
6.8
Mumbai
34.3
52.4
Total
31.8
~~
8.3
11.9
6.1
* Szisffi TJjose wto had sex with any cctiimercialpartner in last 12 rnonliK
“ Base: Those- ivho had sex with any non regular partner in last 12 months
Base: Those wlw had sex with any regular partner in last 12 months
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2002: Part
2. New Delhi <http://www.naco.nic.in/nacp/piiblctn.htin >
Finally, among sex workers, 50 percent reported consistent condom use with paying clients in
the last 30 days (though the figure was higher for brothel-based [57 percent] vs. non-brothelbased SWs [46 percent]). However, among those who had sex with a nonpaying partner in the
three months prior to the survey, only 21 percent reported using condoms consistently. At the
state level, 73 percent of SWs in Maharashtra use condoms consistently with their paying clients,
whereas 54 percent in Tamil Nadu and 39 percent in West Bengal do so. With nonpaying
partners, 7 percent of SWs in Maharasthra, 9 percent in Tamil Nadu, and 10 percent in West
Bengal use condoms consistently (figure 12). 11
Figure 12. BSS: SWs: Condom Use
TABLE 321
SI.
No.
CONDOM USAGE WITH PAYING CLIENTS AND NON PAYING PARTNERS
State/State Group
(Ail figures are in percentages)
Last Time Condom Usage
With Paying Clients
With Non Paying
Partners*
Consistent Condom Usage in
Last 30 days
With Paying Clients
With Non Paying
Partners in last
3 months*
1
2.
78.9
75.2
58.2
53.1
29.1
Assam
48.5
26.9
12.6
3.
Bihar+
65.3
20.0
23.9
5.3
4.
Delhi
72.5
66.7
63.6
5.
Goa
45.8
77.0
44.2
69.3
32.6
6.
Gujarat
77,1
34.5
58.1
26.8
7.
Haryana
69.6
16.6
a
27.6
7.3
Himachal Pradesh
87.8
35.7
41.0
16.3
Jammu & Kashmir
80.7
26.3
50.9
6.3
Karnataka
73.4
58.6
55.7
33.7
it
Kerala
87.8
48.0
73.7
12.
Madhya Pradesh <■
70.9
49.2
65.0
38.2
28,5
13.
Maharashtra
87.7
39.3
72.5
7.1 _______
14.
Manipur______
71.8
67.9
53,3
44.9
Andhra Pradesh
~w~
15.
Orissa
73.0
53.6
65.2
38.5
16.
Other NE States+
64.1
40.2
23.7
17.
Punjab+
79.0
25.4
45.8
20,5
9.7_______
13.3
Rajasthan
67.8
25.6
33.8
19.
Tamil Nadu+
83.3
25.0
54.1
9.2 _______
20.
Uttar Pradesh+
68.9
41.5
61.9
13.8
21.
West Bengal
86.5
22.6
39.0
9.5_______
Brothel Based
75.2
39.0
57.2
21.3
Non Brothel Based
76.5
38.7
45.8
20.2
All India______________
76.0
38.8
50.3
20.5
Base: Al! Respondents
►
' Sos*: Those Respondents who reported any Non Paying Paring in the last 7 days
Source: NACO. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey: 2001: Part
7. New Delhi <http://www.naco.nic.in/nacp/publctn.htm >
I
Youth
I
I
i
India has an enormous population of young people, with about 385 million people under age
15.' * 4BmOn8 reported AIDS cases t0 date>those under age 30 represent 39.7 percent of
cases.
However, according to a study by MAMTA Health Institute for Mother & Child, government
policies and programs, including those related to HIV/AIDS, have largely ignored adolescents.
There is a crucial need for sexual & reproductive health and HIV/AIDS information and
services.
In a study of the patterns and determinants of sexual behavior among unmarried
adolescents, MAMTA found that knowledge among adolescents regarding safer sex and
condoms is inadequate and inconsistent. The information that is imparted to youth is intrinsically
►
tied to societal attitudes on sexual desire and behavior. These attitudes may have little
correspondence to prevailing sexual behavior. For example, the community in general, and
parents of adolescents in particular, stress that knowledge on sexual behavior is not required until
after marriage. There is great reluctance to acknowledge that unmarried people have sex.
Adolescents themselves, however, report a considerable amount of sexual activity, that in some
cases includes intercourse. They express a strong need to gain more information on issues of
sexuality and sexual behavior.415
Studies by FXB India have highlighted that adolescent girls in Mumbai are highly vulnerable to
HIV given their lack of sexual and HIV/AIDS education.416 Belaku Trust and India's National
Institute of Mental Health and Neurosciences deployed a cross-sectional survey of 1,500 rural
and semirural 14- and 15-year-old school-going adolescents in south India. They found strong
gender disparities in HIV/AIDS knowledge, information sources, and consequences of sex.
Although overall knowledge of HIV/AIDS was low, rural residence, being female, and low
socioeconomic status were correlated with low awareness of HIV transmission and prevention.
Boys were significantly more likely to link condoms with HIV prevention. Main HIV/AIDS
information sources for girls were relatives (older sister, mother). For boys, the main sources are
TV, films, sex films, sex books, and male friends, a reflection of greater physical and social
mobility. All participants exhibited zero knowledge of STIs other than HIV. Moreover, girls'
knowledge of menstruation was very incomplete.417 Shantideep, an adolescent health project in'
Jaipur, Rajasthan, has also documented that not only are there gaps in adolescents' knowledge of
HIV/AIDS, but that that knowledge of menstruation, masturbation, and other STIs is poor. 418
Discomfort with discussing sexual behavior has severely constrained India’s ability to address
the sexual & reproductive health needs of young people. There is a paucity of accurate
information on sex and sexuality. Adolescents who seek sexual & reproductive health services
are often met by judgmental health providers; unmarried girls in particular face stigma, which
affects their chances for marriage. Service delivery offers little or no privacy or confidentiality.
Consequently, both girls and boys often seek substandard/illegal services.419
Population Action International reports that premarital sex and pregnancy are more common in
India than generally acknowledged. Persistent ambivalence about sex education has also
impeded the full implementation of a population and family life education program begun in the
early 1980s. Although sex education has recently been included in India’s National Curriculum,
state officials dilute messages to which they object and teachers omit topics with which they are
uncomfortable.420
MSM
See also the Population Mobility, Knowledge, Alcohol, and Human Rights sections.
Indian Penal Code 377, based on a 19th-century British law, criminalizes "the act of anal and
oral sex performed either between two men or between a man and a woman."421 (There is
currently a petition before the New Delhi High Court to repeal section 377.422) Homosexuality is
a taboo topic in India, and MSM are severely marginalized. 423 Several studies have found that
men report their male-to-male sexual activities as masti (fun or play) or to initiate sexual
experiences, and do not equate them with sexual identities such as "gay," "bisexual," or
"homosexual". ,
This scenario may be one reason why condom use among MSM is low;
other reasons include police harassment.4"-6 Many MSM are married or have sex with females,
and may act as a bridge population.427 , 428 FXB India conducted a survey among 72 MSM in
Mumbai. It found that 89 percent also have sex with women. Possible strained relations with
spouses, stigmatization of their families, and discrimination by society were explanations given
for not revealing their MSM sexuality openly 429 As mentioned above, India's BSS found that
about one-third of MSM respondents had ever been married to a female partner. About twothirds (64 percent) of respondents were not currently married nor living with any female partner.
About one-fourth (26 percent) were currently married and living with their wives (female)430
Male-to-female transgenders (TG) experience further discrimination and stigmatization,
particularly if they work in the sex trade (as many do431). Several studies have found high HIV
prevalence among TG, which further compound their sense of isolation and marginalization.432
One of the reasons for sex work is to pay for sex reassignment surgery (SRS), as well as
hormones, facial hair removal, scalp hair growth, and voice change. SRS has ambiguous legal
status in India and is thus not performed in government or private hospitals. Plastic surgeons who
perform SRS charge heavily. Consequently, many TG go to unqualified medical practitioners or
older TG for emasculation, often resulting in urinary problems.433
The Humsafar Trust works with MSM in Mumbai and is one of India's two MSM HIV
surveillance sites. Humsafar collaborates with the departments of Microbiology and
Dermatology of LTM Medical College and General Hospital on surveillance as well as provision
of sexual health services to MSM. At the XIV International AIDS Conference in Barcelona in
July 2002, Humsafar and LTM presented cumulative data on men who had been tested for HIV
at its clinic since July 1999 (n=l,400; 1,276 men + 124 TG). Of all clients, 57.9 percent were
homosexual, 27 percent bisexual, and 15.1 percent heterosexual (terms used in VCT instrument).
Among all clients, HIV positivity was 19.65, 10.58, and 10.84 percent among homosexuals,
bisexuals, and heterosexuals, respectively. (Among TG, 41.12 percent were HIV-positive;
among the men, 13.41 percent.) Of those who tested positive for HIV, 94.57 percent were
between ages 19 and 35.434 , 435
In Barcelona, Humsafar, LTM, and UCSF presented data on the first 150 clients tested for HIV
since March 2001 (122 men + 28 TG). They found that 17 percent of men and 68 percent of TG
were HIV-positive. For both^men and TG, HIV was significantly associated with syphilis,
Among men, 17 percent tested positive for syphilis, 10 percent for hepatitis B surface antigen, 8
percent for hepatitis C, 40 percent for HSV-2, and 11 percent for chlamydia. Among men, HIV
prevalence was 48 percent in those with syphilis; 62 percent in those with hep C; and 38 percent
in those with herpes. The study also found that 22 percent of men were married, of whom 2
percent were HIV-positive. Of married men, 65 percent had children and 20 percent were living
with wives. Among men, 44 percent had visited female sex workers. HIV was associated with
(p<.05) having first sexual experience with a man (26% HIV+ vs. 8%); >10 lifetime male
P^4^0 HIV+ v 8%)’ and having receptive anal sex in the last six months (21% HIV+ v
percent for hepatitis Q 7TpetXnt1 f21 percent for hepatitis B surface antigen 22
prevalence was 88 pement mZse
440 , 441 HIVg ’
sometime^ during receptive^na'sex^fequ™™ of'TT' °f T° rep<”,ed "S'"S condoms
decreased HIV infection. EightyXo percent o'f men,
aSS°ciated with
partners would be angiy if they insisted on condom use 85
SiGZXdXzx^Vhr^
TG responded that condoms were costly difficult tofind"
percent did not feel at risk of acquiring HIV of whom 90
repOrted
their Sex
Ab°Ut half °f men and
embarrassing t0 ^y. Of men, 83
that many
Tclul™
l0W; °nereason is
TG and penetrate them anally). Most TG have little m
Wh° pay t0 bave sex with
services and so may not be aware of the riskTniolved
TuT tOhHIV/STI ^formation and
and suicidal ideation are common among TGs which ma ? n Z6 f°Und that aIcoho1 use
lead to a sense of fatalism/47 Moreover gwen^hei m^ r r
t0 USe Condoms ™
unable to negotiate condom use with theifclients 4«
10W StatUS’ TGs may be
surveyed
/'SS? O” H“"h Sys,e”s
mutual masturbation with men. OnIy 6 percent usedS/ ’“T'Sex’ and 69 P™ ■"
Wtth men due to lack of sexual opportunitymd "W have had
sex
“SM “d TG - hcctmse they do not
vm.enee-Asmdypresente^^^
wedding season), kothis in Bihar and Uttar Pradesh visit villages and towns to dance, with gang
rape and other violence (sometimes fatal) against kothis occurring.451
Sex Work
See also the Population Mobility, Gender, Violence, Knowledge, Alcohol, and Human Rights
sections.
Although sex work is legal in some states, concomitant activities including soliciting and
brothelkeeping are penalized.452
Poverty and marital abandonment are two reasons why women enter sex work.453 As discussed
above, many girls and women are also coerced into it. Sex workers also face emotional, sexual,
and physical violence, which affects their ability to protect themselves from HIV.454 Human
Rights Watch reports that Indian SWs are treated with contempt and commonly subjected to
violations of their fundamental rights by the police, both at the time of their arrest and while in
detention. HRW also documents increasing violence against outreach workers and peer educators
who work with SWs (and MSM).455
The national BSS discussed above found that 61 percent of female SWs were illiterate. The
highest proportions of illiterates were observed in Uttar Pradesh (90 percent), Bihar (84 percent),
Maharashtra (83 percent), Madhya Pradesh (81 percent), Assam (79 percent), and West Bengal ’
(7 percent). The percentage of brothel-based SWs who were illiterate was much higher (77
percent) than the percentage of illiterate non-brothel-based SWs (51 percent). Sixty-two percent
of SWs interviewed in BSS had ever been married; almost one-third of these respondents were
first married when they were under age 15. For 65 percent of ever-married respondents, age at
first marriage was between 15 and 21. Overall, 38 percent of respondents were not currently
married or living with a sexual partner; 29 percent were currently married and living with a
spouse; and 16 percent were currently married but not living with a spouse or other sexual
partner. The proportion of brothel-based SWs not currently married and not living with a sexual
partner was higher than that for non-brothel-based SWs (53 and 28 percent, respectively). Nearly
one-third of non-brothel-based SWs had additional sources of income, including petty business
(6.2 percent) or work as a maidservant (6 percent).
HIV Prevalence
Mumbai has the country's largest brothel-based sex industry, with over 15,000 sex workers.456
According to Committed Communities Development Trust, 70 percent of sex workers in
Mumbai are HIV-positive.457 The Mumbai government and the NGO Asha put this figure at 62
percent. SWs in Mumbai are controlled by madams, pimps, and moneylenders. Because of
complex power dynamics, reaching SWs with HIV prevention services is a major challenge.458
A longitudinal study in Surat found that HIV prevalence among sex workers had increased from
18.5 percent in 1992 (n=108) to 43.2 percent in 2000 (n=124). During this period, syphilis
increased from 18.5 to 29.4 percent.459
The Sonagcichi Project
In 1992, the All India Institute of Hygiene and Public Health launched a program to reduce the
transmission of HIV in Sonagachi, a red-light district in central Calcutta. The project began with
two key interventions: a health clinic and outreach by peer educators.460
Peer education initially targeted about 5,000 female sex workers. Sonagachi was divided into 25
administrative zones. A team of two peer workers (who are from the community and trained as
health educators) carried out outreach activities, including education, condom promotion, and
follow-up of STI cases. A pair of zones was supervised by another sex worker who was
designated as supervisor based on her skill and a minimum of three years' experience in the same
work. Her role was to influence the community through formation of zonal self-help groups so
that the group, as a whole, could take joint decision to ensure condom use by their clients. A
client refused by a sex worker in the same zone could not be entertained by others in that zone.
