ABOUT Hiv/Aids it is often said that it is less important to inquire where it is coming from than focus on where it is going. The implication being that the exponential rate at which the infection is spreading is a cause for alarm and taking preventive action to check that spread is crucial and of immediate concern. The official estimated number of persons carrying the Hiv virus in India is around four million and South Asia will soon cross sub-Saharan Africa as the part of the world with the largest number of persons living with Hiv/Aids (PLAs).
Seminar 520, focusing on Hiv/Aids, makes a comprehensive presentation of the issues involved and the poser by Meenakshi Datta Ghosh traces well the history of Hiv/Aids in India and describes the present status of the spread of the disease and measures being adopted by the government. One of the major initiatives is the vaccine development programme and she quotes both from the prime minister’s inaugural speech at the International Policymakers Conference in New Delhi in May 2002 (‘...a vaccine is the only solution’) and the leader of the Opposition’s equally determined expression ‘as we did with small-pox and are poised to do with polio, so we will succeed in eliminating Hiv/Aids’ as indicative of our political commitment to fight the virus.
The Indian government appears to have made a breakthrough in establishing a collaboration arrangement between NACO, ICMR and IAVI to develop a vaccine against the particular strand of Hiv virus prevalent in this region. However, the development will take at least ten years before it reaches the marketplace and becomes available for common use. Even then, there is some uncertainty about being able to effectively access adult populations with a preventive vaccination programme. In the interim, the best available medical option appears to be treating pregnant women who are Hiv-positive with anti-retroviral drug therapy (AZT) so that newborn babies may be spared the infection. Herbal treatment (Siddha and Ayurveda) is another less expensive option for Hiv-infected persons to postpone and delay the onset of Aids and opportune infections like TB etc. Given the scale and magnitude of the problem, these measures appear to be a mere drop in the ocean.
Hiv/Aids afflicts mainly those from the lower socio-economic strata – commercial sex workers, migrant labour and truckers. From the migrant male workers and truckers who get infected through contact with commercial sex workers, the virus passes on to the wives and make the future progenies vulnerable to infection. The other group of injected drug-users that share needles also belong to the poorer section of society. Professional blood donors are a third group through whom Hiv spreads, though the blood safety protocol set up in the last decade may have considerably reduced this mode of transmission. The main transmission mode is through the heterosexual activity of the high-risk group in contact with commercial sex-workers and /or having sex with multiple partners.
While the surveillance data on Hiv/Aids cases in India puts the figure at four million, the worrying bit is that the transmission has moved on from the high-risk groups to the general population through the families and is affecting unborn children. The challenge lies in arresting the spread and bringing about a behaviour change towards safe and protected sexual practice among those high-risk groups where multiple sexual partners is prevalent. Even if this population is statistically small (12% of all males in the 15-49 age group) it is still significant, especially among particular socio-economic categories. With the availability of AZT the impression is that persons afflicted with Hiv may continue to lead a healthy life. Unfortunately, despite the low price of the drugs in India (owing to our patent laws, which may change after the next round of WTO negotiations) They are still unaffordable by the poor, nor is state subsidy for such large numbers possible. However, those who are economically better off can afford the therapy, as is the case in USA where the spread has been brought under control with AZT alongside effective public awareness campaigns and promotion of safe and protected sexual practice.
Even in other countries, viz. Brazil where the state is offering free AZT supply to registered Hiv/Aids patients, stigmatization of afflicted persons tends to drive the disease underground as persons do not want to disclose their Hiv status. In our country too, the association of Hiv with commercial sex workers stigmatizes those afflicted with the disease making the vulnerable groups aggrieved and desperate. This is a human rights issue with the persons afflicted with Hiv/Aids requiring treatment and care while society, taking a high moral ground, condemns and shuns them or at best has a charitable attitude towards the victims, often innocent families who get infected unknowingly. Societies have to learn to respect and provide adequate care and support for those afflicted with Hiv/Aids. Rather than wishing the problem away as someone else’s on the basis of a misplaced moral high-ground, we need to do much more to contain the rapid spread of the disease.
In Seminar 520, a strong case is made by Kapil Sibal for a comprehensive legislation to enforce the human rights aspects of the Hiv/Aids issue in order to ensure proper care and treatment of PLAs, no discrimination in the workplace, and respect for confidentiality and privacy of the individual for Hiv testing. He argues that though India as a signatory to various international covenants is committed to equal treatment of Hiv/Aids patients, in the absence of a specific legislation courts depend on the wisdom of the judges who are influenced by societal norms and attitudes. A proper legislation safeguarding the interests of PLAs and other high-risk groups will help the dispensation of justice in this regard.
Similarly, Madhu Bala Nath is enthused about the imminent availability of the female contraceptive which will obviate the necessity of persuading reluctant (or macho) men to use condoms. She argues that this will finally empower the vulnerable women to protect themselves from possible Hiv infection (or even STD) and avoid frequent childbirth as well. While both measures are worthwhile, no doubt, they will work only when society, especially its male members and other champions of public morality, are persuaded to accept the changing social reality where sexual behaviour (like domestic violence) is no more a personal and private affair of individuals but affects society to the extent that innocent women and unborn children are being made to pay a heavy price.
In such a context, communication strategies to bring about behaviour change among high-risk groups and in society at large become important. To face the reality of the migrant labour force or truckers cut off from their families, the justifiable demand for the services of commercial sex workers has to be accepted and safe and protected sex promoted more vigorously rather than only make a moral appeal for abstinence or fidelity. For ordinary mortals, particularly those engaged in stressful physical occupations, appetites need immediate fulfillment.
