HIV and AIDS: The Global Inter-Connection

IN THE EPIDEMIC'S SHADOW

By Shyamala Nataraj

"White man's balloons. That's what we call condoms here," Selvi splutters as smothered giggles erupt into general laughter among the women gathered on the floor of her house. Selvi, who lives in one of Madras's slums, is barely nineteen and already big with her third child. "I'll have an operation after this one. No balloons for me, thank you."

Fatima nodded vigorously, saying, "I had to go and get mine done without my in-laws knowing about it. Thank God I did, a fifth kid would have been impossible." Gowri, one of the few who among the group who still had not had an operation explains, "The doctor said I was too weak, no blood you know. So I have to wait." Lakshmi with a sly grin asks, "But that doesn't stop your husband does it?" Amid blushes Gowri plaintively says, "I hope I don't get pregnant again, but what can I do?"

A merry brown face peers through the doorway and the women call out, "Lakshmi, come on in, you're just the right person to talk about all this. Tell us, have you ever used a condom?" While steadily chewing a wad of tobacco, Lakshmi replies, "You mean white man's balloons? Well, we actually used it once, but my man didn't like it at all. I remember him complaining about having to throw it out in the street. You know how these kids pick them up and play with them."

"The children blow them up or fill them with water and play around. God, they can hold an awful lot of water," her friend Gowri quips mischievously. Patting her suckling infant, she says, "When I had this child here, the nurse at the government hospital thrust a handful of them at me and told me to ask my husband to use them. He was livid. He yelled: 'You want to castrate me woman,' and flung the whole lot out of the house." "Mine would immediately think I was seeing another man," says Fatima, whose husband keeps another wife somewhere else in the city. "These men are so suspicious. 'Where are you going?' 'What are you doing there?' 'Who are you talking to?' Imagine asking them to use condoms!"

In India, it is not just the Gowris and Selvis who face the problem of unwanted pregnancies and carry the responsibility for avoiding them. The lack of birth control unites all women. With India's population at 880 million and expected to total more than 1 billion by the year 2000, the need for an aggressive family planning effort has never been greater. Yet the government-initiated family planning campaign has focused solely on women. As Dr. Mira Shiva reported in an article in Health for Millions: "Even when vasectomies on the male are easier to perform and cause less complications, they are unpopular, mainly because they are associated with impotence. No attempts have been made to dispel this myth while great efforts have been made to convince women to get sterilized as the only solution inherent in the social structure."

The spread of HIV is now prompting government and private organizations alike to take a fresh look at existing policy. Successful social marketing of condoms by Population Services International India, a nonprofit society committed to family welfare located in New Delhi, has led to a belated recognition of the need for effective condom marketing strategies.

The need to reach and educate the populace is acute. For example, women who work as commercial sex workers say that clients rarely, if ever, use condoms. And many of the women are themselves unaware of the fact that condom use can prevent sexually transmitted infections (STIs). As one woman said, "I thought they were only for family planning. But I'm careful. I can make out if somebody has something by looking at him, his nose, his hands, his ears."

But commercial condom manufacturers still resist associating their product with STIs, HIV or AIDS. They prefer to position their product as upmarket and trendy. Although this male-focused marketing strategy has increased sales, consumers continue to be from the upper income brackets, while the man on the street remains unconvinced. For him the decision to use a condom has to transcend more than his psychological resistance. It must be viewed in the context of his physical environment, the way he lives, the facilities he lacks, and the lifestyle imposed on him by his surroundings.

As a result, Muthu's attitude is fairly typical. "I work in the port, coolie work. Sometimes there is too much heat in my body from working so many hours in the sun so I have to cool off. So I have a drink with some friends, watch a movie, eat some mutton curry, and have fun with a woman. So do many of my friends. No, we don't use condoms, that's for family planning. Besides, when the chance comes who'll go looking for them? And why pay so much if you can't get the same jolly? Once, in the beginning, I got venereal disease but I took some medicine and it was all right. Now I'm careful to see what kind of girl I pick up. I can make out who's safe by seeing their face."

"Condoms?" snorted Perumal derisively. "What for? My wife has already got operated so we don't need any family planning. These health people keep handing them out to us but we give them to the kids or throw them away. I can't imagine anybody using them. Besides, where would they get rid of them afterwards?"

Perumal's living conditions make his concern about disposal all too understandable. He, his wife, and their three growing children share approximately 100 square feet of space with his two brothers. Their home is one of 700 in a colony meant for no more than 300. The tightly squeezed houses back onto narrow lanes that separate one row from another. Although the lanes and houses are kept scrupulously clean, the common areas around the few water taps and block of toilets are filthy. This is partly due to overcrowding and partly the result of an erratic water supply and no system of garbage disposal.

