Preventing HIV/AIDS in India: Points to ponder

[Guest guest]

Sub: Some points for consideration in your discussion

Friends,

Note prepared on the occasion of the Two day International Conference of

South Asian Parliamentarians (SAARC) for " Advocacy Role of Elected

Representatives in Prevention of HIV/AIDS " , 1-2 August, 2003, Ashok Hotel,

New Delhi (India)

The person writing this letter has some experience gained in the prevention

activities against the spread of HIV/AIDS in India for the last eight

years. Initially the Government and funding agencies came in a big way

addressing the issue of HIV through prevention projects. During the course

of implementing the top down projects, myself and my organization felt some

severe inadequacies starting with its conceptualization, implementation and

down to preparing the ground for it. In short, in project lingo, these are

lessens learned.

# Targeted intervention among " high-risk groups "

This is a highly effective intervention strategy. As the modes of

transmission are through blood and sexual intercourse to address the

high-risk groups (sex workers; injecting drug addicts; mobile work force,

such as truck drivers, construction workers etc.) on a war footing before

it percolates to the general public seemed effective. But we failed

miserably in preparing the ground for intervention. Take for example, the

case of sex workers; we never addressed the laws criminalizing sex work and

its premises, stigma attached to sex work, human rights violations both by

the public and police, gender-power relations in sexuality and differences

among the different segments of sex workers. No project can work

effectively in a criminalized atmosphere. The projects existed in India as

clandestine activity just like contrabands. There never developed a

co-ordination between the law making-implementing authorities and the

health departments.

The projects were drawn in the context of brothels in Europe or US, where

there is relative freedom for the inmates in deciding their personal

matters. But here the situation was of slave trade and there is no

organization of sex workers for collective bargaining either with the

brothel owners or with the clients. Without sexworker's organization they

can never bargain with clients; if one denies, another should not cater.

Except perhaps, in few pockets like Sonagachi in Kolkata, some fifty odd

sites in West Bengal, Sangli in Maharashtra, the sex worker's organizations

are non-existent in India. Here again, we could see the relative freedom of

sex workers running the brothels have decided the matters. But the

Governments policy is still against the sex worker's right and organization.

Again, the projects drawn in the situation of brothels are used to address

the situation of street based sex workers, for example in Kerala, where

there is no red-light area or permanent brothel. All the parameters and

monitoring systems are for brothels, which makes it ridiculous. (For

example, condom tracking, in a brothel situation, a waste basket out side a

room can provide some information but in the street, this exercise is the

joke of the era, but the project reports will be full of condom tracking)

In the absence of brothels, drop-in-centers are a must for executing the

projects. But as there was no ground preparation from the part of

Government in supporting the drop-in-centers it vanished from the projects

in the course of implementation. This means there is no collectivity and

hence no bargaining in condom use. Only a nascent organization is there in

Kerala. But projects go on in papers.

In the absence of collective bargaining the only alternative is using

condoms oneself. But the condoms supplied to the female sex workers are

male condoms, which mean they have to ask the clients, in harrying

conditions, to wear it. The power relations in sexuality are against the

women, all they could do is wear something themselves. If the Government

promoted female condoms in targeted interventions it would have succeeded

immensely. They will cite the prohibitive cost but mass production and

subsidy could have brought down the cost. In a study, it is shown that

tampons can reduce the rate of infection in women. So the Government should

also provide these alternative devices along with male condoms in the

projects and ensure their availability in the market.

There is still no concept of Male Sex Workers (MSW) but only of Men Seeking

Men or Men having Sex with Men (MSM). This stems from the assumption that

sex workers are only women; again no one sees it as sexwork but only as

exploitation of women, because if you admit the reality of sexwork, then

the strategy and policy will have to change. So the authorities just shut

their eyes conveniently against the reality. But those who are involved in

sex work whether they are male or female know it as work. So we should

understand that there is a distinct category of male sex workers, who

should be addressed independently. We are not talking of gigolos, a

minuscule category, which caters to rich independent women. We should know

that we can't address all gay men as sex workers or vice versa. Right now

there is enough confusion in these MSM projects.