Creating peer pressure within the community aided in increasing condom use. When the project
was launched in 1992, 2.70 of sex workers reported condom use. In 1995, this figure had risen to
81.70 percent. In 1998, it was 82.72 percent, and in 2001, 86.29 percent. 461
In 1992, the year the project began, consistent condom use with clients was 1 percent. By 1998,
this figure had reached 50 percent of SWs within the project. During the same period, syphilis
prevalence among SWs covered by the project fell from 25 to 11 percent. In 1998, HIV
prevalence among SWs was 5 percent (compared to 51 percent in Mumbai).462
A key element has been the participation of SWs through the Women's Coordinating Committee
(Durbar Mahila Samanwaya/DMSC). The committee was founded in 1995 and has become a
leading advocate for the rights of SWs and for the decriminalization of prostitution. In 1997,
DMSC organized India's first national SW conference 463
CARE, the Population Council, and Johns Hopkins conducted focus group discussions and indepth interviews with SWs, peer educators, and other key stakeholders such as project staff,
brothel managers, pimps, police, and media covered by the Sonagachi Project. They found that
the following strategies were identified as increasing collective ability to negotiate safe
sex/reduce HIV risk:
1. facilitate sense of community among SWs through community meetings, fairs, and
protests
2. decrease perceived powerlessness among SWs through human capacity building seminars
3. increase access and control over material resources via microcredit and cooperative
banking
4. increase social participation through autonomous organization of SW and self-governing;
5. facilitate social acceptance of SW by involving sex industry and civil society
stakeholders464
In a related study of 512 brothel-based sex workers covered by the Sonagachi Project, CARE,
the Population Council, and Hopkins found that consistent condom use was significantly
associated with:
'
1. believing that sex work is like any other work (OR 2.06)
2. being able to take sick leave (OR 3.38)
3. feeling that violence towards SW has decreased in recent years (OR 2.01)
4. having access and control over material resources (OR 2.51)
5. being a member of a SW organization (OR 1.45)
6. having voted freely in the last election (OR 1,75)465
Other Projects
WVM TD? Kumaramangalam of Prakriti notes that in Chennai, despite high awareness of
Hiy/AIDS and substantial community mobilization, sex workers' behavior change has not been
sus ainable. She attributes this to the focus of prevention on changing high-risk behavior without
addressing underlying sociocultural issues. In interviews with sex workers, she found that despite
good knowledge of HIV/AIDS and relatively easy access to condoms, women's continued
dependence on sex work exacerbated by illiteracy, poor nutrition and hygiene, repeated
nth^TT
S0?'al
CUltUral bi3S ~ contributed t0 their continued vulnerability to HIV and
r STIs. Regular condom usage was only 32 percent, likely the result of their inability to
Z CtOnd°7
W,th ™ale Partners- Almost three-quarters of clients who refuse condoms
are also intoxicated. Some clients refuse to use condoms citing lack of sexual pleasure
premature ejaculation, or fear of rashes or skin problems.466
To assess its interventions, SOS Foundation in Nasik, Maharashtra, interviewed female sex
workers clients. Among clients, 56 percent were ages 25-35 and 66 percent were married Fiftythree earned Rs. 3000 to 5000 each month and spent about 5 to 6 percent of their monthly
income on buying sex. Almost all clients (96 percent) visited SWs while under the influence of
alcohol. Given their fears of contracting HIV, clients had increased their condom use. However
77 percent of them reported that they did not use condoms with their other sex partners.467
Samabhavana, which works with MSM and TG in Mumbai, has interviewed male sex workers
including mahshwalas (masseurs), bazaar boys, beauty parlor boys, sex networks controlled by
pimps, educated young men from the modeling industry, and casual male sex workers. In a study
of 120 male sex workers, Samabhavana found that their median age was 21, with 43 percent
mamed. Fifty-six percent also have sex with women. Although 83.9 percent identified HIV as a
kdler disease, 383 percent identified it as a "foreign" disease. Of participants, 53 percent
ported drug use. Regarding condoms, 60.8 percent reported that they were "not available "
renortede PerCHnt reported
ClientS 46d nOt have condoms during sex- Eighty-seven percent
reported coerced sex with another man. 468
F
Alcohol and Drug Use
Alcohol
The BSS discussed above, found that 67 percent of MSM respondents reported ever having
consumed a cohol. Nearly 16 percent consumed alcohol everyday, followed by 35 percent who
consumed alcohol at least once a week, and 28 percent who consumed once a fortnight. Fifteen
percent of respondents regularly drank alcohol prior to sex. Intoxicating drug use was reported
y nearly 13 percent of respondents. Of them, 76 percent reported trying ganja (marijuana), 42
percent bhang (hemp), 24 percent charas (hashish), 8 percent afim (opium), and 4 percent a
mixture of brown sugar and heroin. Twelve percent also reported injecting addictive drugs
without a medical prescription within the last 12 months.469
Overall, 44 percent of SWs had ever consumed alcohol. Of them, 22 percent reported that they
consumed alcohol every day in the last four weeks; 38 percent reported drinking at least once a
week. Overall, around 15 percent of SWs reported that they drink regularly before sex Six
percent of SWs reported ever trying any addictive drugs. Among them, almost one-third had
injected drugs in the past 12 months.470
Among IDU respondents, three-fourths reported alcohol consumption. The proportion of
respondents reporting having ever consumed alcohol was significantly lower in Manipur (20
percent) compared to the other four locations (Mumbai, Calcutta, Chennai, and Delhi). However
62 percent of IDUs who had ever consumed alcohol in Manipur reported drinking alcohol every ’
day during the last four weeks prior the survey; the proportion of respondents reporting alcohol
consumption on a daily basis m the last month was significantly lower in Delhi (5 percent)
Calcutta (7 percent), Mumbai (9 percent), and Chennai (12 percent).471
Illicit Drug Use
The major drugs being abused in India are opium, heroin, morphine, buprenorphine, diazepam
cannabis, phemramine, promethazine, nitrazepam, spasmorproxyvon, codeine phosphate
cocaine ecstasy, amphetamine type stimulants (ATS), antihistamines, and codeine-based cough
syrup. (Common drugs used by street children include cannabis; crude alcohol; and the sniffing
of gasoline glue pamt thinner, kerosene, and copier and paper correction solutions.) Drugs
injected include heroin and buprenorphine (often used as an alternative among heroin users)- and
cocktails combining buprenorphine with diazepam, avil, and phemergen.472 , 473 Epidemiological
surveys and rapid assessment studies show that polydrug abuse is growing.474
Opium and cannabis have traditionally been used in India.475 India is one of the world’s top
producers of licit opium (monitored by the Indian Central Bureau of Narcotics). Opium poppy is
legally cultivated in Madhya Pradesh, Rajasthan, and Uttar Pradesh. Illegal growing of opium
poppy occurs in Manipur, Mizora, Nagaland, Arunachal Pradesh, Kashmir, and Uttar Pradesh
and n’o,phi"e from
pat,san'and
In the early 1970s, heroin appeared on the market in northemeastem states such as Manipur It '
spread to other parts of the country in the early 1980s gnd has displaced opium and cannabis as
rug of choice. The introduction of the Narcotics and Psychotropic Substances Act of 1985
which criminalized o^ium use, may have led to drug users’ shifting from cannabis and opium to
inhalation of heroin. Some of the heroin available in India is trafficked from the Golden
Triangle, in particular from Myanmar. In Manipur, Nagaland, and Mizoram, closest to the source
of heroin, a purer variety of the drug is found.478
'
injecting) in Mizoram. Injecting drug use is widespread within these states.480
’
’
HIV infections among IDUs first appeared in Manipur. A study conducted among IDUs in
Churachandpur m Manipur in 1996, for example, found that high prevalence of HIV (78 64) ■
hepainis B (43 83 percent) and hepatitis C (98 percent).481 According to an October 2001 sftidy
in HZ?3 ’ 62'1
0f!DUs were HIV-POSitive. Injecting drug use is also a major problem ’
in urban areas such as Mumbai, Calcutta, New Delhi, and Chennai.482
J P
According to the Center for Harm Reduction at the Burnet Institute in Australia, the figures of 1
to 5 million opium users and 1 million heroin addicts from the late 1980s and early 1990s are
NCn'ZZ g0Y™ent officials- The center notes, however, that among unofficial sources from
NGOs, the level of heroin use is considered much higher.483
Generally, syringes and needles are purchased from pharmacies without any need for
prescriptions . Although India does not appear to have a widespread culture of professional
injectors, or street doctors," as in some other Asian countries, there do appear to be shooting
gallenes where IDUs come to inject.
Generally, injecting equipment is discarded
inappropriately.
The sharing of injecting equipment among India’s IDU community is widespread. Recent data
indicate that most IDUs had at some stage (often within the past six months) shared their needle
and syringe. The rates of ever sharing are Chennai (76 percent), Delhi (50 percent) Imphal (86
Clta 78 PerCent) and Mumbai <61 Percent )• Analysis of the Delhi participants
showed that m the past six months, 17 percent of IDUs shared their injecting equipment almost'
always and in Calcutta 52 percent of IDUs shared during their last injecting act Afthough many
hl
Clean heir mJecting equipment, the majority did so inappropriately for protection against
bloodborne viruses such as HIV and hepatitis C. Many IDUs cleaned their equipment with any
avmhble w^er and only a small number used boiling water, and fewer used household bleach
Indirect sharing is also common among IDUs with the use of common spoons, solutions cotton
swabs and the dipping of a needle into an ampoule of a pharmaceutical drug.486
The health of many drug users is often poor. Many IDUs do not inject properly and as a result
experience ulcers, abscesses, cellulitis, and throbophlebitis. Many are undernourished and a
substantial number have experienced a drug overdose.487 The national BSS discussed above
found that among IDUs, the median age of first use of addictive drugs was 20 years This figure
was lowest in Delhi (19 years) and highest in Chennai (21 years). Overall, the mean duration of
injecting drugs at the time of the BSS was 55.6 months, varying from 92.6 months in Calcutta to
around 35 months m Mumbai. Nearly one-third of respondents reported that they started
injecting drugs over five years ago; about 27 percent started injecting within the last 12-24
months. The proportion of respondents reporting injection of drugs during the last year was
about 8 percent. About one-quarter of all IDUs interviewed reported that they started injecting
drugs before age 21, whereas 20 percent began after age 30. The overall median age of starting
injection (of drugs) was 25 years. Nearly half of respondents (45.2 percent) injected two to three
imes a day, whereas 16.1 percent injected more frequently. Fifty-three percent of respondents
reported injecting buprenorphine, followed by heroin (34 percent), crack (22 percent)
dextroproxyphene (6 percent), tranquilizers (3 percent), and cocktail of heroin and cocaine (1
percent). There were wide variations in types of drugs injected across the five locations. In
Manipur, 97 percent of respondents reported injecting heroin. All respondents in Mumbai
injected crack, whereas high proportions in Calcutta (97 percent), Delhi (95 percent) and
Chennai (77 percent) injected buprenorphine.488
The Bss found that 41 percent of IDU respondents reported sharing (i.e., using) previously used
needles/syrmges. This proportion was highest in Chennai (62 percent), followed by Manipur (55
percent), Mumbai (30 percent), Delhi (31 percent), and Calcutta (23 percent). Overall, 4 percent
or respondents reported sharing needles/syringes every time they injected in the past month; 14
percent shared most times, 8 percent shared almost half the time, 29 percent shared occasionally
and 44 percent never shared needles/syringes while injecting in the past month. Across locations,
Chennai had the highest proportion of respondents who shared every time they injected Overall ’
43 percent of respondents reported cleaning needles/syringes eveiy time they injected in the past
one month, 22 percent cleaned most times, and 3 percent never cleaned. About 83 percent of
respondents who cleaned needles/syringes in the past month reported using cold water for
cleaning, 9 percent used hot water, 2 percent used bleach or alcohol, and 1 percent boiled
needles/syringes.
On being asked whether they could obtain new/unused needles/syringes when
needed, 97 percent of IDU respondents answered in the affirmative. On being asked if they knew
a person/place from which they could obtain new/unused needles/syringes when needed, 99
percent of responded positively. Spontaneous responses on place/person from which to obtain
new/unused needles/syringes found that that most respondents reported pharmacist/chemist (94
percent) as a source. Forty percent reported NGO workers, 10 percent reported friends 7 percent
reported drug dealers, and 4 cited other drug users. 490
Overall, 45 percent of IDU had ever received treatment for dmg use; 37 percent had undergone
treatment in the past, and 8 percent were currently receiving treatment. Across sites, the
proportion of respondents who had never received any treatment for drug use was the highest in
Mumbai (70 percent), followed by Delhi (55 percent). The highest proportion of respondents '
who were currently under treatment were in Calcutta (14 percent) and Manipur (13 percent).
Among all respondents who had ever received treatment, most reported either counseling 641
percent) or detoxification (39 percent).491
Women and Drug Abuse
The majority of drug users in India are male. However, use of drug treatment data may
underestimate the number of female drug users, with women addicts a hidden population. There
is great stigma attached to women seeking assistance for drug use, and women's ability to access
treatment is hindered by their myriad responsibilities and workloads (e.g., child care) 492 Drug
abuse by women in the northeast is believed to be growing.493
The social consequences of drug abuse particularly affect women, who face the double burden of
caring for the addict (who may be abusive) and providing for the family. In the northeast, there
are increasing numbers of young widows of addicts, many of whom are HIV-positive as a result
of having been infected by their husbands.494 The Social Awareness Service Organization which
works m Imphal, Manipur, reports that there is a rise in HIV infections among wives and
children of IDUs, highlighting the crucial need to reach the sex partners of ID Us with VCT
con oms, STI treatment, PMTCT, care and support services, drugs to treat OIs, and HARRT.?
A 2002 study by the United Nations Office on Drugs and Crime and India's Ministry of Social
Welfare and Empowerment found that drug abuse has a serious yet inadequately addressed
impact on women not captured in official statistics. The study, conducted in eight sites across
ndia, involved 179 women ages 18-60 with a male relative who abused drugs. Major issues
identified were domestic violence, infection with HIV, and financial burdens. Most of the
omestic violence is directed against women and occurs in the context of demands for money to
buy drugs. Participants reported that they often felt guilt, shame, embarrassment, depression
anxiety, and isolation; over one-third (35 percent) had frequent thoughts of suicide. 496
Another UNDCP-Ministry of Social Welfare and Empowerment study involved 75 female drug
addicts, some of whom were sex workers. Most women (91 percent) were using heroin or
rown sugar," an impure form of heroin. Other common misused substances were
propoxyphene (35 percent), alcohol (33 percent), minor tranquillizers (23 percent), cough syrup
(15 percent), and cannabis (11 percent). Intravenous drug use was reported by 41 percent of
respondents. At least four women reported being HIV-positive. Among all women, nearly 10
percent had attempted suicide at least once. Among married women from Delhi, marital conflict
and misuse of prescription drugs were common starting points for illicit drug use Respiratory
gastrointestinal, genitourinary, liver problems, and STIs were reported by the participants.497 ’
A study of female sex workers found the HIV prevalence among IDU SWs was nine
times higher than among non-IDU SWs.498
There is no government policy on harm reduction, leading to lack of coordination in designing
and implementing interventions. (Some states, such as Manipur, have adopted their own harm
re uc ion policies.) The Ministry of Social Justice and Empowerment provides US$500 000
annually to about 400 NGOs to manage drug counseling, treatment, and rehabilitation centers
lhe Ministry of Health manages about 100 rehab centers attached to hospitals in the country.500
Impact
At a Glance: Summary Bullets
Demographic
no^percelTby 2050
Pr°jeCted t0 increase’ however, AIDS will reduce life expectancy by
' havZ'ntZt AIDS"5 ‘b’' ““ P0P"“°n
■
5 P™ S1”all'r
There were 2.8 million AIDS deaths in India between 1980 and 2000. During 2000-15, the
U.N. projects that there will be 12.3 million AIDS deaths.
Macroeconomic
During the late 1990s, researchers estimated that the total annual cost of HIV/AIDS in India
was roughly equal to 1 percent of GDP. However, this figure did not include numerous
workersSUCH
°f ART’ strenSthcning of the healthcare system, and the retraining of
Household
*
Many households affected by HIV/AIDS fa.ce extreme economic and psychosocial
difficulties in responding to the epidemic.
AIDS treatment imposes a heavy financial burden on Indian families, leading to depletion of
savings and increasing indebtedness of households.
■
In India, AIDS care is being provided by elderly family members, women, and children.