Despite the terrible overcrowding and poor sanitation, Perumal is resigned, even content. "If I were back in my village, I would live in a cleaner place but would have no income. Here at least I make enough to feed my family and to send my kids to school. What else can I do?" Most of the men in the colony work as rickshaw pullers, day labourers, or construction workers. To supplement their income, some of the men used to sell their blood to the hospitals, but they are not buying now. So according to Perumal, "We go to small private places where nobody makes a fuss."

Perumal's home is located in one of approximately 2,500 slums that dot the city of Madras and house more than 100,000 people. Each day migrants come to the city in search of employment, and new colonies appear. This housing phenomenon is occurring in all of India's cities as runaway population growth and increasing poverty destroy the environment and set into motion huge streams of distress migration.

It is estimated that there will be an increase in the nation's urban population of 100 million by the year 2001. Only 60 million of this increase will be due to natural growth. Migration is the major reason for most of this population growth. Agriculture is the principal activity among 75 per cent of the population in rural India. And when drought occurs, people are forced to seek alternate employment. The paucity of labour-intensive industries in rural areas, a lack of alternate skills-training facilities, and the concentration of wealth in urban centres forces people like Perumal out of their traditional niche and into the cities. It is rare that these migrants ever return to their village. As Perumal's sturdy twelve-year-old son put it: "Agriculture is for illiterates. I want a government job."

"Unemployment is our biggest problem," observed Lakshmi the next time we spoke. "Men can always find jobs as construction workers or coolies at the docks, but it's bloody hard work. No wonder the men drink so much. But after a while they can't do without the stuff, then they lose their jobs and it's up to the women again to feed the family. I know some women who buy their husbands their liquor so they can keep an eye on how much he drinks. Besides, if he is at home, there's not much chance of whoring around.

"But women aren't saints either. I suppose it's all natural, what else is there to do. I had a lover myself before I married this man. My first child is actually his, everybody knows, but so what, it's really no big deal. There are a lot of girls in this colony who aren't married but have kids. How do you think they look after them? Certainly not by selling sweets," she winked knowingly. "There are even some men here who like men, you know what I mean? And many of them are married. Some wives know, others don't, but what can they do?"

The emergence of HIV in India has focused attention on certain behaviours that were considered foreign and impossible in our country. "Come with me one night and I'll show you at least three respectably married, well-known men trying to make contact," challenges Ashok Row Kavi, the Bombay-based publisher of India's first magazine for homosexuals.

The existence of homosexuality is finally being acknowledged, so too is the fact that premarital sex is on the rise. Several studies at government-run abortion clinics around the country have found increasing rates of premarital pregnancy. Another survey revealed a significant presence of STIs among unmarried girls in a rural area in the state of Maharastra.

In addition to disproving the smug assumption that the strongest factor in preventing the spread of HIV in the country is India's superior value system, the Maharastra survey is another clear indication of our vulnerability. The high incidence of STIs is now acknowledged as a factor which enables the spread of HIV. A UNICEF-sponsored nationwide survey found that one out of every twenty Indian men and women suffers from some form of STI. The lack of sex education, the reluctance to discuss sex and related matters openly, the stigma attached to sexual issues, and the prevailing belief in folk remedies cause people to delay seeking treatment thus facilitating the further spread of HIV. Despite the presence of more than 300 STD clinics throughout the country, medical treatment is sought only as a last resort.

The superior attitudes adopted by clinic doctors where educational material and prevention information are conspicuously absent serves to maintain the level of ignorance surrounding the epidemic. The dearth of trained women specialists also discourages women from seeking treatment for STIs. Amid rising concern about HIV, many non-governmental organizations (NGOs) are now beginning to recognize the need to address the prevalence of STIs within their communities. Despite reservations about discussing sex and individual behaviour, as one social worker who works with male clients says, "discussing sex is really not as difficult as it is made out to be. People want to be able to talk about some of these things. Only they don't know how and where." Another social worker who works with women in slums in Madras agrees, "It's amazing how frank these people are. But that can happen only if you can also be frank about yourself. I feel that takes more time and effort."

Women who work as commercial sex workers are also vulnerable to contracting HIV. Vijaya has been a commercial sex worker for more than ten years. In 1986, when surveillance had just begun, she was one of the first women found who tested positive for HIV infection. When questioned about HIV she retorts, "What AIDS? I don't have anything, no fever, no diarrhoea. See my hands and legs. I'm perfectly normal." Vijaya was one of 500 women who were arrested in 1989 under the Prevention of Immoral Traffic Act. She was subsequently detained after the expiration of her sentence because of her seropositivity. In the latter part of 1990, after the Madras High Court, in a precedent-setting decision, ruled HIV-related detention illegal, Vijaya and the other commercial sex workers were released and have returned to sex work. In an uncharacteristically confiding mood, she once said, "You say I'm infected and that I can spread the virus to a man. But what can I do if he refuses to use a condom? If I insist, he'll go to somebody else, and I have a living to make. I want to see that my son is educated and has a good job. If somebody can assure me of that and promise me a roof over my head with a decent income, I'll stop this work. But until then what's the use of all this talk? I'll just carry on. What else can I do?"