Again, archaic criminalizing laws coined in the name of " unnatural

offences " hinder all activities among the male sexworkers as well as within

the gay community. There are instances of health activists getting arrested

on these charges. The concept of needle exchange among IV drug users is

still being debated. With the existing laws, as in the case of sexworkers,

no project can be implemented with effectiveness. Change of law is a must

in these situations.

# Condom promotion

The concept of A (Abstinence) B (Be faithful to one partner) C (then use

condoms if you can't stick to the other two) in prevention projects ran

high. All the IEC (information, education and communication) materials

produced by the State Aids Control Societies (SACS) had this moral overtone

in it. I must say they created fear and shame in people on the whole. Now

it is backfiring. People are rejecting their kith and kin and in the case

of strangers they even go to the extent of lynching them. The supposed to

be " Indian Culture " and morals are actually fallout of our colonial

past. The Indians, for that matter the people of the other SAARC countries

also, have a rich tradition in sexuality and a practice so diverse. But,

the prudish postures our administrators take make them fit enough to be

living in the 19th Century n England. Because of this " right " moral

approach, all the people hide their sexuality and pretend otherwise (You

could see this in the speech given by Ms. Sushama Swaraj, Minister of

Health and Family Welfare, in the recently concluded session of

Parliamentary Meet on HIV/AIDS on 26th of July. Referring to the case of P.

Kousalya, the President of the Positive Network who spoke on the occasion,

she stated that she was a prime example of a person who had been affected

through " no fault of hers " .) Yes, sex is a crime!. The existence of several

million female sexworkers along with millions of all other varieties in

India show that we have a highly promiscuous way of life. We all pretend

that we have the barest minimum of sexual life and only the " westerners "

are indulging in sex. If it is true, then how come we, Asians have the two

thirds of the world population? We should know that we are more active in

sex and for that matter, more in 'penetrative' sex and for that matter,

more in 'unsafe' sex among all the people in the world. So it is imperative

to promote condoms in every way possible and also teach non-penetrative

sex. Think about promoting kissing in the movies and tell people to indulge

in non-penetrative sex. Make sexuality a pleasurable act, which could be

safely practiced instead of keeping it as an act of procreation. Keeping

sex as an act of procreation, as religion preaches, is keeping people in

the animal state. Because, westerners were able to conceive sex as pleasure

in their culture, it remains one of the main reasons that brought the

burgeoning population in their countries under control. Here even after

thirty years of condom promotion, in the family welfare scenario, it failed

to click because of the opposite understanding. For us sex means first

procreation and then always penetrative sex. Just think about all the

literature like Kamasutra and all the temples of Khajooraho and Konark,

what a fall! A real fall from heaven. What we call now western is Indian

and what we call Indian is western.

When I talk of condoms, we have to think about varieties. We should invent

different varieties, especially different colors, which suit the Asians. We

can do away with the white variety at all, may be, keep a few for the pale

skin people. We must produce immediately flavored condoms and thus promote

oral sex, another safe sex activity. As I said earlier we must produce

female condoms and tampons to give our women a defense against the

penetrative sex culture of the males. This will remain as a viable

alternative for the meek and submissive " wives " and " girl friends " .

Look at the varieties now available in the market, ribbed condoms, spotted

condoms, dotted condoms etc. etc. The idea of friction inside the vagina is

behind all this, which the male think is a necessity for women. Poor women

have to bear all the thrust and just burn inside. Can't these fellows who

design these condoms, just ask the women? Haven't they heard about a

protuberance called clitoris in women? Didn't they know about the

Grafenberg spot (G-spot) in women's vagina? Ignorance of women's sexuality

is the principal input in the designs of men's condoms now. We have to

consult women for making male condoms. Similarly consult men for designing

female condoms.

# Gender

If we are not addressing gender-power relations in our culture, we are a

doomed people. What we call our culture, is basically an oppressive male

culture. Where, in reality, women are bought and sold by men, whether we

call it marriage or not. What we call families, are slave houses. The

untouchables and stigmatized castes in yesteryears (true, in some parts of

the country, even today) felt it " natural " or " fate " and in some cases even

felt " proud " of their pitiable existence. This role is played to the

maximum by the women now. Talk to the rural (and to most urban) women, they

have no idea of self, freedom or equality but only of an animal existence.