Orphans and OVC
Obtaining data on the number of Indian children orphaned by AIDS is difficult. The
magnitude of AIDS orphanhood has not been adequately acknowledged either in India or in
the international community.
Chi ld vulnerability is already high in India, with large numbers of orphaned and displaced
children, a growing number of street children, poor quality and overburdened child welfare
institutions, and wide-scale abuse and exploitation of children.
■
Although children are not yet being orphaned by HIV/AIDS on a large scale in most cities,
studies in Mizoram and Calcutta demonstrate that the problem of orphans in some areas of
India is already severe.
■
The extended family is the traditional social security system for orphans in India. However,
its ability—as well as that of the larger community—to assume care for orphans may be
imperiled as HIV/AIDS spreads, household breadwinners die, and household resources
become strained.
The U.S. National Intelligence Council report previously mentioned outlines the challenges
HIV/AIDS will pose for India, particularly those regarding treatment and health sector
expenditures. However, even with its projection of up to 25 million Indians infected with HIV by
2010, NIC believes that HIV/AIDS will be "a big problem but probably not devastating...[as,
among other reasons, infected] individuals will remain diffused among very large
populations."501 However, much depends on how the country responds to the epidemic, which
itself is intertwined with national, subregional, and global political and socioeconomic factors.
Whether HIV/AIDS will become a structural part of poverty and socioeconomic development in
India, as it has in southern Africa, remains to be seen. Regardless, there will be an enormous
number of Indians with and affected by HIV/AIDS in the coming years.
Demographic
The U.N. Population Division projects that India’s adult HIV prevalence will peak at 1.9 percent
in 2019. By 2050, the U.N. estimates that prevalence will have fallen to 0.6 percent.502
Life Expectancy
India's life expectancy is projected to increase, to 66.3 during 2010-15, to 67.8 (2020-25) and to
73.8 (2045-50). However, AIDS will reduce life expectancy by 2 to 4 percent by 2050. The U.N.
projects that during 2000-05, life expectancy would have been 65.0 without AIDS (versus 63.9
with AIDS). By 2045-50, life expectancy will be 73.8, whereas it would have been 76.0 in a no
AIDS scenario.503
Population
The U.N. also examined population under a "no-AIDS" scenario (tables 8 and 9). By 2050, the
U.N. projects that India's population will be 5 percent smaller than it would have been without
AIDS.504
Table 8. India: Projected Population with and without AIDS, 2000, 2015 AND 2050
Period
2000
I
2015
2050
With AIDS
Without AIDS
With AIDS
Without AIDS
With AIDS
Without AIDS
1,016,938,000
1,020,302,000
1,246,351,000
1,264,268,000
1,531,438,000
1,612,593,000
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
<http://www.'■un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>
Table 9. India: Projected Population Reductions, 2000, 2015 AND 2050
Period
________________
2000
Population
Reduction
3,364,000
Percentage
Reduction
0
Population
Reduction
17,917,000
2015__________
Percentage
Reduction
1
2050
Population
Reduction
81,154,000
Percentage
Reduction
~
5
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
<http.7/www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>
Mortality
The U.N. estimates that there were 2.8 million AIDS deaths in India between 1980 and 2000,
accounting for a 2 percent increase in mortality. During 2000-15, the U.N. projects 12.3 million
AIDS deaths (representing a 10 percent increase in mortality) and 49.5 million AIDS deaths
during 2015-50 (12 percent increase in mortality) (see.tables 10 and 11).505
Table 10. India: Projected Number of Deaths with and without AIDS, 1980-2000, 2000____________ ________________ 2015, and 2015-2050_______________
_______________________ ___________ Period
1980-2000
_________ 2000-2015
________ 2015-2050
With AIDS
Without
With AIDS
Without
AIDS
AIDS
182,307,000__________________ _ _ _______________
179,533,000
140,546,000
128,295,000
452,901,000
403,398,000
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
<http://www.un.org/esa/population/publicatioris/wpp2002/wpp2002annextables.PDF>
With AIDS
Without AIDS
Table 11. India: Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050
_________________________
Period
1980-2000
Excess
Deaths
2,774,000
Percentage
Increase
2
2000-2015
Excess
Percentage
Deaths
______ Increase
12,251,000
10
2015-2050
Excess
Percentage
Deaths
Increase
49,503,000
12
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat World
Population Prospects: The 2002 Revision. Highlights. New York: February 2003
<http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>
Macroeconomic
hill ^^n19903’ eStlmates of the total annual cost of HIV/AIDS in India ranged from 7
i lion to 60 billion rupees (US$142 million to US$1.2 billion). These figures were obtained bv
a culating the average cost per AIDS case (cost of 01 treatment and lost productivity) and Y
tTe h Phyim5thlS eSt'mate by the nUmber °f CaSeS' The wide range in the estimate resulted from
ighly divergent estimates of the total cumulative number of HIV-infected persons The
nrod^f ers coniiluded that AIDS cost India roughly 1 percent of GDP per year because rflost
Ste cos of ART strXT
nOt include nurnerous factors such a*
of ART, strengthening of the healthcare system, and the retraining of workers.506
HTV/ATn7UdleS °ften USe Prevalence and economic structures to assess the impact of
IV/AIDS on economic growth, this approach does not always yield precise estimates
Household
Many households affected by HIV/AIDS face extreme economic and psychosocial difficulties in
m
communis 7am 1
COntlnue ,worklng due to social discrimination and fear in the wider
a,ly-The p”res'
MDsVam is78
^i^051 Pe°Ple’ eSPecially during sick“ess and death.510 In India
AIDS care is being provided by elderly family members, women, and children.511
resulhin »di5!01"
di!i’ h0USeh°!ds often feel the effect of a loss of adult farm labor. This
suits in a decline in productivity, loss of assets and income, an increase in household
den^d’T8 7
t0 meet mediCal billS and funeral exPenses, and a rise in the number of
dependents relying on a smaller number of productive family members.512
17
iS alS° Hkely t0 inCrease household spending on health A World Bank
SJal hon 7 7 J.11?'3111?0USeh01ds currendy spend 5 to 7 percent of their income on health and
mral households below the poverty line spend even more of their income on health (12 to 19
fn Th ’
!nCTreaSe ln HIV Prevalenee is likely to lead to an increase in these expenditures
households. It is sensible to believe that this added spending will displace consumption of
other necessities such as food and housing. This effect will be most pronounced among the very
Only 10 percent of Indians have some form of insurance, most of which are inadequate.
Hospitalized Indians spend 58 percent of their total annual expenditures on health care. Over 40
percent of those hospitalized borrow money or sell assets to cover expenses. The World Bank
conservatively estimates that one-fourth of hospitalized Indians were not poor when they entered
e hospital but became so because of hospital expenses (the existence and scale of this
phenomenon vary greatly by state).514
A study by YRG Care found that AIDS treatment imposes a heavy financial burden on families
utw1/etlOn °f savm8s and increasing indebtedness of households. Using data from 356
HIV/AIDS clients, YRG CARE found that average monthly expenditure per HIV-infected
person was Rs 1,872 (US$39), or about 80 percent of household income. Treatment costs
increased with the progression of illness. The average loss of income because of illness was
estimated at Rs 377 rupees (about US$8) per month, or 16 percent of a patient's monthly wage
earnings The burden of treatment (measured as the ratio of treatment costs to household income)
was much higher for low-income families than for high-income families. Patients paid for
treatment costs through borrowing (41 percent), sale of assets (24 percent), past savings (24
percent), and mortgage of assets (9 percent).515
^ Western Rajasthan, the FXB Treatment & Care Center in Jodhpur found that the majority of
IV-mfected patients are migrant workers with few means of sustenance. After infection with
V, patients lose their employment due to reduced ability to work and return home for care (as
they are not covered by any social security schemes). The total direct cost of treatment, care and
support per patient each year is US$683, far beyond the reach of patients, whose annual
linC°me 1S beI°W US$300' (C°StS are broken down as followsl treatment for OIs:
US$150, diagnostics: US$135; ART: US$360; and nutritional support: US$38; indirect costs of
t
salanes’ and administration/overhead are not factored into the figure of
USj>6o3.)
India's Tuberculosis Research Centre in Chennai has found that an AIDS death entails numerous
financial, occupational, and interpersonal problems. These include ostracism, family or
community refusal to conduct funeral rites, and adverse impact on surviving family members
especially widows. Widows of men who had died because of AIDS reported being evicted from
heir homes, ostracised by their families and community, and denied medical care.517 In Mumbai
the International Institute for Population Sciences found that discrimination against those
in ected with HIV/AIDS, as well as their family members, is widespread. Most PWHA fear
a±“ bI-fTilJy if they reVeal th6ir HIV StatUS' As daily subsistence is a challenge
for PWHA, finding the funds for long-term treatment is beyond their ability.518
There are myriad psychosocial effects of HIV/AIDS, which are often experienced differently by
ousehold members. Studies of the quality and consistency of home-based AIDS care have
found that some caregivers experience despair, helplessness, frustration, and isolation; however
these psychosocial effects are usually not addressed.519 (See also the Stigma and Gender sections
aDovej
Orphans and Other Vulnerable Children
-
Obtaining data on the number of Indian children orphaned by AIDS is difficult. Two major
publications with country-level on AIDS orphans (Children on the Brink 2002, authored by
USAID, UNICEF, and UNAIDS; as well as UNAIDS' epidemiological updates) do not include
any data on AIDS orphans in India. The proportion of children in India orphaned by AIDS is far
lower than in sub-Saharan Africa. However, the magnitude of AIDS orphanhood has not been
adequately acknowledged either in India or in the international community.520 The FXB
Foundation, which works with orphans and OVC in India, notes that child vulnerability is
already high in India, with large numbers of orphaned and displaced children, a growing number
of street children, poor quality and overburdened child welfare institutions, and wide-scale abuse
and exploitation of children.521 Dr. Bitra George of the Salaam Baalak Trust in New Delhi,
which works with street children at the railway station, finds that the "needs of street children are
varied but the response from organizations—government and NGO—has been patchy and
isolated."522
Against this backdrop of coping mechanisms inadequate to address the current situation, a study
of children in ten cities in India demonstrated that the number of children on the streets will rise
more rapidly in the years ahead, as HIV/AIDS takes the lives of many thousands of parents.
These children are themselves highly vulnerable to acquiring HIV while remaining marginalized
from health care information and services. The Calcutta Samaritans estimate that the over
100,000 children on the city's streets have almost no education and few life or vocational skills.
They are particularly vulnerable to exploitation and abuse by employers, other adults, and other
street children.523 FXB-India also stresses that street children and youth are particularly
vulnerable to HIV infection, given their lack of information and education regarding STIs/HIV
as well as lack of access to formal health care.524 TORCH, a Delhi-based NGO that works with
street and slum children, has found that early onset of sexual activity among street children is
widespread, with many children reporting using sex as a source of affection or in exchange for
protection.525
Although children are not yet being orphaned by HIV/AIDS on a large scale in most cities,
studies in Mizoram and Calcutta demonstrate that the problem of orphans in some areas of India
is already severe.526 The extended family is the traditional social security system for orphans in
India. However, its ability—as well as that of the larger community—to assume care for
orphans may be imperiled as HIV/AIDS spreads, household breadwinners die, and household
resources become strained.528 , 529
Already, groups that work with AIDS orphans are observing the following:
■
■
"
AIDS orphans and other vulnerable children experience social stigma, discrimination,
isolation, shortage of basic needs such as food and clothing, vulnerability, depression, fear,
lack of access to education and health care, malnutrition, and homelessness.1
Many HIV-positive widows lack the physical strength, as well family and financial support,
to care for their children.
Parental death is traumatic, but when a parent dies because of AIDS, the child's trauma is
compounded by HIV/AIDS-related stigma and social exclusion.
■
■
■
There are cases of AIDS orphans' being denied access to schooling, health care, and their
inheritance rights, with particular impact on girls.
AIDS orphans and OVC have been subject to discrimination by child service providers (both
government and NGO).
There are few counselors trained to deal with issues of children affected by HIV/AIDS. For
example, most child service providers do not perceive psychosocial support as an important
need.531 , 532 , 533 534
Agriculture
Relatively few data have been published on the effect of HIV/AIDS on agriculture in South Asia.
However, the FAO has published reports on agriculture and HIV/AIDS in sub-Saharan Africa,
and India may begin to see some of the same impacts. HIV/AIDS negatively affects agricultural
production by reducing the labor force. It reduces investments in irrigation, soil enhancement,
and other capital improvements, thereby inhibiting agricultural production. Affected households
begin to focus on crops that are less labor-intensive but also less nourishing.535, 536
At the household level, both the quality and quantity of labor are reduced. Initially, productivity
falls when the HIV-infected person becomes ill, and later the supply of household labor falls
with the death of that person. Furthermore, there is a high probability that more than one adult in
a household is infected. As other household members devote productive time to caring for the
sick persons, the labor effective labor supply declines. HIV/AIDS also affects the availability of
disposable cash income. During episodes of illness, household financial resources may be used
to pay for medical treatment and eventually to meet funeral costs. Family assets such as livestock
may be sold off to finance these expenditures. These resources may have otherwise been used to
purchase agricultural inputs, such as extra seasonal labor, new seeds or plants, fertilizer,
pesticides, etc.537
Industry
HIV/AIDS may have a profound effect on the private sector in all countries affected by the
epidemic, including India. Firms may face higher costs in training, insurance, benefits,
absenteeism and illness. AIDS is reducing the ratio of healthy workers to dependants. The World
Bank estimates that this may reduce productivity growth by up to 50 percent in the most affected
countries. Combined with the erosion of human capital and loss of skilled workers, this will
result in a mismatch between labor requirements in the private sector and labor availability.538 In
a disconcerting finding of a study by UNAIDS that interviewed private sector business leaders
and managers in India, most displayed denial about HIV/AIDS. The majority refused to
acknowledge either that HIV infection was a problem or that it might be so in the future.539
(Several companies have responded with HIV/AIDS policies and programs [see Response
section].)
Prisons
so* La
y
U8386
GO'S
'
See also the Govemance/Judiciary and Population Mobility sections above.
According to the International Center for Prison Studies at King’s College of the University of
London, India had 281,320 prisoners (72.7 percent of whom were pretrial detainees and those on
remand) in 1999 (data provided by India's National Crime Records Bureau). The official capacity
of India's prison system in 1998 was 193,4OO.540
National and state-level data on HIV prevalence among those incarcerated are not available.
Researchers have consistently found that HIV prevalence is higher among prisoners than among
the general public. This may be due to a variety of factors, such as composition of the prison
population (e.g., preponderance of those from more marginalized/vulnerable communities), low
awareness of HIV/STIs, lack of access to preventive practices, overcrowding, injecting drug use,
mobility (releases, admissions and transfers), and sex (including rape).541
Response
At a Glance: Summary Bullets
Government
■
In many ways, the government’s response to the epidemic has been appropriate. In other
respects, substantial material and political commitments have been too little and too late.
Successes
■
After the first AIDS cases were identified in the U.S., the Indian Council of Medical
esearch established an AIDS task force. By 1986, surveillance centers designed to detect
HIV were established at several medical colleges throughout metropolitan India.
Following identification of HIV in India ini 986, the government took steps to target
screening and prevention efforts to populations at high risk of infection. A high-profile
National AIDS Committee was launched, and in 1987 the National AIDS Control Program
was established, focusing on increasing awareness of HIV/AIDS, screening blood for HIV
and testing of individuals with high-risk behaviors.
*
By 1991, the government perceived a need to establish a multisectoral program for
prevention and control of HIV/AIDS. There was also a need for an agency to help establish a
s^a e-level response to HIV/AIDS. To fulfill these objectives, the government established the
National AIDS Control Organization in 1992.
