Harassment of outreach workers is a major obstacle in the fight to educate people about the threat of HIV/Aids in rural India. But some groups are now mounting a successful challenge to the culture of discrimination and denial, reports Munizha Ahmad
the benefits of bill gates's recent donation of $100 million towards tackling HIV/Aids in India will largely depend on the management of these funds and the work into which they are channelled. For now, it has at least contributed towards raising awareness of a problem that has until recently made slow progress in attracting international attention. After South Africa, India has the largest number of HIV cases. According to a UNAIDS "high estimate", the figure currently stands at around 4.3 million. Gates's donation follows on a report published in the American magazine, Foreign Affairs, which predicts that by 2010, 20-25 million Indians will be affected. Regardless of whether or not such figures convince, even a small increase in the rate of infection in India and China will result in more infections than those of the world put together from the start of the pandemic to date.
Despite launching a National Aids Control Programme in 1987, following the discovery of the first HIV case in Chennai a year before, the Indian government has continued to play down the extent of crisis. In addition to this, the intensity of political will required to make a far-reaching impact has been far from adequate. Awareness campaigns, surveillance and screening programmes have no doubt had a positive effect but these have not been sufficiently followed through with, for example, the provision of counselling or the extension of basic health services to the more remote regions or isolated communities. Furthermore medical professionals are often the worst culprits in stigmatising marginalised groups. As a result much of this work has been taken up by charitable organisations and NGOs, whose resources are far more limited.
The reticence of the government in the international arena with regard to the scale of the problem could be due to fears about the effect it may have on tourism and foreign investment. Within India, however, the prevalence of conservatism regarding the open discussion of sexual matters, which is reinforced rather than challenged by the authorities, remains one of the biggest obstacles in addressing the issue. This is compounded by the perception of HIV/Aids as a disease of the "immoral" - sex workers, homosexual men and drug users - which serves only to fuel the chain reactions, both official and social, of discrimination, stigmatisation and denial. Government statements that acknowledge the importance of focusing particular attention on high-risk groups, such as women in prostitution (WIP), continue to ring hollow in the face of continued marginalisation and unprotected rights. A Human Rights Watch report, launched earlier this year at the XIV International Aids Conference in Barcelona, documents the many cases of police harassment and violence towards Aids prevention outreach workers and peer educators. Last year employees of the Naz Foundation in Lucknow, which raises Aids awareness among men who have sex with men, were arrested and charged with promoting homosexuality. The law used to justify this was an anti- "sodomy" law, which dates back to the nineteenth century. Similarly the WIP collective, Vamp, and its parent organisation, Sangram - which has built up a successful network, distributing 350,000 condoms to sex workers each month - has met with increased police harassment and violence as it has become more empowered.
Such a situation only impedes the already difficult gains in mobilising awareness and action for Aids prevention. Angela Russ, Programme Manager for the Village Service Trust, which has supported HIV/Aids prevention activity in Theni District, Tamil Nadu, for the last 10 years, explains: "Television campaigns and literature about HIV/Aids are of little use in rural areas where illiteracy rates are high and there is limited access to television. The best means of education has been through drama and speaking to people directly. But this is far from easy.
Russ recalls a Women's Day celebration when, as one speaker started to talk about condoms in relation to HIV prevention, the audience of 2000 got up and left. With more exposure to the programme, attitudes have changed and people are far more co-operative. But overcoming such obstacles is an integral part of the process. "Just getting people to talk about sex openly is a very long process," says Russ, "particularly when most women lack basic sexual and reproductive rights and those in prostitution face constant discrimination and harassment. When people feel they can't be honest about their sexual behaviour, this presents an immediate difficulty and makes our work hard to monitor."
Confidence has to be gained through devising alternative information-gathering strategies, such as private ballot. For example women are first asked to put a pebble in the relevant box to indicate whether they had rice or kul for breakfast. When the results are counted, they are asked if they can tell which woman had what, which of course they can't, and they are reassured of their anonymity. This then allows the questioning to move on, through similar means, to matters of sexual practice such as whether they have sex with regular or non-regular partners and if they use condoms, which are illustrated by pictures on ballot boxes. Although such methods require a lot of time and sensitivity, they are starting to pay off. As Russ states, "condom use has increased significantly and, with enough encouragement, people are willing to listen and also get involved as peer educators".
India's rural areas have remained largely neglected by "national" surveillance and awareness programmes and HIV/Aids has largely been portrayed and tackled as an urban problem. While there have been reports of increased condom use among sex workers in Mumbai and Calcutta, there has been little indication of developments outside cities and towns. "If anything," says Russ, "the incidence of HIV/Aids among the general population is higher in rural areas where the high levels of STDs are linked to low levels of education and access to health care.
Lack of employment causes more people to migrate for work or to take up occupations such as truck driving, which are both "high-risk", and poverty levels mean that there are sex workers in every village.
Migrant workers and truck drivers in India have been identified as high-risk groups because a large number frequent sex workers (which is usually cheaper than going to the cinema) and, after having unsafe sex away from home, come back and infect their wives. It is their wives however who are often blamed for their husbands' promiscuity and who suffer the greatest social and financial estrangement once infected.
The Village Service Trust seeks to establish models for development through small local projects and it works in partnership with seven organisations which together constitute "Network Theni". For the last 20 years, it has supported projects which focus on Dalit women's empowerment and stigmatic diseases that mainly affect the poor, issues which are an integral part of the HIV/Aids problem. National and state programmes have so far failed to extend to remote regions and communities where the mutually enforcing factors of poverty, rights and infection provide the greatest threat to stabilising the problem.
Bill Gates has stated that he intends to work closely with the Indian government in tackling HIV/Aids. However if these funds are administered solely through the National Aids Control Organisation (NACO), there is a risk of their having little effect. Corruption among the state aid cells through which NACO currently channels money is widespread, and organisations allegedly have to "buy" their grants from them.
If big donations like this are to make a difference, perhaps it would be more worthwhile to directly support and increase the protection of those networks whose programmes extend from the local, and to adopt such examples as a blueprint for future HIV/Aids work.
For more information about the Village Service Trust, visit: www.villageservicetrust.org.uk or Email: info@villageservicetrust.org.uk
