AIDS In India
April 3, 2000
A version of this article first appeared in Family Practice Magazine, Feb. 10, 1997, under the title, “Naz Project Tackles India’s AIDS Epidemic.” It is reproduced here with the author’s permission.
The words “AIDS epidemic” have become part of our everyday North American lexicon, so much so that it’s easy to let their meaning slip from conscious thought. But the HIV/AIDS problem here pales to that in India where, by WHO estimates, the prevalence of HIV has reached 2 million adult cases –the highest in the world. By 2020, the region will see more HIV/AIDS cases than the rest of the world combined. Given India’s other pressing concerns –its poverty, overpopulation, ecological and security crises– the addressing of its HIV/AIDS epidemic takes on dimensions unseen in the West.
Into this milieu has risen a certain non-governmental organization (NGO) called The Naz Project. Spawned philosophically from a group by the same name in England, Naz is a small organization of 9-13 counselors and volunteers working out of the New Delhi home of founder Anjali Gopalan.
“Our strength is that we work with groups off the beaten path, groups that other organizations tend to neglect,” explains Pamela Dorrel, an American development worker who has been working in India for the past four years. Naz primarily targets street children for its safe sex counseling, and prides itself in seeking out the lowest possible income groups.
But Naz counselors will speak to anyone who needs their information. They are sometimes invited to present workshops at college campuses, supposed niches of almost Victorian prudishness. Information about sex, it seems, is a rare and precious thing in a place as conservative as India. Not surprisingly, Naz‘s sexuality hotline is overwhelmed by all kinds of callers. One man even phoned to ask how to tell if his new bride is a virgin.
“Middle class students are hungry for information about sex,” says Naz counselor Vijay Rajkumar. “They are very open about their personal experiences and gaps in their knowledge, more than people in the West –or other Indians– would expect.”
The expectations of conservative Indians is very important to Naz workers. They are eager that the middle class world of government and media comes to accept that homosexual, pre-marital and extra-marital sex are rampant at all levels of Indian society. Indeed, 8 out of every 9 HIV cases in India are contracted through sex, not through other avenues common in the West, such as intravenous drug use.
AIDS in South Asia has typically been described as a heterosexual phenomenon. It’s possible, however, that a very large homosexual population has been under-sampled. India’s huge population of slum-dwellers (measured in the millions in each city) tends not to be captured in clinical HIV/AIDS surveys, and tends to include a large number of street boys furiously engaging in sex.
Just like in large American cities, these children are often runaways from all over the country, or from neighbouring countries like Nepal and Bangladesh, who find their way to the New Delhi bus station. There, they are instantly preyed upon by pimps and abusers.
Rajkumar claims that street boys are sexually active at 9 years of age, and are often sexually abused at age 7 or younger. Even though these boys are usually involved in the sex trade, a large part of their sexual activity is with other street kids, leading Naz to make one of its most controversial recommendations. “We don’t try to discourage sex,” says Rajkumar. “We want to make it safer. That’s why we’ve recommended to the government that they provide child-sized condoms for the street kids.”
Part of Naz‘s mandate is to provide services for “men who have sex with men.” This euphemism for homosexuality is necessary because of the way homosexuality and AIDS are perceived in India. Since anti-AIDS ad campaigns typically depict photos of a man and a woman, such as those common on condom packages, many people believe that AIDS can only be contracted through heterosexual activity. Men therefore seek out other males as sex partners, even though they would not identify themselves as homosexuals. Homosexual activity is accordingly more widespread than more superficial examinations would reveal.
“The man doing the penetrating considers himself to be heterosexual,” Rajkumar explains, “while the man being penetrated may consider himself to be gay, but would tend not to identify himself as such.” In short, the terms “homosexual” and “heterosexual” may not have the same meaning in South Asia as they do in the West.
Because of this, Naz believes that no one is scared away from their counseling centre by any homosexual stigma. “Only the upper class who may have read foreign newspapers would ever think that there’s a connection between AIDS and homosexuality,” Dorrel says.
The treatment of HIV/AIDS is culturally laden, and strategies common in the West cannot be considered in Asia. “Sometimes we must go beyond informed consent,” Rajkumar declares, “even though you may consider this unethical.” India is a society in which an expert, such as a doctor, has the moral authority to command certain behaviours. Naz members follow this thread in that they will order individuals to seek medical help, to be tested, or sometimes to contact former sex partners.
The responsibilities concerning AIDS testing prior to an arranged marriage, or whether homosexual activity constitutes infidelity, are further cultural considerations that complicate AIDS outreach work in India.
Some epidemiological models estimate that the actual Indian HIV/AIDS prevalence level can be 36 times greater than that actually reported. Given this staggering figure, the work of a lone organization like Naz can almost be considered heroic.
Ray Deonandan is an epidemiologist and co-owner of The Podium. His personal website is at www.deonandan.com