■
In 2001, the government adopted the National AIDS Prevention and Control Policy.
Important among the government's interventions are programs of condom promotion
e avioral changes, community information and education, targeting and involvement of
vulnerable groups at risk, blood safety, and STI treatment.
Challenges
In July 2003, Dr. Meenakshi Datta Ghosh, project director of NACO, stated that HIV/AIDS
is no longer affecting only high-risk groups or urban populations, but "is gradually spreading
into rural areas and the general population."
°
•
In the eyes of many critics, the allocation of only $38.8 million of the government’s own
n s (excluding funds from the World Bank and other donors) over the period 1999-2004 is
a major indication of insufficient governmental commitment.
■
Critics also argue that there is inadequate governmental response in the area of IDU and
MSM interventions.
■
Although the national policy on HIV/AIDS addresses discrimination, there is no national
legislation on HIV/AIDS-related discrimination to serve as an implementing instrument.
■
Additional criticisms include the perception that although there has been much commitment
to addressing HIV/AIDS at the national level, this commitment is not matched at the state
level. Currently, approximately one-third of India’s 35 states and UTs have what the World
Bank deems "good" HIV-control programs, one-third are "making some effort," and one
third “are not on board, but are in denial.”
■
Another frequent criticism of the government’s efforts is that during the initial response
phase, NACO was focused on centralized, top-down planning and implementation. This led
to insufficient “buy-in” at the state level and to uneven implementation of projects in the
different states.
Blood Safety
■
The country has 1,500 blood banks spread across large hospitals and small clinics, with
quality varying among them.
■
In June 2001, the government passed a law making it mandatory to test all donated blood for
HIV, hepatitis C, hepatitis B, syphilis, and malaria.
■
In December 2002, India’s MOH announced that blood donors who tested positive for HIV
would be told of their infection and asked to seek confirmatory tests and counseling.
However, doctors working in blood transfusion services caution that the new policy will be
difficult to implement given the current decentralized, fragmented state of blood banking
services in India.
Budget Allocations
■
NACO's budget for 1992 through 1998 was US$100 million, funded by government and
external donors. For 1999-2004, NACO’s budget is US$300 million. Of this amount, the
government allocation is US$38.8 million; US$191 million is financed through a World
Bank loan, and the remainder from other donor.
■
India's federal budget caps the amount that foreign donors can contribute to HIV/AIDS.
Thus, some Indian states have the capacity to absorb more resources but are denied them.
The government argues that its control of resources ensures that no one disease receives
favor over any other.
Nonhealth Ministries
■
Although the central government exerts considerable influence through the National Council
of Education Research and Training, it has thus far not elaborated a concrete policy on an
HIV curriculum. Persistent ambivalence about sex education has also impeded the full
implementation of a population and family life education program begun in the early 1980s.
■
Some state and municipal governments are implementing school-based-prevention programs,
often in partnership with NGOs or multilateral donors such as UNICEF.
■
India's National Cadet Corps has implemented an HIV/AIDS awareness program. The
program, implemented at the National Integration Camp in Delhi, has trained 600 cadets
from all over the country in basic HIV prevention. These cadets will be further trained as
resource persons, and will be responsible for training other cadets upon returning to their
states.
■
Collaborations with the transport sector on HIV/AIDS prevention activities have been
popular. However, the fragmented structure of the transport industry is a major constraint to
identifying replicable approaches.
Human Rights
*
In India, there is widespread discrimination against people infected with HIV. Indian PWHA
have great difficulty accessing support and are usually unable to discuss their HIV status for
fear of repercussions.
■
There is no national legislation to protect the rights of Indians with HIV/AIDS.
■
The number of HIV/AIDS-related court cases has been rising rapidly. In the absence of
HIV/AIDS-related legislation, the role of the judiciary in the evolution of legal principles
regarding the epidemic has become crucial.
HIV Testing
■
NACO has developed a VCT policy that states that "No individual should be made to
undergo mandatory testing for HIV" and that "No mandatory HIV testing should be imposed
as a precondition for employment or for provision of health care facilities during
employment" (India's Armed Forces are exempt from this condition).
*
NACO has also developed guidelines for VCT centers, which address consent and
confidentiality issues.
■
However, many Indians are tested for HIV without their knowledge or consent.
■
Some government officials (including legislators in Goa and Andhra Pradesh) have voiced
their support of mandatory premarital testing for HIV and are proposing related legislation.
Right ofPWHA to Marry
■
In 1998, India's Supreme Court delivered a judgment that suspended the right of PWHA to
marry, despite that the issue of PWHA's marrying had never come before the Court.
■
The Lawyers Collective HIV/AIDS Unit contested the constitutionality of the 1998 ruling
regarding marriage. In early 2003, the Supreme Court passed an order that all observations
relating to marriage in the 1998 case were not warranted as they were not issues before the
Court.
■
However, the case highlights the massive stigma and discrimination faced by PWHA in India
and their vulnerability—particularly given the lack of legal instruments—to human rights
abuses, including those perpetuated by governmental institutions.
Violence Directed at MSM, SWs, and HIV/AIDS Outreach Workers
■
A July 2002 report from Human Rights Watch documented how HIV/AIDS projects,
particularly those that provide essential information and services to SWs and MSM, are
undermined by frequent and widespread police harassment and abuse of outreach workers.
Donors
■
Major HIV/AIDS donors include the World Bank, Bill & Melinda Gates Foundation, Global
Fund to Fight AIDS, Tuberculosis & Malaria, DFID, USAID, CDC, NIH, UNDP, JICA,
AusAID, Sida, GTZ, and the EU.
Civil Society
■
Numerous NGOs and CBOs, including associations of PHWA, are providing critical
HIV/AIDS prevention, care, and support information and services. Many are playing
leadership roles in their state and districts, particularly with regard to reaching marginalized
populations.
■
Although about 600 NGOs receive financial and technical support from the government,
academic institutions, and external donors, many more work without any such assistance.
Much of the work of NGOs and CBOs has not been evaluated, an impediment to scaling up.
■
Major international NGOs working on HIV/AIDS in India include the International
HIV/AIDS Alliance, Family Health International, Population Council, Marie Stopes
International, CEDPA, Medecins sans Frontieres, and CARE.
■
Numerous Indian and international academic and research institutes are undertaking crucial
HIV/AIDS research, as well as providing HIV/AIDS prevention, care, and support
information and services.
VCT
India has over 265 public VCT centers at state and local level (primarily in high-prevalence
oLdLUS ).
■
Although the number of private laboratories (which utilize rapid tests) is increasing, these
labs generally do not offer client counseling.
In its GF ATM proposal, the government states that it aims to establish a VCT center in each
of the country's approximately 600 district hospitals. VCT is also incorporated into the
proposal s plans for scaling up PMTCT and expanding access to ART.
PMTCT
'
InMr AC^000’ AZT was introduced in a PMTCT feasibility study supported by UNICEF
and NACO in 11 medical colleges of the five most affected states.
With GFATM funding, the government plans to scale up prevention and care interventions
among women of child-bearing age and their families in partnership with the private sector
by providing a package of primary prevention, family planning, VCT, NVP, and counseling
on infant feeding. Specifically, the GFATM proposal sets out that:
-> PMTCT interventions will be scaled up from 81 public sector hospitals to 444 public and
private, tertiary and secondary health institutions (primarily in the six high-prevalence
states).
Maternal and child health personnel (2,200 workers) will be trained in PMTCT to
integrate activities into reproductive and child care programs.
-> Linkages between PMTCT programs, PWHA, NGOs, and CBOs will be established
> Capacity to provide treatment, including ART to HIV-positive mothers, their children
and partners (10,000 individuals), will be built.
Care and Support
Since the launch of the second phase of the National AIDS Control Program in 1999 the
established 25 community HIV/AIDS care centers across the’country.
With GF ATM funding, it plans to create drop-in centers for PWHA in high-prevalence
states.
‘
many countries, an enormous amount of HIV/AIDS care and support is provided by
MCrOs and CBOs, including associations of PWHA.
Treatment of Opportunistic Infections (OIs)
■
Twelve percent of NACO’s budget is allocated to care and support, including treatment of
OIs.
Antiretroviral Therapy (ART)
Availability
■
India's 2002 proposal to the GFATM states that only 1,500 PWHA are receiving (and
adhering to) ART, and that another 8,000 to 10,000 are intermittent users or poorly adherent.
■
ART has generally remained unaffordable for most Indians and has been prescribed primarily
to those who can pay out of pocket or who are enrolled in research studies.
■
To reduce prices, the government is making efforts to exempt customs and excise duty on all
antiretroviral drugs available in India.
■
Indian pharmaceutical firms are currently manufacturing generic versions of ART and selling
them at less than US$1 a day. The manufacture of generic ART drugs has been an essential
element in the dramatic reduction of drug prices.
■
However, India is a member of the WTO, and its patent law will change on January 1, 2005.
The effect will be to decrease the likelihood that Indian firms will be able to manufacture
generic versions of additional ART drugs.
■
This scenario will affect not only the cost of ART programs in India, but in countries to
which Indian firms currently sell relatively inexpensive ART drugs.
■
India's GFATM proposal delineates the government's plans for increasing access to ART.
The emphasis is on PMTCT (including ART for HIV-positive mothers and their families).
The proposal appears to state that beyond the 10,000 individuals projected to receive ART
through the PMTCT program, an additional 15,000 PWHA will be receiving structured ART
through the private sector by 2008.
■
The GFATM proposal does not address the myriad constraints in the largely unregulated
private health care sector that will affect ART provision, monitoring, and adherence.
Adherence and Resistance
■
Concerns about adherence and the spread of resistant viral strains may be particularly
pertinent in India because the generic, low-cost, triple-drug formulations available in India
include NNRTIs such as nevirapine. Evidence suggests that an easily acquired single point
mutation can confer resistance to all the agents in the NNRTI class when the virus becomes
resistant to nevirapine alone.
■
Many Indian doctors and government officials note that greater access to ART could lead,
particularly in the largely unregulated private sector, to faulty prescription practices that
might set the stage for the emergence of drug-resistant HIV strains.
■
Knowledge and practices of physicians in three low-prevalence and three high-prevalence
states found that 70 percent of family physicians were unaware of the HIV ELISA test, and
80 percent unaware of ART except for AZT. CD4 and viral load monitoring facilities were
nonexistent, and counseling concepts alien. Parameters to initiate therapy, drug regimes, drug
combinations, and patient monitoring are poorly known. About 5 percent of family
physicians attempt ART use, with AZT+3TC the most frequently used regimen, though
monotherapy is also common.
Female-controlled Prevention Technologies
■
India's National AIDS Research Institute is actively involved in preclinical and clinical trials
of microbicide candidates. Phase III multicenter trials of Buffer Gel, Pro2000, and
Carraguard are planned for 2003. Other research institutions involved in microbicide research
include the National Institute of Pharmacological Education and Research and the Institute
for Research in Reproduction.
■
In February 2002, Hindustan Latex Limited signed an agreement with the U.K.-based Female
Health Company to market (and eventually produce) female condoms in India. The female
condom would be priced at Rs 45 per piece (approx US$0.95). HLL is exploring commodity
and funding assistance to subsidize the cost.
Economic Interventions
■
There are numerous projects that seek to reduce HIV vulnerability (particularly of young
women) through vocational education, literacy interventions, and income-generating
activities.
Vaccine Trials
■
Since 2000, the International AIDS Vaccine Initiative has been working with the Indian
Council of Medical Research and NACO to develop and evaluate AIDS vaccines in India.
The National AIDS Research Institute in Pune will launch phase I trials of an AIDS vaccine
in late 2003 or early 2004.
Industry
■
Several private sector employer organizations are actively involved in HIV prevention,
including workplace interventions, community programs, and support for NGOs. The
Confederation of Indian Industries, Associated Chambers of Commerce and Industry of
India, and Federation of Indian Chambers of Commerce and Industry are involved in
HIV/AIDS workplace activities and are part of India’s Country Coordinating Mechanism,
which designed the country's GFATM proposal.
■
The ILO has an India HIV/AIDS project and is working with businesses, trade unions, and
employer federations.
■
ILO has documented the HIV/AIDS programs of several Indian businesses, which span
awareness raising, training, condom distribution, VCT, and care & support. Some companies
also offer treatment of STIs; some, treatment of OIs as well. Very few appear to offer ART.
■
Among prominent companies with HIV/AIDS programs are:
-> Tata Tea, Ltd
-> Tata Steel
-> Hindustan Petroleum Corporation
-► Steel Authority of India Limited
Government
The Government of India states that its national priorities for addressing HIV/AIDS are to:
1. scale up PMTCT services (including short-course NVP, as well as VCT) to prevent HIV
among and provide care to mothers and their infants and families
2. provide antiretroviral treatment to PWHA through public-private partnerships.542
Other stated features of the national response include:
■
■
■
■
■
to prevent socially vulnerable groups from becoming infected with HIV and to improve their
health education, legal status, and economic prospects to diminish their vulnerability to
acquiring HIV543
to ensure blood safety544
to protect the rights of PWHA to education, work, and privacy, and to ensure care and
support for PWHA545
to render India s response to HIV/AIDS inclusive of all sectors and communities,
emphasizing decentralization to the state levels and below546
to place greater emphasis on international partnerships with the UN and other agencies547
In many ways, the government’s response to the epidemic has been appropriate. In other
respects, substantial material and political commitments have been too little and too late.
Because of India’s sheer size, the number of actors involved in combating HIV/AIDS, and the
complexity of their interactions, India’s response to the epidemic does not lend itself easily to a
summary appraisal. However, any assessment of the government’s response should consider the
following successes and continuing challenges.