This animal existence is the back bone of the so-called " Indian Family " . We

show the increasing divorces of the west and talk about the " strong "

families of the east. But if you look into the cities, where the women have

developed some self and knowledge of right, you will see divorces

increasing. Everyone will say, " western " influence. Nothing of that sort,

it is the identity of the women as a conscious subjects that produces the

schism in the family. We will see more of it in the future if democracy

percolates into this so called " Indian or Asian families " . As more and more

of women break free of their millennia-long dominated trance, they are

becoming aware that much that was once viewed as just and natural reality

was socially constructed -- and hence, that it can be deconstructed and

reconstructed. Of course, the Asian men are wary of it and that is why they

are spreading this rumor of our " ancient culture " , which was all cozy,

cozy. And they use religion for this end; all talks of religion and culture

boil down in the end to the curtailing and controlling women and their

sexuality. Women as a section, in all the classes, remain the most

exploited. A Dalit woman has to bear the oppression of class and caste as

well as of gender and race.

We should know that it is men who take initiative in sexual matters and for

that matter, we should address them in all corners, in all walks of life.

We should teach them, first to respect women; I mean their wives and

sisters, not some eulogized Deities or " Devies " . Teach them not to see them

as " fields " to be sowed with their seeds, but as partners in their life, as

another human being. Teach them to ask their permission first before they

make sexual advances. Teach them to talk to their partners about sexual

matters. Teach them not to use violence, physical or mental, upon their

partners if they refuse coitus. Above all teach them to love them instead

of inflicting conjugal rape. Then, teach them that penetrative sex is not

a must for sexual pleasure and for women it is the least desirable. Make

them understand the sexuality of women and if not for procreation, make

them avoid, at all costs, penetrative sex. Break the inflated balloon of

" masculinity " ; teach them to be just another human being. Tell them they

don't have to carry all the weight of masculinity of eons and prove their

virility by raping their partner. Teach them the so-called feminine values

of care and love. Teach men to daily attend the women and children, not

just be the bread winner. A man caring for the children and women won't be

that violent.

You may ask what all this means in the field of HIV/AIDS prevention, I will

say everything. If we can address men as a section and device projects for

them specifically, we will achieve the impossible. Right now, all the

health programs are targeting women because it is easy to avail them.

Unless and until the women recognize their status as equal to men, it is

useless to spend billions on them. It is the men, who decide. Take for

example, in the family planning scenario, when first male condoms where the

only the option available, men used it more. Then vasectomy came and men

queued to get operated upon. But once tubectomy came into vogue, men shed

all their responsibility of using condoms and undergoing vasectomy. So we

have to educate men on their responsibility in sexual matters, which will

bring a sea change.

# Sex education in Schools

" Experience of AIDS control in other countries has shown that education is

crucial to the success of the struggle against this epidemic. Only

education can empower young people with the knowledge they need to protect

themselves and their communities. Only education can combat the problem of

stigma and discrimination " . Mr. Atal Bihari Vajpayee, as quoted in SAATHI,

newsletter in the recently concluded session of Parliamentary Meet on

HIV/AIDS on 26th of July.

See the conscious avoidance of the word Sex before the word education.

Don't you think Mr. Vajpayee is referring to sex education in this context?

But that is how clever our administrators are, talk big and leave the

necessary. Any thing reminiscent of sexuality is looked down upon, so sex

education in schools and colleges remained a far-fetched dream. Increased

segregation of girls and boys and the pregnant silence on sexuality

produced hypocritical and ignorant as well as violent " citizens " and

administrators/rulers. Right now our schools are acting as factories

churning out violent men and submissive women. The main duty, other than

teaching, of the teachers is to play police in monitoring the pupils. Their

sadistic interests are in catching young students writing love letters,

talking to each other and even glancing to the girl's side. Even from the

first standard, children are separated and made " boys " and " girls " . If

pregnancy is the problem they are trying to avoid, the teachers should know

the basics that children before the age of puberty are not capable of

making others pregnant. This unhealthy situation in schools brings out

violent young men, who have no knowledge of sexuality and of tenderness.

