Paradigm shift in HIV policy in India ?

[Guest guest]

Hullo all,

I am a new entrant in this group.

I was wondering if there had been any discussion or policy analysis done

on the grp mails as regards the health minister's decision to change what

constitutes the ABC of AIDS prevention@ Abstinence, Being faithful and

Condom use.

I have not had the opportunity to go far back into the archives to look if

there had been any discussion on the issue but there have been no current

mails to the effect.

I am surprised that such an issue with far reaching implications has not

been discussed threadbare.

The issues I would like to hear discussed range from:

1) Is this in keeping with the " best practices " as prescribed by

international bodies?

2) Cost issues (rupee/$ terms and also of morbidity/mortality indicators)

of such a huge policy deviation

3) Stance of the international funding/aid bodies that push " condom use "

as part of " international best practices "

4) How far gone is it in terms of becoming the mainstay ?

5) M & E systems, if any, to monitor an " intervention " such as this.

Regards,

Yatin Gadgil

E-mail: <yatingadgil@...>

[Guest guest]

Re: Paradigm shift in HIV policy in India ?

Dear Dr. Gadgil,

I was happy to see the question you have raised about the relevance of ABC

approach to India. I was not sure whether you were critical of the government

approach or and supportive of the condom centric approach followed in India.

Without any hesitation I will state that India needs a programme appropriate

for its culture. International programmes working in Thailand and USA will not

necessarily work in India.

Abstinence is strong cultural norm even though changing at the urban levels. In

spite of 50 years condom promotion its use on a national level is about 10% only

although among high risk it may be much higher. Uganda has very successfully

promoted ABC approach and effectively reduced HIV prevalence.

Therefore ABC is not based on any government or religion. It is closest to

Indian values and therefore has the best chance of success if promoted

correctly. Even now it is not too late to fall back on ABC approach.

Yours sincerely,

Abel

E-mail: <rajaratnamabel@...>

[Guest guest]

Dear Dr Gadgil & Abel

I would agree that ABC is an effective approach suitable to the culture of

India. I would think it will be as successful (if not more) as in Uganda.

We like to believe that Abstinence is a strong cultural norm. However I have

evidence to believe that an average Indian is as human as everyone else in their

sexual practices and abstinence is not a norm either in urban or rural areas.

Hence the ABC message would be an essential and workable HIV prevention

policy.....

Sincerely

Ruth Kattumuri

E-mail: <r_katts@...>

[Guest guest]

Re: Paradigm shift in HIV policy in India ?

Dear Abel,

Could you please share the source of your data that abstinence is a " strong

cultural norm in India " ? Did any one / any organisation do a nationally valid

randomised sample survey of Indian sexula norms ever? A peek into our 'cultural'

texts seem to point to just the opposite. Has any one of the hundreds of

'rishi's in Mahabharata missed a chance to have sex?

On the contrary, scientific data on HIV/AIDS in the Indian context clearly

states

1. We have around 4 million (and counting!!) HIV positive people in India

2. The greatest proportion of infection in India occurs through the sexual

route!

And this in a country with a " strong cultural norm " of abstinence!! Therefore,

it is time to remove such 'hypocritial' blinkers from our minds - take for

granted that sex occurs (and in copious amounts - and in multifarious

configurations) in India (after all we are more than 1 billion - abstinence?!)

and develop HIV/AIDS prevention/control activities from there. If we stick to

such sorry relics like the ABC modes, then God help us!

Thanks and regards,

Dr. Amitrajit Saha

E-mail: amitrajitsaha@...

[Guest guest]

Dear Mr. Gadgil,

The ABC approach does indeed seem to be an expanding concept in the

HIV/AIDS prevention community. It is a very interesting subject that you

have brought up.

I believe that as long as people have adequate knowledge and can view

and conceptualize their own sexuality without guilt and shame, they can

make the behavioral choices that are in their best interest, choices

that they are able to control and sustain. Unless there is enough basic

knowledge and a fundamentally positive attitude to sexuality for both

sexes (and homo as well as heterosexuality) the moralistic overtones in

the ABC-message may become counterproductive (a fear I seem to share

with Dr. Saha).

The Swedish experience is that open and positive sexuality education as

well as services (in Sweden as well as internationally) has been a

fruitful combination in reducing unwanted pregnancy as well as STI.

Information seems to make young people more likely to take pride in

their sexuality, and actually internalize their sexuality into their

process of individuation. We have also found that increased information

increases safe sex practices, such as delayed sexual debut, increased

condom use, etcetera.

