Re: HIV in Rural India: Many challenges ahead of us

[Guest guest]

Dear Forum Members,

This is in response to the spread of HIV in rural areas in India and

a need for an immediate intervention:

I am glad to see a discussion on HIV spread in rural areas. I do hope

some of you may elaborate on these issues.

Let me add some of my observations. I come from a small village in East

Godhavari District in Andhra Pradesh, which is a prosperous village, due

to the availability of water for irrigation. It is by the most beautiful

river, Godhavari and flushed with greenery and beauty. In our village

ignorance and innocence with regard to sexual issues are equated with good

behavior.

Literacy levels are low especially among the lower economic strata, and

economical independence by women is often unheard of or unaccepted in

the village system.

I am already hearing many stories about the number of people my

village and surrounding villages lost to AIDS and this spread worries

me. Yes it is a development issue for our village and other villages,

as many of these villagers work on the farm for their living, and

agriculture is main staple of our income. With regards to to HIV in

rural areas are:

1) Use of any barrier methods either in lower or higher income

stratum, by educated and uneducated individuals is very low

(insignificant). Many women are not simply aware of barrier methods.

Those who are aware simply have no power in negotiating or they don't

seem themselves at risk for acquiring infection.

2) There is tremendous amount of sex trade at many levels in the

villages, may be much more than at urban level. Farmwomen trade

unsafe sex with farmer/land lord for a bag of rice to feed her

family, for a small loan to get her daughter married or for a palm

leaf to cover her hut or for lack of power over the landlord. Many of

these men from all social economic levels (and castes) also frequent

small towns near by and cities (Kakinada, Peddapuram and Rajamundry

etc) to visit commercial sex workers. [For those who are interested

data on these networks, you can get them from APSACS office, as they

have already mapped these sexual networks]

3) Wives of these men may be aware of their husband's sexual

practices, however, they continue not to question as they accept it

as a normal practice or left with no economic options in case they

would fight against it.

4) It is an empowerment issue, it is a negotiation issues, it is a

poverty issues, it is an issue of education, it is an issues of

gender inequality and finally it is an issue of misuse of power by

men.

5) Until we bring about massive changes in education, economic situation

and empowerment issues among these women (which I am afraid will

take few decades), women-specific barriers methods are the only

immediate option we have in fight against HIV in India.

6) Enhancing access to PHC with specific HIV related services is emerging as

an urget need.

If we succeed in empowering these women, where will we house them when

they are thrown out for their homes for wanting to negotiate barriers

methods with their partners or husbands?

Dr. Sai Subhasree Raghavan

Columbia University

New York

E-mail: subharaghavan@...

__________________________

[Guest guest]

Dear Dr.Sai Subhasree Raghavan,

I appreciate your analysis on the continuing rapid spread of HIV in India

and the plight of women. I would not be scared of a situation where women

may be thrown out of their homes for wanting to negotiate use of safety

device. Our strategy should address both women and men folk right from the

beginning. The incindents of women thrown out from house would be very

minimal. Indian family ties are still very strong.

Dr. Ashok Kumar Agarwal, MBBS, MD

South Asia, Regional Technical Advisor- HIV/AIDS

Catholic Relief Services

4/2 Orient Row, Kolkata - 700 017

E-mail : crsei@...(aagarwal)

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[Guest guest]

Dear Ms Jayasree,

Thanks for the comments. I never denied the risk of " women being thrown out " if

she starts negotiating with her male partner. My intention was only to make the

issue light and address both the female and male. Do you know of any study or

report saying, large number of women being thrown out as they started

negotiating on sex ? Strategies are not made on rare events. There may be many

other social reasons for the women being thrown out. I agree, we need to react

fast and adequately for curbing the HIV epidemic. That is why, I said, we should

not hold back the empowering interventions for women and also include men in the

program.

Introduction of female condoms may be applicable for sex workers but I am not

sure of them being recommended for housewives. Please let me know of any study

you know of.

The isuue of strong family ties is a debatable one. Over the years, my view has

changed. I agree, the ties may also work towards disadvantages but then I find

there are more advantages. During my twenties, I used to feel, the ties are more

of a disadvantage. Now in thirties, I feel, they are more of advantage.

Hope I have been able to clarify myself to some extent.

Dr. Ashok Kumar Agarwal, MBBS, MD

South Asia, Regional Technical Advisor- HIV/AIDS

Catholic Relief Services, 4/2 Orient Row, Kolkata - 700 017

India. Tel. No. 91-33-247 6433/1969. Fax No. 91-33-240 8652

E-mail : crsei@...(aagarwal)

____________________

[Guest guest]

Dear Dr Ashok Kumar Agarwal,

I am surprised how easily you brushed aside a pertinent problem raised

by Dr Sai Subhasree Raghavan. I am positive what she wrote is true

from our experience working with the PLWHAs and other communities for

the last five years in the so called progressive state of Kerala.

Then one can imagine the plight of illiterate rural India with strong

feudal values. The women has no say in sexual matters let alone using

condoms. Any initiate from the part of women in sexual matters will be

looked down upon and with suspician. The 'strong family ties' is so

strong it actually strangulates the women. So that they don't open

their mouths at all.

This can be seen very easily from the number of housewives getting

infected with HIV. They are just sitting ducks waiting at home. If the

women open their mouths I am definite they will be thrown out the

houses. So your 'strong family' remains strong because of the silence

imposed on women. For this we will pay heavily in the future.