Successes
After the first AIDS cases were identified in the U.S., the Indian Council of Medical Research
established an AIDS task force. By 1986, surveillance centers designed to detect HIV were
established at several medical colleges throughout metropolitan India. The first HIV-positive
individual (a sex workers in Chennai) was identified in 1986 at a surveillance center at Madras
Medical College. Soon after, other HIV-positive individuals were identified in Tamil Nadu and
Maharasthra, and the first AIDS patient in India was subsequently reported.548
Following the 1986 case reports, the government took steps to target screening and prevention
efforts to populations at high risk of infection.549 A high-profile National AIDS Committee was
launched, and in 1987 the National AIDS Control Program was established, focusing on
increasing awareness of HIV/AIDS, screening blood for HIV, and testing of individuals with
high-risk behaviors. With the help of WHO, the government launched a program in 1989 that
focused on the states most affected by the HIV/AIDS epidemic, including Maharasthra, Tamil
Nadu, West Bengal and Manipur.550
By 1991, the government perceived a need to establish a multisectoral program for prevention
and control of HIV/AIDS. There was also a need for an agency to help establish a state-level
response to HIV/AIDS. To fulfill these objectives, the government established the National
AIDS Control Organization (NACO) in 1992. NACO is an autonomous body with the Ministry
of Health and Family Welfare. It is responsible for training, research, surveillance, and program
management, in collaboration with other ministries and parastatals, and advocacy.551
Under its second phase (1999-2004), NACO has decentralized it program. NACO grants funds to
state AIDS control societies for targeted interventions, blood safety, IEC, youth campaigns,
VCT, care and support, and social mobilization. The state AIDS control societies, in turn,
contract with over 600 NGOs to implement numerous program activities. NGOs and associations
of PWHA are represented on the executive committees of state AIDS control societies. At the
district level, district nodal officers are appointed to oversee implementation of AIDS
activities.552
NACO states that its current priorities include:
1. reducing the spread of HIV among high-risk populations through targeted peer
counseling, condom promotion, and treatment of STIs
2. reducing the spread of HIV in the general population through awareness campaigns,
testing and counseling and reduction of transmission through blood transfusion
3. strengthening the impact and sustainability of national, state, and local HIV/AIDS
programs
4. increasing capacity for provision of low-cost community-based care
5. promoting intersectoral links to combat HIV/AIDS, including collaborations between
public, private, and voluntary sectors.553
In 2001, the government adopted the National AIDS Prevention and Control Policy 554 During
that year, Prime Minister Vajpayee addressed Parliament and referred to HIV/AIDS as one of the
most serious health challenges facing the country. He argued that as AIDS affects the future of
India:
We must therefore, intensify prevention activities and focus on awareness of
young people who are the most vulnerable. These should include programs for
school children, street children and other young people to help them adopt a
responsible lifestyle. We should also involve religious establishments who can
have a strong positive influence over large sections of society.555
The prime minister has also shown commitment at local levels and has reviewed the
implementation of prevention programs with the chief ministers of the high-prevalence states. In
addition, he has met with business and industrial communities that have shown an interest in
addressing the HIV/AIDS epidemic, and he recently inaugurated the Business Coalition Trust on
HIV/AIDS in India.556 In late July 2003, India held its first Parliamentary Forum on HIV/AIDS,
cosponsored by NACO and UNAIDS 557
The World Bank argues that although it is difficult to attribute India’s relatively low HIV
prevalence to any one intervention, the government’s actions have contributed significantly to
keeping HIV prevalence under one percent nationally. Important among the government's
interventions are programs of condom promotion, behavioral changes, community information
and education, targeting and involvement of vulnerable groups at risk, blood safety, and STI
treatment.558
In addition to low HIV prevalence, the World Bank posits that the government has contributed to
several other positive outcomes. Government programs have contributed to capacity building,
including technical and managerial assistance to 150 NGOs. The government has established 140
blood surveillance centers (leading to almost 100 percent blood transfusion safety) and 180 HIV
sentinel surveillance sites. The World Bank also suggests that government social marketing
efforts have led to a 50 percent increase in the volume of condom distribution.559
USAID also quantified some of the government’s successes in responding to HIV/AIDS. By
2001, 20 to 25 percent of schools hosted school-based AIDS education programs, including peer
education. University-based AIDS programs have reached approximately 4 million college
students. In addition, over 200 voluntary counseling aqd testing facilities have been established,
mostly in high prevalence states. By 2003, each of the country's approximately 600 districts is ’
projected to have at least one VCT center. To improve management of STIs, over 504 STI clinics
have received further financial support from the government, and a campaign has been
established to increase knowledge of STIs among 15- 45-year olds.560
Intersectoral collaboration is one of the key components of the second phase of the government’s
National AIDS Control Program (1999-2004). The program aims to promote collaboration
among public, private, and voluntary sectors and would be focused on:
■
■
learning from innovative HIV/AIDS programs in nonhealth sectors
collaborating to generate awareness, provide advocacy, and deliver interventions561
In May 2001, the prime minister met with the chief ministers of the six high-prevalence states of
Andhra Pradesh, Karnataka, Maharasthra, Tamil Nadtf, Manipur, and Nagaland to plan
intensified implementation of strategies to prevent and control HIV/AIDS in those states. The
chief ministers view school- and college-based educational programs, involvement of informal
leaders in spreading the message of HIV/AIDS, and enlisting the support of community leaders
as priorities for the states. Furthermore, the chief ministers requested increased funding for areas
such as support to hospital infection control measures, provision of medicines for opportunistic
infections, PMTCT. The prime minister added the importance of involving religious leaders in
the effort to disseminate information about HIV/AIDS.562
Challenges
Notwithstanding the successes outlined above, India is facing an increasingly generalized
epidemic. According to Dr. Richard Feachem, executive director of the Global Fund to Fight
AIDS, Tuberculosis & Malaria:
In some parts of India, particularly the states that are reporting the higher
prevalence, the tipping point is long past. I think there is absolutely no doubt that
the virus is moving into the general population.563
In July 2003, Dr. Meenakshi Datta Ghosh, project director of NACO, stated that HIV/AIDS is no
longer affecting only high-risk groups or urban populations, but "is gradually spreading into rural
areas and the general population."5^4
In the eyes of many critics the allocation of only $38.8 million of the government’s own funds
(excluding funds from the World Bank and other donors) over the period I999-2004565 is a
major indication of insufficient governmental commitment. In addition, there is significant
skepticism regarding the ability of the Government of India to implement HIV/AIDS programs.
Although the government has designed various programs to help prevent the further spread of
HIV, lack of funding and poor regulatory systems are serious barriers to their successful
implementation.566 Others argue that health officials face significant cultural barriers to
education and prevention and a lack of leadership at high political levels.567 Richard Feachem of
the GFATM has stated that:
There is a fairly widespread view among educated people and opinion leaders in
India that HIV/AIDS is primarily an African problem and that Hindu and Muslim
culture will protect India from the most serious consequences of the virus....As in
other countries, there has been a resort to the mythology of cultural immunity it
can’t happen to us because we’re different....! found on my visit a persistent
tendency to minimize the current scale of the epidemic and the potential future
growth.568
A recent article in The Lancet noted that:
The problems facing HIV/AIDS prevention efforts are compounded by the refusal of
many Indians in positions of power to accept that their country faces a grave threat from
the pandemic. On the surface, HIV/AIDS seems to have become a priority. As long ago
as 1998, Prime Minister Atal Behari Vajpayee conceded, ’’HIV/AIDS is the most serious
public health problem facing India.” And AIDS is now a fashionable cause among actors,
fashion divas, rock stars, and socialites. But when the discussion of AIDS shifts from the’
vague to the explicit, from talk to action, problems crop up....As the epidemic spreads,
the battle against AIDS in India is mired by a lack of consensus within the political
establishment and among NGOs on the extent of the HIV/AIDS pandemic, the ’’right
strategy” to combat it, and how to deal frankly with sexuality.569
Critics also argue that there is inadequate governmental response in the area of IDU
interventions. Although the government acknowledges that IDUs are at risk of HIV infection,
prevention activities for them are generally poor. Most drug treatment centers lack information
about HIV/AIDS and STIs.570 There is no government policy on harm reduction, leading to lack
of coordination in designing and implementing interventions. (Some states, such as Manipur,
have adopted their own harm reduction policies.)571 Although NACO has approved needle and
syringe programs (in Manipur, New Delhi, Mumbai, Calcutta, and Chennai), there are too few
programs and the coverage is insufficient to substantially reduce HIV infection among IDUs.572
(See also the earlier section on Alcohol and Drug Use.)
Additional criticisms include the perception that although there has been much commitment to
addressing HIV/AIDS at the national level, this commitment is not matched at the state level.
Critics argue that in many cases, a lack of advocacy from high-level political leaders led to a lack
of response at the state level.573 Currently, approximately one-third of India’s 35 states and UTs
have what the World Bank deems "good” HIV-control programs, one-third are "making some
effort,” and one third “are not on board, but are in denial.”574
Another frequent criticism of the government’s efforts is that during the initial response phase,
NACO was focused on centralized, top-down planning and implementation. This led to
insufficient “buy-in” at the state level and to uneven implementation of projects in the different
states. Subsequently, efforts have been made to decentralize to the state and district level,
realizing the differences in the nature and level of the HIV/AIDS epidemic in the different areas
of India. As discussed previously, however, decentralization does place further burdens on
state governments, already struggling with severely inadequate health (and other) infrastructure.
Moreover, decentralization does not automatically result in pro-poor and gender-sensitive
expenditures, 576 which are necessary to address to HIV/AIDS directly (prevention education,
services) and indirectly (socioeconomic investments in health, education, etc.).
There are additional shortcomings in the governmental response: Few prevention programs exist
for MSM, and information campaigns have not adequately addressed myths such as that HIV is
spread only by vaginal sex. Although the national policy on HIV/AIDS addresses discrimination,
there is no national legislation on HIV/AIDS-related discrimination to serve as an implementing
instrument. As discussed in the Human Rights section below, discrimination directed at PWHA,
SWs, and MSM, as well as those who work with them on HIV/AIDS projects, is rampant,
including discrimination perpetuated by government officials and employees. (See also the
Stigma section above.)
Blood Safety
In June 2001, the government passed a law making it mandatory to test all donated blood for
HIV, hepatitis C, hepatitis B, syphilis, and malaria. To improve compliance, blood bank
personnel are being trained in quality assurance.577 In December 2002, India’s MOH announced
that blood donors who tested positive for HIV would be told of their infection and asked to seek
confirmatory tests and counseling. Previously, blood donor testing was anonymous, and blood
infected with HIV was discarded without conducting a confirmatory test or any informing of
donors. However, doctors working in blood transfusion services caution that the new policy will
be difficult to implement given the current decentralized, fragmented state of blood hanking
services in India. The country has 1,500 blood banks spread across large hospitals and small
clinics, with quality varying among them. Moreover, there is no efficient HIV counseling
infrastructure established nationwide (though the number of VCT centers is increasing; see
below), and links between VCT and blood banks are not firmly established. Medical officers in
transfusion centers are also concerned that a substantial proportion of donors will not return for
confirmatory tests.578 (NACO's National Blood Policy may be found at:
http;//www.naco.nic.in/nacp/bldprog.htm. NACO has drafted the Blood Safety Plan 2003 and is
seeking feedback on it: http://naco.nic.in).
Budget Allocations
As mentioned above, India's public spending on health remained constant at 0.9 percent of GDP
during the 1990s. Private expenditure on health accounts for 4.0 percent of GDP.579
On a per capita basis, public health spending is far less than the amount recommended to provide
basic services by the World Development Report 1993. In addition, public sector health spending
is significantly lower in the poorer states, where health outcomes are also poorer. The World
Bank argues that India has also failed to address the important determinants of good health that
lie outside the health system, such as in water and sanitation, nutrition, and education.580
NACO s budget for 1992 through 1998 was US$100 million, funded by government and external
donors. For 1999-2004, NACO's budget is US$300 million. Of this amount, the government
allocation is US$38.8 million; US$191 million is financed through a World Bank loan, and the
remainder from other donors (see below).581
India's federal budget caps the amount that foreign donors can contribute to HIV/AIDS. The
government usually insists that all foreign aid flow directly to it, rather than go directly to private
groups (though an exception was made with regard to the Gates Foundation grant [see below]).
India's Planning Commission sets annual ceilings on the amount of money—governmental or
nongovernmental—that can be spent on various programs, including those related to HIV/AIDS
This results in a situation in which donor commitment and available resources for HIV/AIDS are
greater than those permitted by the plan ceilings. Thus, some Indian states have the capacity to
absorb more resources but are denied them. The government argues that its control of resources
ensures that no one disease receives favor over any other.582
Nonhealth Ministries
'
Education, gication is developed and funded at the state level. Although the central
govemmenWCerts considerable influence through the National Council of Education Research
and Training, it has thus far not elaborated a concrete policy on an HIV curriculum. Persistent
ambivalence about sex education has also impeded the full implementation of a population and
ami y i e e ucatl0p program begun in the early 1980s. Although sex education has recently
been included in India’s National Cuiriculum, state officials dilute messages to which they object
and teachers omit topics with which they are uncomfortable.583
Some state and municipal governments are implementing school-based-prevention programs
often in partnership with NGOs or multilateral donors such as UNICEF. Maharasthra State, and
e city of Mumbai in particular, has undertaken noteworthy schools-based AIDS prevention
programs. An educational initiative called the AIDS Prevention Education Program (APEP)
trams teachers and young peer educators in promoting life skills, including negotiation of safe
sex. APEP was launched m 1993 and had expanded from 51 Mumbai municipal schools to 743
wSttrpp ’■ Initi±Cat?ed °Ut by d0Ct°rS °f the Public Health DeP^ment in partnership
with UNICEF, since 1998 it has been under the direction of the Education Department and is
being carried out by a total of 1,589 APEP-trained teachers. The teachers complete a three-day
training in life skills focusing on human sexuality and including HIV prevention and safe sex
negotiation. They then provide sessions to their ninth grade students. APEP has reached all
schools municipal, state, trust managed, private, central government and the Archdiocesan
Board of education schools in Mumbai. It has been adopted by Maharashtra for all schools in the
state and is also being adopted by schools in Bihar.584 , 585 , 586
In Tamil Nadu, the "School Talk AIDS" program was implemented by the Madras School of
ocial Work in 200 schools spanning 20 districts. The program includes both teachers and
student peer educators. In a recent evaluation, 56.4 percent of responding peer educators had
problems implementing the program, including nonacceptance by students and opposition from
teachers, parents, and the general public. The evaluation highlighted major, widespread
misconceptions about sexuality and conception among Indian students.587
University Talk AIDS (UTA) began in October 1991 and is a collaborative partnership among
the National Service Scheme, Department of Youth Affairs & Sports, and NACO. The project
involves a team of peer educators in universities, colleges, and some schools to reach other
students as well as surrounding communities with information on HIV/AIDS as well as drug
abuse relationslups, courtship, and marriage. Evaluation of the project has indicated that it has
reached 7,595 institutions and 6.5 million youth all across the country.588
Defense. India's National Cadet Corps has implemented an HIV/AIDS awareness program The
program, implemented at the National Integration Camp in Delhi, has trained 600 cadets from all
over the country in basic HIV prevention. These cadets will be further trained as resource
persons, and will be responsible for training other cadets upon returning to their states.589
Transport. Collaborations with the transportation sector on HIV/AIDS prevention activities have
been popular. From 1996 to 1998, a consortium of 11 NGOs (PATH) worked to reduce the
transmission of HIV/AIDS among truckers in Tamil Nadu. The program focused primarily on
meeting and advising truckers, their helpers, and female sex workers at various points along the
highway. It also focused on those allied with the road transport industry, including loaders,
employees in vulcanizing shops, workers in roadside workshops, filling station employees, and
lodge owners where sex workers operate. PATH states that it was able to reduce the proportion
of truckers having sex with nonregular sex partners from 48 to 32 percent and to increase
condom use from 44 to 66 percent.590
However, one study argues that several attempts to establish transport-related HIV/AIDS
mitigation activities in India have been unsuccessful (all under the DFID-financed Healthy
Highways project). The study argues that the fragmented structure of the transportation industry
has thus far thwarted the search for feasible and replicable approaches. It points out that a
combination of forces would be required for effective intervention, and a successful model
would combine private sector organizations with transport companies and associations.591
Another study undertaken of the largest truck terminal intervention project in Mumbai evaluated
treatment and prevention of STIs and HIV, and promotion of consistent use of condoms. The
study concluded that peer education programs are difficult to implement effectively given the
high mobility of the target population. It also suggested that project activities are most effective
at the terminal sites and that information on HIV/AIDS has to be customized and culturally
appropriate.592
Indian Railways has also been conducting HIV/AIDS awareness and education among its
workforce as well as its ridership.593
Human Rights
(See also the Governance, Stigma, Gender, and VCT sections.)
In India, there is widespread discrimination against people infected with HFV. Indian PWHA
have great difficulty accessing support and are usually unable to discuss their HIV status for fear
of repercussions. The Lawyers’ Collective HIV/AIDS Unit reports that:
The discrimination and stigma faced by PWHA has brought into focus gross violations of
human rights. For example, people have lost their jobs because they were HIV-positive.
There is a palpable reluctance among employers to keep the services of HIV-positive
employees, mainly because of their own ignorance and fears. People in the prime of their
working life are being forced to leave jobs or denied employment due to their HIV status.