A note on the experiences of ABC in Uganda: I believe that the main

effect found in the study by Singh et al was that the main effect on HIV

was the increased use of condoms among young sexually active unmarried

women. Other, less important factors were later sexual debut for young

women, and fewer sexual partners amongst sexually active unmarried

women. More information on this can be found at

http://www.guttmacher.org/pubs/journals/gr050401.html

Yours sincerely,

Niklas Dahlquist

E-mail: <list@...>

[Guest guest]

Dear Amitrajit,

Thanks for your response. I have well done representative sample studies which

talk of the sexual behaviour of the youth in different parts of the country. I

will share with you shortly. By the way from where did the 4 million HIV cases

come from. Can you please quote well done epidemiologic studies to prove your

figures. For a number of years the government figures and the International

Agencies figures don't tally. Based on my experience I would like to support the

conservative Government figures.

That does not mean that India does not have a HIV/AIDS problem. India has to

wake up. While Indians are not saints there is no denying the fact that Indians

are far more conservative which could be India's strength if addressed properly

allowing people to choose what is appropriate for them. I think Ruth has

responded in a balanced manner recognising the potential weaknesses as well as

strengths.

I am planning to address this issue in greater detail little later with

published data.

Yours sincerely,

Abel

E-mail: rajaratnamabel@...

[Guest guest]

Dr Saha is correct of course, but no one in the establishment in India wants to

hear what is correct, only what is culturally sound.

If people are going to see a decline in HIV infections there is another

arrangement of the alphabet that is necessary and some of us are using it in

direct contact with sexually active Indians world wide who are anything but

abstinent.

So I would propose a strategy that will be more effective and the first letter

will be E. Educate about sexual practices and their risk factors. In my classes

after I deal with the section on STI's some of my students begin to wonder if

they will start or continue to be sexually active.

I believe that the starting point for any program to work is to affirm sexuality

as a good gift that is practiced in many ways. India has a rich history of many

of the ways carved into stone at some of the temples I have visited. Penetrative

anal and vaginal sex is one way to achieve pleasure and enjoyment from sexual

behaviour, but it is hardly the most profound for everyone involved.

It should be noted that despite the fear campaigns sex is as popular as ever and

the old addage that " where ignorance is bliss tis folly to be wise " is the

operative word around sexual practice in India except for the better educated or

the effectively frightened.

Second letter is C for condom use but only where penetrative anal and vaginal

sex is involved, even in marriage unless strictly trusting relationships are

identified and even there there is a need to establish a strategy for dealing

with lapses in faithfulness.

Third letter is S for safe injecting practices reinforced by harm minimisation

policies and a total reform of the zero tolerance attitudes of the law

enforcement agencies.

Fourth letter is R for relationship education which will include respect for

gender categories M. F. G. L. B. T. & I

For these categories there will be the necessity for some of the older

generation to go back to relationship school and upgrade their skills.

Fifth letter is A Abstinence is a foolproof method to avoid STI's of all sorts

but the statistics in India reflect that it should be practiced by all

sexually active married couples as well, particularly where married partners are

not always living and working together.I'm sure that there are a miriad of other

alphabetical contributions that other readers might be able to imagine from the

perspective of their interaction with their communities of

interest.

I would also want to finish here with an appeal for the stimulants of hysteria

around HIV and suggest that these include doctors and allied health

professionals but also include the constabulary, that they should develop a much

more intelligent and factual approach to transmissability and include universal

safe practices in all the places where they have involvement.

If I thought I was Positive in India today the last thing I would want is to

find out for sure.At that point I would be paranoid about who else would know

and who else would find out. Stigma and discrimination would then

finish off my immune system long before the AIDS virus had a chance.

I am likely to lose my health, my family support, my home, my job, my respect

and most of the reasons the rest of us stay alive.While unidentified vectors

live on in the community with no incentives to test and no efective and

affordable testing facilities or treatment when necessary why would I or anone

else want to take that risk.

Of course while that state of mind persists we will still be shutting the gate

after the HIV horse has bolted. Such is my reaction to the ABC approach.

Geoffrey is writing from a relaxing break in sunny Singapore. I will return to

India later this year. They have entrusted me with another 6 mths Visa. I am as

always looking for opportunities to build capacity within the existing networks

of dedicated NGO's who in the most part have perfected the art of pushing water

uphill.

Please keep this discussion alive around the effectiveness of ABC versus the

present realities.

Geoff Heaviside

E-mail: gheaviside@...