It's ironic that women commercial sex workers are seen as the source of infection, when they have been infected by male clients.

One positive outcome of the Madras High Court ruling has been the shift in policy from eliminating commercial sex work to providing commercial sex workers with support. Surveys to determine the women's priorities are being conducted for the first time. Predictably their own health is way down the list. Their main concern is about their children, followed by a demand that the police be kept off their backs. To their credit, government is listening and several states have ordered police to lay off. In another major development, male clients are now being targeted for health education as well. Organizations are exploring the possibility of taking STI and HIV education door-to-door in the red-light areas. The rationale is that people should be treated as human beings, all vulnerable when practicing unsafe sexual behaviour, rather than as specific groups, which then get labelled as pools of infection. Perhaps the best thing that has occurred is that women are beginning to demand recognition, and as a result, the country's first union of commercial sex workers has been established.

Drug use is also not as uncommon as generally thought. According to Shanti Ranganathan, director of the T.T. Ranganathan Clinical Research Foundation, a well-known detoxification center for substance abuse in Madras, "We're seeing more drug addicts than before. Those who are addicted cut across all classes. We have executives, businessmen, students, slum people. More men than women of course, but more women than earlier. We didn't have any injecting drug users (IDUs) until a couple of years ago, so it's obvious this is catching on."

In an effort to address this relatively new aspect of the epidemic, voluntary groups are working in collaboration with government to explore the possibilities of setting up needle-exchange centres in several parts of the country. In a radical departure from what has been the norm, most authorities are willing to try things that work without getting drawn into controversies. Non-judgmental, voluntary, anonymous, confidential, and counselling are the new buzzwords that sit with surprising comfort on the bureaucratic tongue. This has, without doubt, helped heal some of the traditional distrust that inevitably exists between activists and government.

Problems still remain though. One is the absence of a policy that mandates informing infected people of their status and restricts the persistent disregard for patient confidentiality. Shantini holds an executive position in a corporation. She is married and is the mother of two small children. She is also HIV positive. Her status was discovered the last time she donated blood but she has yet to be informed. Talking to her, it seems impossible to believe that this beautiful, articulate, and obviously intelligent woman should not know something that will affect her life so drastically. "What do we do after we tell her she is seropositive? We just don't have the facilities for pre- and post-test counselling," explains one doctor, nor are any support services visible. Yet no such compunctions prevented the disclosure of her status to me, which points out a serious lapse in professional ethics.

The reluctance of medical personnel to treat HIV positive patients is another. Veenet and Rohit Oberoi are brothers with haemophilia who became infected though the use of blood products. Once it was know that they were HIV positive, Veneet says, "all the hospitals in the area refused to treat us." In addition to being refused medical help, the brothers, who live with their parents in a flat in New Delhi, have also been shunned by their neighbors.

Although screening of blood and blood products is now mandatory and a network of sixty-seven surveillance centers has been established, the lackadaisical approach to hospital hygiene and the fact that people like Perumal continue to sell blood to private clinics, where testing may not be strictly adhered to, is a continuing cause of concern. The possibility of cross infections occurring in hospitals cannot be ruled out. Money is also an issue here: less than 1 per cent of the total federal budget goes to public health. Medical staff constantly face shortages of items ranging from disposable needles and gloves, to major equipment such as incinerators.

Unfortunately, there is mud-slinging and manipulation going on as is usually the case where large sums of money are involved. The prospect of trips abroad, exposure at international meetings, and the chance to make a name for oneself has set off a tug-of-war among medical specialists over who should be recognized as HIV authorities. This attitude is also increasingly evident among NGOs that must compete with one another for the limited funds available for HIV programmes both on a national and international level. Other organizations are quick to resent the attention being paid to HIV and AIDS, and they accuse those involved of jumping on the bandwagon.

Yet HIV offers the best chance for India to examine policy issues that have not been debated so far. The government has taken a fresh look at the AIDS Prevention Bill that was introduced in 1989. At that time several organizations denounced it as discriminatory against infected people and a violation of civil liberties. The bill allowed for involuntary detention of HIV positive people. It has now been reviewed by a select committee, which, among other things, will discuss licensing of commercial sex work, maintaining confidentiality, and support services for patients and their families.

As one person put it, "The best thing about HIV is that I can peg it to almost anything: public health, accountability, rational drug policy, sex education, sexuality, and gender issues. Then people will start listening." The good news is that some already have.

Biographical Note

Shyamala Nataraj started the South India AIDS Action Programme in 1991. A former newspaper editor, she currently works as a freelance journalist. After reporting on the detainment of HIV-positive commercial sex workers in Madras, Shymala helped bring their case before the court, an action which led to their subsequent release.