The resultant economic deprivation leads to poverty, poor health, family problems and
children unable to access education. Women face harassment and encounter problems
with regard to maintenance and their share of the matrimonial property. Their problems
are heightened after the death of their husbands.594
There is no national legislation to protect the rights of Indians with HIV/AIDS.595 This scenario
has myriad consequences, as discussed below. (The Lawyers' Collective HIV/AIDS Unit has
been asked by Kapil Sibal, a member of Parliament, and NACO to draft legislation on protecting
the rights of PWHA for presentation to Parliament in 2003.596 The Collective also stresses the
urgent need to address the legal rights and needs of women and create supportive legal structures
for them.597)
The number of HIV/AIDS-related court cases has been rising rapidly. In the absence of
HIV/AIDS-related legislation, the role of the judiciary in the evolution of legal principles
regarding the epidemic has become crucial. One critical legal victory was the Indian judiciary's
acceptance of the suppression of identity principle, permitting PWHA to access legal services
without revealing their identity.598 The Lawyers' Collective and others have also filed suits
related to the right of PWHA to marry (see below), health care provision, and the use of funds
allocated to the state AIDS control societies.599 , 600
HIV Testing
NACO "feels that there is no public health rationale for mandatory testing of a person for
HIV/AIDS....HIV testing carried out on a voluntary basis with appropriate pre-test and post-test
counseling is considered to be a better strategy and is in line with the WHO guidelines on HIV
testing."601 As discussed in the VCT section below, NACO has developed a VCT policy that
states:
■
No individual should be made to undergo mandatory testing for HIV.
■
No mandatory HIV testing should be imposed as a precondition for employment or for
provision of health care facilities during employment. (India's Armed Forces are exempt
from this condition.)602
NACO has also developed guidelines for VCT centers, which address consent and
confidentiality issues:
HIV testing...must always be undertaken after pre-test counseling and informed
consent....The confidentiality of the test result (either negative or positive) should be
strictly maintained. It is essential to respect the privacy and rights of the individuals to
protect them from discrimination, victimization and ostracisation.603
However, many Indians are tested for HIV without their knowledge or consent. For example,
FXB Society-India reports that over 95 percent of patients scheduled for surgical procedures are
involuntarily tested for HIV; for those who test positive, their treatment/surgery is cancelled.
Most health care professionals do not differentiate between routine offering of HIV tests and
mandatory testing, particularly in the context of PMTCT.604
Some government officials (including legislators in Goa and Andhra Pradesh) have voiced their
support of mandatory premarital testing for HIV and are proposing related legislation.605
Right ofPWHA to Marry
In 1998, India's Supreme Court delivered a judgment that suspended the right ofPWHA to
marry, despite that the issue of PWHA's marrying had never come before the Court. (The 1998
case in question involved the issue of breach of confidentiality, wherein a hospital blood bank
had disclosed the plaintiffs HIV status to his relatives.) The Lawyers Collective HIV/AIDS Unit
contested the constitutionality of the 1998 ruling regarding marriage. In early 2003, the Supreme
Court passed an order that all observations relating to marriage in the 1998 case were not
warranted as they were not issues before the Court.606 The case highlights the massive stigma
and discrimination faced by PWHA in India and their vulnerability—particularly given the lack
of legal instruments—to human rights abuses, including those perpetuated by governmental
institutions.
Violence Directed at HIV/AIDS Outreach Workers
A July 2002 report from Human Rights Watch documented how HIV/AIDS projects, particularly
those that provide essential information and services to SWs and MSM, are undermined by
frequent and widespread police harassment and abuse of outreach workers. This despite that in
its official policies and statements, the Indian government has recognized that reaching SWs and
MSM is central to the response to HIV/AIDS.607
Using data gathered in March and April 2002, HRW report that police have beaten peer
educators, claimed that HIV/AIDS outreach work promotes prostitution, and brought trumped-up
criminal charges against HIV/AIDS workers. Police also extort money and sex from these
workers. The possession of condoms often spurs police harassment. In the absence of appropriate
protections from the state, peer educators are subject to the same sorts of criminalization (and
marginalization) as the populations they are trying to reach.608
MSM
The July 2002 HRW report also detailed how the criminalization of anal and oral sex under
section 377 of the Indian Penal Code contributes to "the impunity with which police harass
[MSM] and those who work with them.”609 Police also accuse those carrying out HIV/AIDS
outreach of promoting homosexuality and have sometimes attempted to link them to national
security offenses, narcotics-related crimes, or other criminal acts.610
Organizations that conduct HIV/AIDS education activities with MSM in Lucknow, Mumbai,
Chennai, Sangli, Bangalore, and New Delhi described police abuse that had sometimes halted
their outreach work. These organizations also reported that it is common for police to extort
money or sex from MSM; physical abuse of MSM by police is also widespread. Discriminatory
police practices that keep MSM from filing complaints or seeking redress, combined with the
financial difficulties of making bail, lead to long periods in detention facilities, where MSM are
subject to further abuse.611
HRW notes that police abuse of HIV outreach workers ’’parallels police abuse of other
marginalized or minority populations in India...dalits, religious minorities, women, and street
children, among others.”612 Although they are generally culturally accepted, TG, as previously
discussed, also face significant discrimination. As the Indian Penal Code criminalizes
emasculation, TG are denied legal, safe medical facilities for castration and sex change
operations. Their access to education, employment, and health care is severely restricted.
Subsequently, many turn to dancing, begging, or prostitution as their means of livelihood. They
face regular harassment and abuse by police.613
Access to Treatment
There is increasing discussion in India of access to ART (discussed below). The Lawyers
Collective HIV/AIDS Unit and its partners have launched the Affordable Medicines and
Treatment Campaign (AMTC) to coordinate an advocacy response to raise awareness and
influence policy.614
Donors
Below is a summary of the assistance programs of India's major HIV/AIDS donors and technical
partners.
World Bank. The World Bank lent India US$191 million to implement the second phase (19992004) of NACO. 15 Activities include targeting interventions for groups at high risk, specifically
SWs, IDUs, migrant workers, MSM, and STI clinic attendees; providing locally appropriate
information, communication, and awareness campaigns, VCT, and a strengthened infrastructure
for blood safety; establishing new sources of support for AIDS care in partnership with NGOs.
The Bank project also provides institutional strengthening by enhancing planning, management,
and implementation capacity at the national, state, and local levels. It also strengthens the
leadership capacity of India s Ministry of Health and Family Welfare; conducts training; builds
capacity for ongoing monitoring and supervision; supports operational research and R&D; and
supports broad social mobilization and cooperation and information.616
Bill & Melinda Gates Foundation. The Bill & Melinda Gates Foundation provides significant
support for health programs in India, including HIV/AIDS prevention efforts. The Foundation
supports the Partnership Project in Andhra Pradesh, providing $25 million for a joint project
between the Childrenjs Vaccine Program (run by the Program for Appropriate Technology in
Health) and the government of Andhra Pradesh. The program aims to strengthen the state’s
infant immunization program and to provide hepatitis B vaccine. In addition, the Gates
Foundation provides the Franyois-Xavier Bagnoud Foundation with a $300,000 grant to develop
community-based HIV, AIDS programsjn rural Rajasthan. The FXB Rajasthan Society has
developed a model for HIV/AIDS education that includes using village counselors and peer
educators, and that targgte migrant workers. The goal is to increase awareness of STIs and to
promote VCT.617
Most recently, the Gates Foundation announced the India AIDS Initiative, a ten-year, US$100
million grant designed to reduce the spread of HIV/AIDS.618 In partnership with the Government
of India, community organizations and the private sector, the project will intensify prevention
efforts aimed at highly mobile populations, including migrant laborers, truck drivers, rail
workers, and military personnel.6 9 The India AIDS Initiative will support Indian partners,
primarily NGOs. The initiative will support programs that offer condom promotion, behavior
change programs, VCT, and STI screening and treatment. It will also provide support for current
projects focused on mobile populations, such as the Healthy Highways Project and APAC
P^ojectwiTamil Nadu. The initiative also aims to reduce HIV/AIDS-related stigma and
discrimination by providing grants to organizations that raise awareness, provide education, and
build political support to control the spread of HIV/AIDS.620
Global Fund to Fight AIDS, Tuberculosis & Malaria. In the first round of grants, announced in
April 2002, India's TB proposal was funded, at US$8,784,999, In the second round of funding,
announced in January 2003, India was granted US$100,081,000 for HIV/AIDS and a further
if|ESSESSHSEss"
I’WHA through pubhc-pnvate partnerships.6 2
2Fm Granted India US$21.67 million over 1999-2004 forHIV/AIDS interventions in Andhra
rad?s_h, Gujarat, Kerala, and Orissa. DFID has provided prevention programs in West Bengal
and has recently extended its assistance with the implementation of sexual health projFcte in ’
AndhriPradesh. In addition, DFID has funded the Healthy Highways Project, which assesses the
easibihty of improving the use of health facilities by truckers to reduces the risk that they and
their sexual partners will be infected with HIV623(see above).
K^takl^Th^13
mjllionOTer^OOUOb for HIV/AIDS interventions in Rajasthan and
Karnataka
Through the India-Canada Collaborative HIV/AIDS Project, CIDA is supporting
the strengthening of state AIDS societies in Karnataka and Rajasthan, as well as NACO^nd
ManTP «S°UrCeS groups'
.
The Pr°Ject involves a consortium led by the University of
Project (APAC). Among its activities, APAC provides technical assistance to NGOs focusing on
supLrtto'pATHTN^5 m Urban S1T and tourist arcas; tra‘ning for staff of STI clinics;
support to PATH, the NGO consortium that works with truckers.628 APAC collaborates with
h3<Fa™
IntaatmaMMFACT, PrOBram for Appropriate Technology
P„,T ■ ? f
? T f“ D,SeaSe Cl>”trol <CDC)>,he International Clinical
Bpidemiology Network, and other medical and research institutions.629
In J^harasthra, the AVERT Project, also launched in 1995, seeks to strengthen the capacity of
womenealdVcehii7nt T t ?°S t0 reSP)°nd t0 the
with an ^phasis on issues affecting
shdt
n h d
Actmties targeted to children include assistance to NGOs to establish
US A tn edu'a^n at^ hcalth awareness programs, counseling, medical care, and advocacy
USAID granted India US$51.5 millionfor APAC and AVERT projects during 1999-2OO4.630
Sg GDC priorities in India include supporting Vcf; strengthening surveillance and
lahnrd^
eyelopment (e.g., capacity of state AIDS control organizations and NGOs
boratory strengthening and support); providing support for 01 surveillance and case
management; and assisting in the development of PMTCT programs.631
■
Sna^°F0’
Department of Health and Human Services and the Indian Minister of
Sorts m HWM
6 8Ded tW° <°int StatementS Pledging tO Stimulate ncW -operative
ii HIV/AIDS preventlon ’■esearch. Topics covered under these agreements span improved
ryeillance, prevention research, vaccine research and development, technology transfer and
health services research. Participants include the U.S. National Institute of Child Health and
Human Development, National Institute of Mental Health, National Institute of Allergy and
■
Infectious Diseases, National Institute on Drug Abuse, the Fogarty International Center, and
other agencies of the U.S. Government (including the CDC and USAID).632
■
JICA. Inl994,Japan announced the Global Issues Initiative (GII), a seven-year, US$3 billion
program of assistance for population and AIDS-related projects.633 Jfec’enFprqjects include an
Hiy/AIDStraining course, which was attended by participants from India634
AusAID. In India, Aus AID’s efforts have focused on creating more effective partnerships with
NGOs. For example, AusAID funds the SHALOM project, a community-based intervention
Basedonjwni reduction principles (such as needle exchange and condom promotion).635^
Sida, Sida has contributed to national program aimed at reducing child and maternal mortality
and improving women’s reproductive health. In Manipur, Sida was the first donor to support
NGO program, based on the philosophy of harm reduction, with the aim of reducing the spread
of HIV/AIDS among IDUs and their sexual partners. A more recent initiative is the twinning of
two NGOs, RFSU in Sweden and Mamta in India, to address the need for strategies focusing on
the health and well-being of young people.636
GTZ. GTZ states that since 1993,.its priorities have shifted from “supporting vertical HIV/AIDS
projects to supporting the integration of these projectsjnto reproductive health or primary care
European Union. In India, the EU supports programs focus on safe blood management, life skills
education, and_STI pre:vention. The EU plans more activities targeting policy research and"
Hiy/AIDS_surveillance.638
------------------- --- ---- —--------UNDP- Granted India US$1.5 million for HIV/AIDS interventions in Tamil Nadu and
Maharasthra, Gujarat, Rajasthan, Himachal Pradesh, and Delhi during 2002-04.639,640 UNDP
focuses on HIV prevention in the workplace, interventions with SWs and others in the sex
industry, and the greater involvement of PWHA in HIV/AIDS prevention and care. UNDP works
with government, civil society, academic and research institutions, the corporate sector, and legal
and human rights organizations. In addition, UNDP’s HIV and Development Project for South
and Southwest Asia has developed the National Consultation on HIV/AIDS and the Media. The
project provides a forum for media practitioners, experts, advocacy group, and PWHA to discuss
the media’s response to the epidemic.641
^AIDS. UNAIDS aims for a multisectoral response to HIV/AIDS in India, and therefore
Wordin ate s and monitors all activities by UN agencies. Additionally, the agency works to
disseminate best practices, linking the country to information regarding both global and regional
efforts to combat AIDS. Specific priority areas for UNAIDS include advocacy; surveillance at •
national and statejevels; support to states in implementing HIV/AIDS prevention and care
programs, specifically for vulnerable and difficult to reach populations; protection of the rights
of PWHA; impact mitigation; and facilitation of technical resource groups to increase access to
technical resources at the state level (including blood safety, clinical management and hospital
infection control, counseling, epidemiology).642
'
WHO. The objectives of WHO’s South Asia Regional STI/AIDS Program are to provide
tec mca and programmaticjsupport, support the WHO India office in responding to the technical
and operational needs, assist the MOH and other technical units to incorporate HIV/AIDS into
their existing programs and activities, and collaborate as a UNAIDS cosponsor in carrying out
mtercountry and regional activities in selected areas and programs.
UNE£A. Together with UNESCO, UNFPA assists in AIDS education programs among both .
school-based and out-of-schoofyouth. In addition, UNFPA has responded to the crisis by
integrating HIV/AIDS programming into its reproductive and child health programs in India.643
UNICEE. In India, UNICEF is implementing school-based AIDS education programs, as well as
a feasibility study on PTMCT in 11 centers 644
International Labor Organization (ILO). Under an agreement with NACO, the ILO has created a
project that promotes behavior change and encourages health-seeking behavior in the workplace
and in communities of unorganized labor. The ILO is implementing this program with the
Mmistry_QfLabor,_and employers’ and workers’ organizations in six states. One example of the
LO s work is the support that it has given to the Network of Positive People of Delhi a
grassroots organization for HIV-positive individuals. Through thiscollaborationjLo’is reaching
men, women, and children in the informal economy who are affected by HIV/AIDS. Workers in
this sector comprising 92_percentpflndia/s workforce, are particularly vulnerable because of
their hmitedpccess to medical services, social security, or support networks. The Network of
Positive People of Delhi has created program in Delhi and other severely affected districts
seeking to inform workers about the disease and what resources are available to them. The
network provides training and job assistance to HIV-positive workers and to the families of those
who have died. It also arranges for medical care and organizes support groups. In an effort to
address the lack of awareness of the epidemic’s impact on India—particularly outside urban '
areas—ILQ i&xurrently^reparingirenoWon the effects of HI V/AIDS on women, children
househokimcome^ancEniralpconomies.645 (See also the Private Sector section below, j
’
National NGOs and CBOs
The Links section provides a continually updated list of major NGOs and CBOs.