Arvind Singhal and Everett M Rogers in their well-documented book titled Combating AIDS: Communication Strategies in Action (Sage Publications, Delhi, 2003) stress that Hiv/Aids is more a behavioural issue than a bio-medical problem. While not discounting the scientific research in finding an effective vaccine against the Hiv virus and the significance of the breakthrough with the anti-retroviral drug therapy that checks the onset of Aids, Singhal and Rogers argue that there is no time for complacency. Hiv/Aids has been with us now for over two decades and while there has been some success with AZT, the price is prohibitive for the large numbers afflicted with the virus, mainly from the poorer socio-economic strata.
Singhal and Rogers trace the history of the Hiv/Aids pandemic since its first reporting in the United States in the early ’80s. While it was initially restricted to the gay community, the closed nature of that group fighting for recognition and acceptance resulted in the development of effective communication strategies like peer-education, counselling and other public awareness building campaigns at a stage when there was still no treatment. Combating Aids also documents the effective communication strategies adopted in Thailand for widespread condom promotion and government commitment for care of afflicted persons. The authors present extensive research from five countries – Brazil, India, Thailand, South Africa and Kenya – and make a convincing case for urgent and increased advocacy and communication action to bring about behaviour change. Apart from the case-studies from the five countries and critiques of policy and programmes, Singhal and Rogers also provide a guide to effective planning of communication strategies and programmes including the importance of training in counselling among persons living with Aids (PLAs) and developing innovative monitoring and evaluation tools.
Their central thesis, backed by evidence and the resolution of the first UN General Assembly Session on Hiv/Aids (UNGASS) in 2002 and the International Policymakers Conference in New Delhi in 2002, asserts that though medical research on Hiv/Aids has been phenomenal in the last two decades and the AZT is a landmark breakthrough, for the millions of poor people who are afflicted with the disease or belong to those vulnerable sections (particularly poor women) the answer lies in awareness through communication and affecting behaviour change. Hiv/Aids cannot be regarded merely as a bio-medical problem.
A bio-medical solution through a vaccine, as being initiated in India, is far into the future and the need of the hour is for a humane attitude towards the PLAs and vulnerable groups. In our country, beset with a wide number of illnesses from diarrhoea and cholera (gastro-enteritis) to tuberculosis to Hiv/Aids, we tend to remain unmoved by numbers of persons afflicted. The non-availability of any immediate bio-medical solution/treatment that is affordable on a scale necessary is what makes the case for a human rights approach to Hiv/Aids. There is no escape from the problem of Hiv/Aids, which is with us to stay, even if it is apparently contained among the socio-economically disadvantaged sections of society. Already it is spreading from the more urbanized and industrialized states of Maharashtra, Tamil Nadu, Kerala and West Bengal to the Hindi heartland. The network of good voluntary agencies (NGOs) is not available in these Hindi-speaking states and the communication strategy will have to be different in view of the low literacy levels and other indicators of socio-economic development.
Singhal and Rogers document many effective communication strategies adopted worldwide, including the excellent work in several states in India. They are enthusiastic about the Entertainment-Education (E-E) format of multimedia programmes that are based on social learning theories and audience research. Some notable examples that Singhal and Rogers highlight in the context of Aids communication are the Soul City television programme (with off-shoots in other media and events) in South Africa that has consistently remained one of the three top TV drama series in South Africa. It increased person to person communication on Hiv/Aids, STD and other related health issues manifold. Radio Tanzania’s Twende na Wakati, a highly successful story of Mkwaju (negative role model) and his wife Tunu (a positive role model who overcomes her circumstances), has been equally effective. In India there has been some effort with E-E in the context of family planning – Hum Log was the first. The present BBC World Trust TV series, Jasoos Vijay, combined with other public service spots and radio talk shows is expected to have a significant impact on targeted audience groups.
Other innovative communication projects across the world draw upon the compassion and commitment of religious leaders in the face of social stigma and opposition. Some of the successful Indian efforts like the Healthy Highways Project using appropriate materials and contact with truck drivers or the Tamil Nadu programme of street plays, Nalamdana, that uses every performance as an educational tool with the community, have been very effective. The role of peer-educators in the Hiv awareness programme among commercial sex workers has increased condom use among clients dramatically in Kolkata (from 3% in 1992 to 92% in 1998) leading among other things to the formation of the DMSC (Durbar Mahila Samanvay Samiti) which is fighting for recognition as a trade union in West Bengal.
In the film, Tale of the Nightfairies by Shohini Ghosh the work of the DMSC in Sonagachi in Kolkata is documented through the narratives of some of the sexworkers and DMSC activists. One of the protagonists demands the recognition of their union of commercial sex workers with 60000 members, arguing that they are servicing a social need and what they need is freedom from harassment and police brutality and social security for themselves and their families. The DMSC opposes trafficking in minor girls – child prostitution (below 18 years) is down in Sonagachi from 20% in 1995 to 3% in 1998 – and takes care of the health and economic security of its members in times of need, apart from fighting exploitation and brutality by the local hoods and police.
The success of DMSC in Kolkata may not be adopted easily elsewhere but the film captures the confidence of the members of the union and helps break the artificial ‘moral’ barrier of decency as defined by society. It is significant that the use of condoms among clients of commercial sex workers is highest in Kolkata (90% in 1998) and the Hiv affliction among them has been contained significantly, while in other cities it continues to rise fast. In Kolkata, only 5% of commercial sexworkers were Hiv positive in 1998 as against 70% in Mumbai in the same year. The case for the DMSC and its positive empowering effect on commercial sexworkers needs no further evidence.
Avik Ghosh, Delhi