We give male condoms through projects to the sexworkers. Eventhough

they got more negotiating power, it is still very difficult for them

to bargain with the male clients who have to wear the condoms.

Millions of rupees are being wasted on unused and thrown away male

condoms through the AIDS prevention projects. But if we can supply

female condoms the sexworkers at least will be able to use it. But the

housewives will still be at a lose to use it. Only by empowering the

women, as Dr Sai Jayasree pointed out, we can cross over this hurdle.

But again this process, if at all it takes place, will take a long

time. Do you think HIV will wait that long? Let us cross our fingers.

Meanwhile let us not wait complacently resting against the 'strong

family ties' that kills women (and men).

Love

Maitreya

maitreya@...

Foundation for Integrated Research in Mental Health (FIRM),

Convent Road, Vanchiyoor PO, Thiruvananthapuram Kerala,

India-695035, Tel: 0471 598186, 470896, 300334 Fax:551669,

email maitreya@... jayasree@...

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[Guest guest]

Dear Dr. Ashok Kumar Agarwal,

I would respectfully suggest that you read the UNAIDS report by Dr. Shalini

Bharat on HIV/AIDS discrimination and stigmatization -- especially with

respect to women.

She has documented how (in urban settings) the experience of the epidemic is

intensified for women due to the family ties of which you speak. Women tend

to carry a disproportionate share of the blame for infecting their husbands

with HIV, and the burden of caring for those infected. The responsibility

accorded to women for the epidemic is disproportionate to the control they

have over their risk.

" ...it is the context of relationships that sets apart women's experiences

from those of the men. Women are wives, mothers, daughters and

daughters-in-law before they are HIV-positive women... to the extent that

familial and social relationships are dictated by societal and sexual norms,

the impact of HIV/AIDS for men gets blunted and shared; for women it gets

sharper and more focussed in her. ...

Daughters, wives, and daughters-in-law experienced greater discrimination in

comparison to sons, husbands, and sons-in-law. "

[bharat S (1999). HIV/AIDS related discrimination, stigmatization and denial in

India. Mumbai, India, UNAIDS and Tata Institute of Social Sciences]

With kind regards,

Shepherd

PhD Candidate, School of Hygiene & Public Health

s Hopkins University

615 N. Wolfe St., Rm W4510

Baltimore MD 21205

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[Guest guest]

Dear Dr. Agarwal:

Current UNAIDS and NACO figures for HIV infection in India show that the

epidemic is moving steadily beyond its initial focus on sex workers to the

general population, especially women (25% of infections are in women). In

Maharashtra data show that wives of men attending STD clinics who have only

had sex with their husbands are increasingly becoming infected (14% in

Pune), and the proportion of women attending Antenatal Clinics who are

infected is also steadily increasing (2% in Maharashtra which indicates

that the epidemic has spread to the " general " populations). What this

tells us is that the epidemic in India is no longer just about " sex

workers " . Women in primary partnerships (i.e. housewives) in India are not

only at risk, and becoming infected, but as much as sex workers are unable

to convince their partners to use the male condom. Therefore, advocating

the female condom only for sex workers, and not for housewives is not only

contrary to the hard evidence provided by the NACO figures, but also does

not take into account the realities of women's situation in our society.

We have enough studies conducted in India that clearly show the

vulnerability of Indian women in their family context with respect to not

being able to talk about fertility, sex, STIs, and contraception including

condom use with their partners, and experiencing violence especially if

they dare to question them about their sexual behaviors (refer to study by

et al., in UP, Annie 's study on sexual communication and

negotiation in urban areas of Mumbai - Tata Institute of Social Sciences,

Bang and Bang study in Gadchiroli on high levels of RTI in rural

Maharashtra and many others). These studies clearly tell us that the our

notion of the famous " Indian family ties " really rests on denying women

their right to information that will protect themselves and their families

from STI and HIV, and denying their right and the necessary means to act

upon that information by negotiating safe sex with their partners. While I

agree with you that men need to be an integral part of the solution (as

they are more than a part of the problem), negotiating safe sex with men

will remain a distant dream for all women (housewives and sex workers) in

India unless we start thinking of empowering them with concrete strategies

like the female condom.

Furthermore, efficacy studies conducted on the female condom in other

countries (both developed and developing - US, UK, Thailand, South Africa,

Brazil) show that the female condom not only protects against HIV, but also

also against STIs, RTIs and unwanted pregnancy. Even if you feel that the

HIV epidemic is really a problem of sex workers (which itself is

debatable), surely you would agree that other STIs, RTIs and of course

fertility (and we have enough evidence for this) are a huge problem for all

women in our country. So the female condom, controlled by women themselves

might be worthwhile advocating for all women, not just for sex workers.

I hope this has provided enough hard evidence from numerous studies

conducted in India and published that test the notion of " Indian family

ties " , and demonstrate the need for concrete strategies to protect Indian

women (and yes men as well) not just from HIV, but from other STIs as well.

Avni Amin

Avni Amin, Ph.D.

Senior Program Associate

Center for Health and Gender Equity

6930 Carroll Avenue, Suite 910

Takoma Park, MD 20912

Tel: 301-270-1182

Fax: 301-270-2052

Website: www.genderhealth.org

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