Numerous NGOs and CBOs, including associations of PHWA, are providing critical HIV/AIDS
prevBntion, care, and support information and services. Many are playing leadership roles in their
state and districts, particularly with regard to reaching slum dwellers, truck drivers, MSM sex
workers, IDUs, youth, street children, orphans, and other marginalized populations. The
communities targeted for interventions lead many of these projects. Several NGOs are also
contributing to national policymaking. In addition, projects such as Sonagachi have become
global best practice, as discussed above.
Although about 600 NGOs receive financial and technical support from the government
acadeimc “stitiitions, and external donors, many more work without any such assistance. Much
of the work of NGOs and CBOs has not been evaluated, an impediment to scaling up 646 For
example, onlyabout 20 to 30percentof marginalized populations are currently reached by
Indian civil society. In absolute numbers, this is an extraordinary accomplishment, especially in
such a poor country. Yet the need for scaling up of activities and wider coverage is urgent.647
With regard to faith-based organizations, researchers from Mamata Medical College in
Khammam examinedlhe attitudes of Hindu, Christian, and Muslim organizations vis-a-visHIV/AIDS. They found that 73 percent of "moderate religious believers" believe that HIV is not
merely a virus, but a "social disorder with deteriorating moral and ethical values."648 Some faith
based organizations are involved in HIV prevention and education activities (see the I .inks
section). Efforts are under way to spur their greater involvement; for example, the Jammu and
Kashmir State AIDS Prevention and Control Society is working with imams.649
In rural areas, many people often consult with indigenous and folk practitioners in seeking health
care. However, whether traditional healers are playing any role in the country's response to
HIV/AIDS is unclear.
International NG Os
Again, the Links section provides a continually updated list of major international NGOs.
Among them are:
International HIV/AIDS Alliance
<http://www.aidsalliance.org/ docs/ languages/ eng/ content/ 1 about/ fieldprog/ asia/india.h
tm>. The Alliance’s programs focus on building existing capacity and expertise in HIV-related
programming and on NGO support. Currently, the Alliance is working with three partner NGOs
that have HIV-related expertise, and the NGOs are, in turn, providing financial and/or technical
support to 31 other NGOs/CBOs located in 13 states across India. Efforts are focused on specific
communities, including those that are marginalized and are highly vulnerable to HIV infection
(MSM, IDUs, and PWHA). The Alliance, with support from the European Union, also has a
major new initiative to mobilize care and support for PWHA and their families in Andhra
Pradesh, Delhi, and Tamil Nadu.651 The Alliance works closely with YRG Care in Chennai; the
two have developed a project to scale up the continuum of care and support model for PWHA in
four other centers within south India. The Alliance has facilitated the planning of this project and
provided technical support and training to YRG Care staff who are coordinating the work. In
collaboration with the Horizons Project of the Population Council, the Alliance is also supporting
YRG Care in carrying out an operations research study on a care and support model for PWHA
and in developing and implementing methodologies for assessing the costs of YRG Care's
program and the potential for cost recovery. Also works closely with Maharashtra Network for
Positive People (MNP+), Society of Friends of Sassoon Hospitals (SOFOSH), Salvation Army,
and Committed Communities Development Trust (CCDT). With funding from the Gates
Foundation, the Alliance initiated the Frontiers HIV Prevention Program in Andhra Pradesh
<http://www.aidsalliance.org/ docs/ languages/ eng/ content/ 1 about/ projects/frontiers.htm>
Family Health International
<http://www.fhi.org/en/CountrvProfiles/India+main+country+page.htm>. FHI collaborates with
USAID on the APAC projects. In addition, FHI supports research, capacity building, and direct
intervention programs through the IMPACT program. IMPACT has supported numerous
■
baseline studies, provides support to NACO, and helps to build capacity of local NGOs. The
program has developed interventions for men who have sex with men (MSM) and for children
affected by AIDS. FHI also manages the Rapid Response Fund, which provides a quick response
mechanism for funding community-based HIV/AIDS prevention activities.652 In collaboration
with the Population Council, FHI organized a workshop that brought together scientists, policy
makers, health service providers, activists and community members to discuss critical issues
surrounding counseling and testing for HIV in South Asia.653
Marie Stopes International <http://www.mariestopes.org.uk/ww/india.htm>. MSI supports a
range of sexual and reproductive health services including family planning and contraceptive
services; contraceptive social marketing; obstetric care; female sterilization; vasectomy; primary
health care; safe abortion; youth services; STI prevention, diagnosis, and treatment;
STI/HIV/AIDS awareness-raising initiatives; and VCT.654
Center for Development and Population Activities fCEDPAl <http://www.cedpa.orv/> CEDPA
has implemented the Better Life Options Program in India. The program offers adolescent girls a
combination of life skills, including literacy and vocational training, support for entering and
staying in formal school, family life education, and leadership training. A holistic approach
integrates education, livelihoods, and reproductive health. (See also the Economic Interventions
section below.)
Medecins sans Frontieres <http://www.msf.org/ >. MSF currently supports programs to treat TB
and a team is currently working with the MOH on the Revised National Tuberculosis Control
Program (RNTCP). The program aims to support the public and private health sectors in the
implementation of DOTS in collaboration with local communities.655
CARE <http://www.care.org/>. CARE’s Chayan project includes interventions aimed at
preventing HIV within both the general population and high-risk populations. The project also
addresses reaching adolescents and youth with information and appropriate services and
fostering public-private partnerships.656
Population Council <http://www.popcouncil.org/asia/india.html >. Projects include study of
factors that facilitate or limit PWHA involvement in NGOs (in partnership with the International
HIV/AIDS Alliance, Tata Institute for Social Sciences, and local CBOs in Maharashtra);
assessment of intervention package for improving clinical services for and reducing stigma and
discrimination against PWHA in public and private hospitals (partners include SHARAN,
NACO, Institute for Economic Growth, and the Tata Institute for Social Sciences); analysis of
role of community development strategies in contributing to effective and sustainable
interventions for sex workers (partners include the Socio-legal Aid Research and Training Centre
and the Durbar Mahila Samanwaya Committee; and study identifying the components of YRG
CARE’s care and support program with greatest impact on clients’ quality of life and and
determining the process and costs of scaling-up these services at four other sites
<http://www.popcouncil.org/horizons/newsletter/horizons(5).html >.
Academic and Research Institutes
Numerous Indian and international academic and research institutes are undertaking crucial
HIV/AIDS research, as well as providing HIV/AIDS prevention, care, and support information
and services. See the Links section.
HIV Prevention Trials Network (HPTN)
Studies in India (either under way or in development) include:
■
HPTN 033: HIV Prevention Preparedness Study: to establish effective standard operating
procedures to recruit and retain high-risk populations in future HPTN trials and to
characterize HIV risk behaviors and HIV incidence in these populations (heterosexual
men and women in Chennai)
*
HPTN 034: HIV Incidence and Participant Retention Protocol: HIV-uninfected non-sex
worker women and HIV-discordant heterosexual couples attending STI clinics in Pune
HPTN 035. Phase II/IIb Safety and Effectiveness Study of Vaginal Microbicides
BufferGel and 0.5% PR02000/5 Gel (P) for Prevention of HIV Infection in Women
(Pune)
HPTN 047: Phase I Safety and Acceptability Study of Investigational Vaginal
Microbicide PRO 2000/5 Gel (P) (Pune)
HPTN 052: Randomized Trial to Evaluate Effectiveness of Antiretroviral Therapy Plus
HIV Primary Care versus HIV Primary Care Alone to Prevent the Heterosexual
Transmission of HIV-1 in Serodiscordant Couples (Pune)657
VCT
See also the Human Rights section above.
As previously mentioned, NACO has established policies and guidelines on VCT (see
http://naco.nic.in/nac p/ctrlpol.htm and http://naco.nic.in/nacp/guidel.htm , respectively). Its HIV
testing policy outlines that:
■
No individual should be made to undergo mandatory testing for HIV.
No mandatory HIV testing should be imposed as a precondition to employment or to
provision of health care facilities during employment. However, with regard to India's Armed
Forces, preemployment HIV testing may be carried out (with appropriate pre- and posttest
counseling).
■
Adequate voluntary testing facilities with pre- and posttest counseling should be made
available throughout the country in a phased manner. There should be at least one HIV
testing centre in each district in the country with proper counseling facilities.
‘
All necessary facilities should be in place so that HIV results are strictly confidential. Such
results may be given to a client’s family with his consent. Disclosure of HIV status to the
spouse or sexual partner of a client should be done by the attending physician with proper
counseling. However, the client should also be encouraged to share this information with his
family.658
■
With regard to HIV testing facilities in the private sector (hospitals, clinics, nursing homes,
and diagnostic centers), state governments should adopt legislative and other measures to
ensure that these testing centers conform to the national policy and guidelines relating to HIV
testing.659
NACO’s VCT guidelines outline in detail:
■
■
*
■
■
■
required VCT site infrastructure
counselor and lab personnel qualifications
training
external review mechanisms
consent and confidentiality (as discussed in the Human Rights section above)
linkages with AIDS care & support and other health programs660
India has over 265 public VCT centers at state and local level (primarily in high-prevalence
states). 6 ,-6 States have some flexibility with regard to adapting the national VCT policy and
guidelines to their local situation(s). Although the number of private laboratories (which
utilize rapid tests) is increasing, these labs generally do not offer client counseling.664
In its GFATM proposal, the government states that it aims to establish a VCT center in each of
the country's approximately 600 district hospitals. VCT is also incorporated into the proposal's
plans for scaling up PMTCT and expanding access to ART (see sections below).665
PMTCT
J
As mentioned in the Epidemiology section, the percent of HIV transmission attributed to mothe'rto-child transmission has increased, from 0.33 percent in 1999 to 2.61 percent in 2002.666
The Government of India has responded with a program to prevent mother-to-child transmission.
In March 2000, AZT was introduced in a PMTCT feasibility study supported by UNICEF and
NACO in 11 medical colleges of the five most affected states. Babies received an 18-month
follow-up and were tested for HIV with PCR at 48 hours and at two months. As of the end of
March 2001, over 150,000 antenatal women were reached; 79 percent of these women were
counseled, ?? .percenttested^ 1.8 percent found to be HIV-positive, and over 600 mothers
provided with AZT.667
An analysis of this experience revealed that, for logistical and cultural reasons, compliance was
evaluated as “good” in only 54.1 percent of women (it was “fair” in 45.1 percent and “poor” in
0.9 percent). Also, that women received varying doses and duration of AZT prophylaxis was a
barrier to its effective use. The government concluded that the two-dose NVP regimen might be
a more suitable option to overcome this problem, and subsequently launched a new feasibility
study of NVP in the same 11 centers.668
The evaluation of the AZT feasibility study also found .increased infant mortality in babies of
HIV-infected women who were given replacement feeding versus those who were breastfed for
two months (although the difference was not statistically significant because of the small sample
size). NACO concluded that the government should have a concrete policy on infant feeding
practices among HIV-infected mothers and that the best option is exclusive breastfeeding for the
first four months of life, gradual weaning between four and six months, and termination of
breastfeeding by the end of six months.669 Strengthened programmatic support for these
recommendations would be particularly salient in view of a recent study indicating that 42
percent of women who intended either to exclusively breastfeed or exclusively provide
replacement foods in fact provided mixed feeding.670
with GFATM funding, approved in January 2003, the government plans to scale up prevention
and care interventions among women of child-bearing age and their families in partnership with
the private sector by providing a package of primary prevention, family planning, VCT, NVP,
and counseling on infant feeding. Specifically, the GFATM proposal sets out that:
■
■
■
■
PMTCT interventions will be scaled up from 81 public sector hospitals to 444 public and
private, tertiary and_secondary health institutions (primarily in the six high-prevalence '
states).
------ •
Maternal and child health personnel (2,200 workers) will be trained in PMTCT to integrate
activities into reproductive and child care programs.
Linkagesjbetween. PMTCT programs, PWHA, NGOs, and CBOs will be established.
Build capacity to provide treatment, including ART to HIV-positive mothers, their children,
and partners (10,000 individuals).671
Among expected results:
■
■
Each year, over 7 million pregnant women will become aware of HIV prevention strategies
and will have access to condoms and STI treatment.
The number of infants infected with HIV through MTCT annually will fall below 10,000.
Presumably, the expanded PMTCT program will include development of ART treatment
guidelines for pediatric populations.672
Care and Support
Since the launchofthe second phase_of the_National AIDS Control Program in 1999, the Indian
government has demonstrated its commitment to provide lbw-cost care to PWHA. This is
evident in the allocation of 12 percent of NACO's budget to care and support (this figure
includes providing treatment for tuberculosis and other common OIs).677 Among its activities,
the government has established 25 .community HIV/AIDS care centers across the_GDuntry. With
GFATM funding, it plans to create drop-in centers for PWHATn high-prevalence states.674
I
i
As in many countries, an enormous amount of HIV/AIDS care and support is provided by NGOs
and CBOs, including associations of PWHA. These organizations are delivering nutrition
information, counseling for PWHA and their families, school fee support, vocational training,
and—in some cases—provision of drugs for OIs. However, they struggle with highly inadequate
financial and human resources coupled with increasing demand for their services. Many PWHA
experience difficulty in accessing such services because of stigma.675 (See the Links section for a
comprehensive, continually updated list of Indian NGOs and CBOs.)
Treatment of Opportunistic Infections (OIs)
As mentioned above, 12 percent of NACO's budget is allocated to care and support, including
treatment of OIs. (About 16 percent of the total budget of the World Bank HIV/AIDS loan is
designated for medicines to treat OIs). NACO's care strategy covers 30 percent of an estimated
500,000 AIDS__cases_that seek treatment at government-run and some selected NGO hospitals.
NACO's budget does not cover antiretroviral therapy except in cases of postexposure
prophylaxisfor health care providers and the PMTCT programs cosponsored by UNICEF.676
The government has strengthened the capacity of states by training physicians and technicians,
installing flow-cytometers for CD4/CD8 testing at apex medical institutions in 25 large and
mediuntsize-states, and allocating Rsl250 (US$25) per patient per year for the purchase of
drugs to treat common OIs. The national treatment guidelines also recommend prophylaxis with
cotrimoxazole for ill PWHA.677
With the exception of UNICEF s support of the PTMCT program, major donor organizations
have generally avoided financing ART. In the treatment area, they have instead focused on
strengthening the treatment of OIs.678
As previously mentioned, TB is the most common OI in India.679 , 680 In January 2003,
researchers from YRG Care and the Dr. ALM Post Graduate Institute of Basic Medical Sciences,
University of Madras, in Chennai reported the results of a retrospective analysis of 594 AIDS
patients .(TZSjjeicent male; baseline 004 cell count, 216 cells/microL) receiving care at YRG, a
tertiary HIV referral center in southern India. The mean duration of survival from serodiagnosis
was 92 months. Ninety-three percent of patients acquired HIV through heterosexual contact. The
most common OI was pulmonary tuberculosis (49 percent; median duration of survival, 45
months), followed by pneumocystis carinii pneumonia (6 percent; median duration of survival,
24 months), cryptococcal meningitis (5 percent; median duration of survival, 22 months), and
central nervous system toxoplasmosis (3 percent; median duration of survival, 28 months).
