Lessons learned in India
Maitreya, India
***************

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)

Subject: Some points for consideration in your discussion

Friends,

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 lessons 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 Victorian 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), India
Email:maitreya@asianetindia.com

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A posting from SEX-WORK (sex-work@healthdev.net)