International agencies, public health experts and Aids activists have dismissed the Indian government’s claim of a massive drop in new HIV infections between 2003 and 2004 as incorrect and misleading, according to reports on the Science and Development Network. India’s health minister Anbumani Ramadoss claimed the country recorded only 28 000 new infections in 2004, compared to 520Â 000 in the preceding year.
He attributed the precipitous 95% decline to the government’s awareness campaigns. In total numbers, with 5Â 134Â 000 people infected across the country according to Ramadoss, India ranks second only to South Africa, which has 5,3- million HIV infections. India’s overall HIV prevalence, however, is low: 0,91 % of the population is infected, compared to 21,5 per cent in South Africa.
Ramadoss claimed there was no national HIV epidemic in India but that there are “sub-national” epidemics in six of the nation’s 28 states. This includes the southern state of Andhra Pradesh, where the infection has reached two percent of the population for the first time. But international agencies and public health experts have cast doubt on the government’s figures and its claim that its public awareness campaign has been effective.
Denis Broun, the UN Programme for HIV/Aids (UNAids) country coordinator for India, says that although UNAids believes that the total number of people living with HIV is probably close to the Indian government’s estimate, it is wrong to think that there were only 28Â 000 new infections in 2004.
“The difference in numbers … does not represent the number of new infections because this calculation ignores the fact that people die of Aids-related causes.” “There has not been a huge decline and HIV is still increasing in India, even if at a slow pace,” Broun says, warning that the government should not be lulled into complacency or reduce the intensity of its prevention efforts.
“The figure of 28Â 000 new infections and the 95 per cent drop are wrong — they are misreading the underlying data,” agrees a Geneva-based representative of the Global Fund to fight Aids, Tuberculosis and Malaria.
“The numbers are so uncertain that using them as a reason for complacency is wrong and risky.”
“We have a slowly growing epidemic in India and nobody can afford to be complacent about it,” he warned. “Epidemics affecting around one percent of the population are often at a point where they can jump from vulnerable groups to the general population.” In April, Richard Feachem, executive director of the Global Fund, caused controversy in India when he said the HIV epidemic in India was getting “out of control” and that the country’s total number of HIV infections had overtaken South Africa’s. India’s National Aids Control Organisation immediately dismissed Feachem’s statement as “nonsense”, and last week released its estimates.
The estimate of 5Â 134Â 000 infected people overall is probably correct, says Ritu Priya, associate professor at the Centre for Social Medicine and Community Health at Delhi’s Jawaharlal Nehru University. But she says it is difficult to understand how the government came to the conclusion that new infections dropped by 95 percent. Public health experts and Aids activists are sceptical about the government’s claims of a successful public awareness campaign, given the widespread lack of awareness about the epidemic and the huge stigma and discrimination facing those affected and their families.
“There are no studies to show exceptionally high levels of awareness or drastic changes in behaviour to explain such a drop,” says Priya, adding that public awareness alone cannot make that great an impact. If the government detected so few new infections, it indicates that “something is definitely wrong” in its method of tracking new infections, says Ryan Fernandes, programme manager at Delhi-based Sahara Care Home, which provides care and support to people with HIV/Aids.
Fernandes says that infected people who are unaware of their status are still passing the virus to others. “What awareness campaign?” he asks.
“The ground realities are different,” says a member of the Delhi Network of Positive People, which represents people with HIV. “We are seeing more and more cases around us. We do not understand how the government observed such an outstanding decline.”
Officials at the Indian health ministry’s National Aids Control Organisation say their annual survey of 670 sites across the country was undertaken with the New Delhi-based Institute of Research in Medical Statistics and the National Institute of Health and Family Welfare, and followed the procedures and guidelines of the World Health Organisation and the Joint UN Programme for HIV/Aids (UNAids). Meanwhile, Keya Acharya of PANOS says sexual taboos are hampering India’s fight against Aids, according to an article available on the Science and Development Network website.
A Delhi-based nongovernmental group, the Naz Foundation Trust, wants the government to repeal part of the Indian Penal Code which criminalises homosexual behaviour, saying the penal code is a “major impediment” in carrying out HIV/Aids work among men who have sex with men. It has asked that the section cover only child sexual assault and exclude consensual sexual activities between adults. But some experts interviewed by Acharya doubt that repeal in the law will improve the country’s approach to HIV/Aids prevention. Researchers say that because talk of sex itself is taboo in Indian society, male to male sexuality is hardly recognised in HIV research and policy-making.
“The country’s male homosexual population is estimated at a considerable 50-million by the Mumbai-based Hamsafar Trust. Criminalised by the penal code and pressurised by mainstream family culture to marry, many seek out same-sex partners in an undercover world,” writes Acharya.
What makes HIV prevention harder still is the lack of a single gay identity in India, says Sheena Asthana of Plymouth University. The researchers identified several categories of men who have sex with men. According to Asthana, “very few of these men would even identify themselves as ‘gay’.” The groups include: hijras, men who may or may not be emasculated and who dress permanently as women; kothis, who have overtly feminine traits and panthis, the kothi’s partner.
Theoretically identified as the overtly masculine sexual partner, he could be a father, brother or son who considers himself to be “straight”. The implications of HIV spreading to wives and unborn children through their panthi husbands is worrying. “These patterns are important for both the transmission of HIV and its prevention,” says Asthana.
“In the West, in part because of the development and acceptance of a positive identity, homosexual activity has become more narrowly defined,” writes Acharya. “Gay men tend to have sex with other gay men and there has been a drop in the numbers of men who have sex with other men who are also involved in heterosexual relationships.”
“In India, by contrast, panthis provide a bridge between heterosexual and homosexual circuits and a high level of bisexual activity tends to facilitate the rapid spread of HIV,” adds Asthana. In a cramped office that doubles as a medical clinic-cum-lunchroom in a busy commercial street in the southern city of Bangalore, a group of young men meet to share their experiences. Trained by the non-governmental organisation Jagruti to disseminate sexual health information and condoms in Bangalore’s cruising areas — parks, movie theatres and public toilets — they say that most clients are panthis.
They also say that less than 50 percent of practising sex workers use condoms for fear of losing their clients. The relief of being able to open up and talk about their almost-surreal daily existence is palpable among the group. “You keep your condom ready in your hand inside your pocket while you tell your client to go into the bushes for secrecy. Then you quickly tear the wrapper, cover your mouth as though coughing and place the condom on your tongue like an inverted foot-sock, ready for the penis,” demonstrates a field-staffer, who did not want his name divulged.
India’s national message on safe sex does not highlight same-sex behaviour. As a result most people think that heterosexual and multiple partner behaviour are the only way to spread HIV. Condom-usage appears to be the government’s main message. But condoms distributed by each state’s Aids department are usually unsuitable for oral and anal sex, and most cash-strapped organisations are hard put to buy and distribute other kinds of condoms. The government policy also promotes monogamy, saying people should be faithful to one partner. This has made it difficult for women to negotiate safer-sex options in India’s male-dominated society.
If one partner asks the other to use a condom, the former stands accused of suspecting the other of infidelity, says Elavarthi Manohar of Bangalore-based sexual-minority organisation Sangama.
Dr Venkatesan Chakrapani, co-ordinator of the Chennai-based Solidarity & Action Against HIV Infection In India, a countrywide network of NGOs, warns against only targeting men who have sex with men. Homosexual behaviour also happens with truckers, drug-users and prison inmates, he says.
“Providing common prevention messages such as safer-sex in same-sex behaviour is a possible solution.” There is some evidence that same sex behaviour occurs among the police as well. Commercial sex workers complain that policemen use rounded-up male suspects for sex.
SciDev.Net