Persons with a CD4 lymphocyte count of <200 cells/microL were 19 times (95% confidence
interval [CI], 5.56-64.77) more likely to die than were those with CD4 cell count of >350
cells/microL. Patients who had one or more OIs were 2.6 times more likely to die (95% CI, 0.957.09) than those who did not have an OI.681
Antiretroviral Therapy (ART)
Availability
k
Indian HIV treatment guidelines call for ART at CD4 levels of 350 for symptomatic patients and
20^fpr_asymptomatic patients. However, ART has generally remained unaffordable for most
Indians and has been prescribed primarily to those who can pay out of pocket or who are
enrolled in research studies.682 , 83 India's 2002 proposal to the GFATM states that only 1,500
PWHA are receivingJand adhering to) ART, and that another 8,000 to 10,000 are intermittent
users or poorly adherent. 8 Although Indian pharmaceutical companies are manufacturing
generic AIDS drugs and selling them overseas, the Indian government has not focused on
provision of treatment in the public sector.685
To reduce prices, the government is making efforts to exemptcustoms and excise duty on all
antiretroviral drugs available in India. The government has a mandate to provide access to
treatment to all the employees working in various central government departments.686 The
Employees’ State Insurance Corporation (ESIC, the country's social security program), which
covers 8.6 million employees (total beneficiaries = 232million), does not currently offer ART.687,
In June 2003, UNICEF, WHO, UNAIDS, and MSF included 14 Indian pharmaceutical
I companies m their joint guide to global sources of HI V/AIDS drugs (Cipla, Ranbaxy
Laboratories, IPCA Laboratories, Neon Antibiotics, Gracure Pharmaceuticals, Lyka Labs,
Strides Arcolab, Intas Pharmaceuticals, Aurobindo Pharma, Lupin Laboratories, Founts
Laboratories, Glenmark Pharmaceuticals, Intas Pharmaceuticals, and CLARIS Life Sciences)
(more information on each firm may be found in the report's annexes). 688
Indian pharmaceutical firms are currently manufacturing generic versions of ART and selling
them at less than US$1 a day. The manufacture of generic ART drugs has been an essential
element in the dramatic reduction of drug prices.689 However, India signed the Agreement on
Trade-related Aspects of Intellectual Property Rights (TRIPS) as a member of the World Trade
Organization in 1994. As a result, Indian patent law will change on January 1, 2005. The effect
will be to decrease the likelihood that Indian firms will be able to manufacture generic versions
of additional ART drugs. This particularly affects on-patent drugs used in second-line therapies
and future new ART agents that may be developed. These changes will affect not only the cost of
ART Pro£rams in India, but in countries to which Indian firms currently sell inexpensive ART
drugs.
In the meantime, national and international interest groups are lobbying the Indian government to
expand access to ART. Proposals range from simply encouraging the use of ART by the patients
of private physicians to government provision of free ART to all HIV-infected persons. As time
passes these interest groups will gain strength and the cost and difficulty of administering ART
will continue to decline, such that pressure on the Indian government to finance or provide
expanded access is likely to intensify.691
India's GFATM proposal, approved in January 2003, delineates the government’s plans for
increasing access to ART. As discussed above, the emphasis is on PMTCT (including ART for
HIV-positive mothers and their families). The proposal appears to state that beyond the 10,000
individuals projected to receive ART through the PMTCT program, an additional 15,000 PWHA
will be receiving structured ART by 2008. A total of 200 institutions are scheduled to have
capacity to provide ART by that year. To this end, the government has reached an agreement
withfourpharmaceutical manufacturers, who will participate in a graduated cost recovery
program.692
The ART program will initially involve the following model institutions:
1. AIDS Research and Control Center (ACORN), Mumbai (which will administer the
GF ATM's ART component)
2. YRG Care, Chennai
3. Freedom Foundation, Bangalore
4. Freedom Foundation, Hyderabad
Patients at these institutions have usually had to pay the full cost of ART treatment and
monitoring. Under the GF ATM-funded program, PWHA will be able to access ART monitoring
at these institutions at a subsidized rate of US$12. Four Indian generic drug manufacturers have
agreed to a sliding scale pricing mechanism, based on patient's income.
The GFATM proposal does not address the myriad constraints in the largely unregulated private
health care sector that will affect ART provision, monitoring, and adherence. (See the previous
sections on the health sector and on TB.)
Box 3. St John’s Medical College and Hospital: Implementing ART in India
St. John's Medical College and Hospital was established in 1963 and is now a well-known referral center and
tertiary hospital in Bangalore, Karnataka. It is one of the top medical colleges in south India and a leading
private provider of affordable medical care in Bangalore City. In addition to being a main hospital and teaching
institution, St. John’s runs three rural/periurban health centers. St. John's also provides VCT and is one of the
major providers of care for HIV/AIDS patients in Bangalore, seeing nearly 1,000 HIV-positive patients for
regular follow-up. It is one of the few hospitals in Bangalore where ART has been prescribed since it became
available in India. Approximately 250 HIV-infected patients are admitted each year as inpatients, and the
number of new patients who test HIV positive each month is around 30. ART is prescribed to all patients with
<350 CD4, if they can afford it. The HIV clinic patient population is 90 percent male; 91 percent are Hindu, 2
percent Muslim, and 6 percent Christian. The adult patient age range is 21-68; most are in their late 20s to mid30s. Faculty and students conduct research on a variety of issues including HIV/AIDS, maternal and child
health, and TB. Since 1994, a Clinical Epidemiology Unit has been active at St. John's. Current studies include
HIV prevalence among outpatients at St. John's, overlapping HIV and TB epidemics among patients, and the
role of nutrition for HIV-infected patients.
Adherence and Resistance
Treatment adherence is a critical issue. Poor adherence to ART leads both to poor clinical
outcomes and to the transmission of drug-resistant viral strains, thus lowering the effectiveness
of ART in the infected population. These considerations are supported by experience that
strongly suggests that ART programs should put sufficient resources into supporting high levels
of adherence counseling and monitoring. Concerns about adherence and the spread of resistant
viral strains may be particularly pertinent in India because the generic, low-cost, triple-drug
formulations available in India include so-called nonnucleoside reverse transcriptase inhibitors
(NNRTI) such as nevirapine. Evidence suggests that an easily acquired single point mutation can
confer resistance to all the agents in the NNRTI class when the virus becomes resistant to
nevirapine alone.693
Some investigators argue that although too few studies have been published on adherence to
ART in resource-poor countries to draw firm conclusions, the results of those that have been
done indicate that adherence rates are similar to those seen in resource-rich countries. Although
high levels of adherence can be achieved, a wide range of adherence levels has been reported in
both industrialized and developing countries. Data from India and Uganda indicates that drug
cost can be a significant barrier to adherence. In a study of 100 patients on triple-drug ART
treatment in India, 60 percent of patients stopped within a few months because of high cost and
because they preferred to take alternative treatment. (These data are derived from conference
proceedings but have not been published.) Thus, a program of operations research to identify
effective adherence technique specific to India appears warranted.694 Such research is being
undertaken in Bangalore by Dr. Maria Ekstrand of the University of California San Francisco.
Many Indian doctors and government officials note that greater access to ART could lead,
particularly in the largely unregulated private sector, to faulty prescription practices that might
set the stage for the emergence of drug-resistant HIV strains.695 These concerns are reflected in
the findings of a recent multicenter study of the causes of ART therapy failure in India. In the
study, led by Grant Medical College & GT Hospital in Mumbai, only 10 percent patients were
counseled prior to initiating ART. Adherence was observed in only 10 percent of cases and all
were on (suboptimal) Pl-sparing regimens. In over 90 percent of cases, the long-term goal of
therapy was not determined, and dual-drug regimens were used in 70 percent of cases and
monotherapy in 23 percent. In 61 percent of cases, ART was used without treating underlying
OIs. The authors found that initiation of salvage regimens from among the scant number of
currently available drugs indicated improvement in 30 percent of these previously failing cases.
They recommend that only specially trained doctors should prescribe these drugs.696
Another study of family physicians and consultants examined the knowledge and practices of
physicians m three low-prevalence and three high-prevalence states. Among the chief findings of
this study, led by Grant Medical College & Sir JJ Hospital in Mumbai: In low-prevalence states,
70 percent of family physicians were unaware of the HIV ELISA test, and 80 percent unaware of
ART except AZT. CD4 and viral load monitoring facilities were nonexistent, and counseling
concepts alien. In high-prevalence states, 85 percent of family physicians know of ELISA and
Western Blot tests. Elementary counseling concepts are known but seldom practiced. Parameters
to initiate therapy, drug regimes, drug combinations, and patient monitoring are poorly known.
About 5 percent of family physicians attempt ART use, with AZT+3TC the most frequently used
regimen, though monotherapy is also common. Internists, chest physicians, and
dermatologists/veneriologists also practice HIV medicine, of whom 60 percent know of
HIV/AIDS drugs and regimens. Their knowledge of patient selection criteria and monitoring,
including CD4 and viral load, is vague. Over 90 percent are not familiar with salvage therapy. 697
Dr. Ruairi Brugha of LSHTM also highlighted these concerns in a June 2003 article in BMJ.6™
Female-controlled Prevention Technologies
: . iruPatl)> and Dr- Surya Rao (Vishakapatnam) indicate high acceptability of
microbicides. These surveys underscored that:
Most women are reluctant to discuss sex-related matters with their husbands. Most are not in
a position to negotiate (male) condom use. It is therefore crucial to include men in dialogue
about gender power imbalances and improved communication related to sex
Cost-effectiveness, efficacy, accessibility, and need for privacy should be crucial
considerations in microbicide development.700
*
In February 2002, Hindustan Latex Limited signed an agreement with the U.K.-based Female
Health Company to market (and eventually produce) female condoms in India. HLL and FHC
have launched operations research and social acceptability studies of the FC in three statesMaharashtra, Kerala, and Andhra Pradesh. The female condom would be priced at Rs 45 ner
piccejapprox US$0.95). HLL is exploring commodity and funding assistance to subsidize the
COS i.
Economic Interventions
See also the Human Trafficking section above.
Examples include:
ResP°nse through Capacity-building and Awareness
(CHARCA): Collaboration of NACO, U.N. Foundation, and the U.N. Theme Group on
HIV/AIDS in India. Seeks to reduce young women’s vulnerability to acquiring HIV/STIs
through skill building and other inventions. Currently being implemented in six districts
in six different states.
•
Better Life Options Program, implemented by CEDPA: uses an empowerment model to
integrate education, livelihoods, and reproductive health; offers adolescent girls life
skills, including literacy and vocational training; support for entering and staying in
formal school; family life education, and leadership training. A study of the program’s
effects in Delhi, Madhya Pradesh, and Gujarat indicated that it had significant impact on
participants’ economic empowerment (literacy, completion of secondary education,
employment, and vocational skills); autonomous decision making (when to marry how to
spend money); reproductive health (visits to health centers alone, knowledge of
HIV/AIDS), self-esteem and confidence; and child survival practices.703
"
South India AIDS Action Program (SIAPP): facilitates establishment of thrift
cooperatives for SWs and MSM so that they may access savings and credit facilities.
Activities include identification of areas for cooperatives, training of specific community
members to initiate programs, public meetings-to highlight advantages of cooperatives,
open session for local community to observe the working of a thrift cooperative, and
periodic technical and administrative support to cooperatives, including leadership and
accountancy training.704
Adolescent Livelihood Project, University of California San Francisco: provides
adolescent girls in Bangalore with economic opportunities, thereby enhancing their
bargaining power in sexual relationships and reducing their susceptibility to STIs/HIV.
-
Johns Hopkins University Bloomberg School of Public Health: Organizes devadasi
women into self-help groups for income generation activities. In addition to job training,
they are also provided health services and education programs, with a focus on HIV/STI
prevention.
Vaccine Trials
Since 2000, the International AIDS Vaccine Initiative has been working with the Indian Council
of Medical Research and NACO to develop and evaluate AIDS vaccines in India. The National
AIDS Research Institute in Pune will launch phase I trials of an AIDS vaccine in late 2003 or
early 2004.
Industry
See also the section on ART above, which described the actions Indian pharmaceutical firms.
The industrial sector is beginning to respond to HIV/AIDS in India. The prime minister recently
urged private industry to work with the government to help spread awareness of HIV/AIDS
Specifically, the private sector was asked to focus on funding health services for employees and
their families, ensuring easy access to condoms among employees, eliminating HIV screening as
a requirement for employment, and ensuring nondiscrimination in the workplace.707
Several private sector employer organizations are actively involved in HIV prevention, and
projects include workplace interventions, community programs, and support for NGOs. The
Confederation of Indian Industries (CII) mobilizes industry to implement nondiscriminatory
policies vis-a-vis employees with HIV/AIDS, as well as to encourage implementation of
behavioral change programs for prevention of HIV. CII is also committed to providing advocacy
and leadership; increasing business action on the national and regional levels; and promoting
multisectoral partnerships with business, government and civil society. CII has supported over
1,700 companies in establishing workplace programs.708 , 709 In addition, the Associated
Chambers of Commerce and Industry of India and theFederation of Indian Chambers of
Commerce and Industry are also involved in HIV/AIDS workplace activities (they, along with
CII, are part of India's Country Coordinating Mechanism, which designed the country's GFATM
proposal).
APAC, the joint NACO and USAID collaboration, encourages the involvement of the private
sector in the marketing of condoms. Specifically, APAC supports a manufacturer of condoms,
J.K. Ansell, to increase accessibility in Tamil Nadu; between 1996 and 2000, the number of
condom retail outlets in Tamil Nadu increased from 17,600 to 31,600.711 In addition, APAC has
created a training manual for private sector workers, aiming at educating different types of
retailers (medical, general, grocers, cigarette shopkeeps) in condom promotion.712
Tamil Nadu also worked with a multinational advertising agency to launch a social marketing
campaign targeting young men. Advertisements were screened at major cricket matches, using
cricketing language to promote protection against HIV/AIDS (“If you bowl a maiden over
tonight, use a condom”).713
The ILO has an India HIV/AIDS project and is working with businesses, trade unions, and
employer federations. ILO has documented the HIV/AIDS programs of several Indian
businesses, which span awareness raising, training, condom distribution, VCT, and care &
support. Some companies also offer treatment of STIs; some, treatment of OIs as well. Very few
appear to offer ART.714
Among prominent companies with HIV/AIDS programs are:
■
Tata Tea, Ltd., employs 27,000 workers spanning 30 tea estates (six in Tamil Nadu and 24 in
Kerala); considering the families of employees, beneficiaries total 100,000. Tata Tea has
invested in a program to train, educate, and counsel its employees on STIs and HIV/AIDS. It
also works with sex workers in Munnar.715,716
■
Tata Steel: From April 2001through January 2002, the company's Core Group on AIDS, in
coordination with its drug & alcohol awareness program, reached 25,025 participants with
HIV/AIDS awareness and training interventions. Referrals are made to the AIDS Cell at Tata
Main Hospital for further VCT and care & support services.717
‘
Hindustan Petroleum Corporation (HPCL) has enacted an AIDS prevention plan, including
educating staff on HIV/AIDS, training peer educators to work with employees, displaying
HIV/AIDS publicity materials, distributing AIDS-related literature to customers, and
promoting condoms at the company’s retail outlets.718
Steel Authority of India Limited (148,000 employees), Larsen & Toubro Limited (26,000
employees; engineering and construction firm), GlaxoSmithKline Pharmaceuticals Limited
(5,000 employees), Mahindra and Mahindra Ltd. (autos and farm equipment), and Bajaj Auto
Ltd. all have HIV/AIDS prevention and care programs.719
■
(See also previous discussion of projects that work with the transport sector.)
Links
For queries regarding links, please contact the project director: Lgarbus@psg.ucsf.edu
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396 NACO. National Baseline General Population Behavioural Surveillance Survey: 2001 New Delhi
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449 Hausner DS, Ramasundaram S, Murthy N, et al. "Condom use is rare among male college students who have
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