These half baked human beings are then forced to tie the nuptial knot. And

what can you expect in this " married " life? When literacy increases, which

mean even the last of them, are going through the mill of school, violence

will also increase in proportion. We should make all the students of young

age till the 10th standard, sit together and know each other. We should

abolish all girl's and boy's school at the earliest, make co-education a

reality.

Then, introduce sex education in schools. This will bring down, unnecessary

pregnancies, illegal abortions, rape and violence in married life as well

as in the society at large. This alone will help to have healthy sexual

life, which naturally will prevent the spread of AIDS.

# Treatment and Care of PLWHAs

This has been already pointed out by many people who are involved in this

field. Right now we test people, know their status and leave them on the

road. The only contribution of the testing is increasing stigmatization of

HIV+ people. Catching a disease in the words of Ms Sushama Swaraj " is their

fault " , a crime. Any test in Medical field is to recognize about the state

of disease and for treatment. But when it comes to AIDS, for the

Government, it is only to know and make people either commit suicide or get

lynched. NACO in its policy says because of its prohibitive cost the

Government is not considering treatment. Hope this could be said of the

" knees " or " eyes " of ministers.

After forgetting about the inhumanness of this statement, I must say this

is faulty logic, people falling ill for considerably long period and

filling up beds and wards of hospitals will incur more expenditure than

healthy people walking around. We must remember that it is people of the

productive age that are being wasted by this policy. Urgent intervention is

necessary for correcting this attitude and introduce the available

treatment as soon as possible. In India we have companies producing the

cheapest of medicines in the world. Look at Ms Kousalya, who represented

the HIV+ person in the above said meeting, bubbling with enthusiasm and

energy. We are losing hundreds, daily, like her because of our neglect.

VCT Centers are established by the Government for counseling and testing

but there are umpteenth number of private labs that have mushroomed all

over the country with no facility for counseling. None of the labs do three

testing, which is mandatory. They, with impunity and insensitivity, tell

the patient or relative about their status and create much trauma for

everyone. Even with three tests ELISA has prohibitive false results, and

then think about one test. Immediate intervention with necessary laws in

this field is a necessity of the hour.

# The formation of SACS

Before concluding, a few words on the AIDS Control Societies formed in the

country. Though I am not sure of the rest of the country, the one formed

here, in Kerala, where I reside, is no society but an inefficient extension

of the health department. AIDS Cells, the forerunners of AIDS Control

Societies, were dismantled for efficiency and given relative autonomy.

Probably this has been implemented on the insistence of the Foreign Funding

Agencies. But, it is the same old soup in a new name. The SACS remain a

society in name. It is the same old staff, with the same old attitude,

inefficient, spiritless, spineless and useless. All they did was create

fear in the minds of people, increase stigma against the positive people

through their " moralistic " awareness campaign. ( " Avoid sex with strangers " ,

one caption goes. Think about a country where arranged marriages take place

and people marry only strangers. No dating, nothing. Again, if you make

friendship and buy a coffee and then have sex, no fear of infection! The

stranger is a friend now, no friends will infect... All this happens

because they want to be moralistic.) We have to be innovative and bold to

face such a situation. But that is exactly missing in these societies.

There are now international covenants that stipulate the formation of

institutions with autonomy on human rights, women's welfare and social

justice. So the Government goes on making the Human Rights Commission,

Women's Commission, etc. etc., but all are toothless, wasteful and are only

making a lot of noise, creating an impression that something is being done.

Adding to these now, we have the SACS, but we should know that we can't get

away this time. AIDS is not like Human Rights, it will get you even if

funding agencies don't. So I plead to you all: let us be serious in our

efforts in addressing this deluge of a disease. Let us not try to delude

ourselves.

Maitreya

Foundation for Integrated Research in Mental Health (FIRM)

PTPN-E30, PTP Nagar PO

Thiruvananthapuram, Kerala, India-695038

Tel: +91 471 2598186®, 2368142, 2300334

Emai:maitreya@...