Gender Continues To Complicate HIV Prevention and Intervention Programmes

Representative image. Photo: HopeMedia/Flickr CC NC 2.0

This is an edition of the Science & Gender column, which explores the intersection of these two realms in all their forms. Editions will be published once every six weeks.

2002 saw billboards in Mumbai inundated with posters that posed a curious refrain: Balbir Pasha ko AIDS hoga kya? (“Will Balbir Pasha contract AIDS?”) Along with Balbir Pasha, purportedly a representation of the “common Indian male”, there was another character that found mention – Manjula. She was represented as the quintessential sex worker, provocatively standing with a hand above her head, the other at her waist, with her cleavage revealed just enough to solicit clients like Balbir Pasha. A billboard with Manjula’s picture posed an interesting scenario: Balbir Pasha sirf Manjula ke paas jata hai, par Manjula ke paas aur bhi toh jaatein hain. (“Balbir Pasha visits only Manjula, but Manjula is visited by several others.”) The refrain returned: Balbir Pasha ko AIDS hoga kya?

Balbir Pasha and Manjula were characters in a campaign spearheaded by Population Services International (PSI), a non-profit global health organisation working in areas of reproductive health, HIV, malaria and child survival. Their campaign was immensely popular – to the point where their helpline was flooded with calls from several women named Manjula expressing their displeasure at the billboards. Amul dedicated a poster to the campaign; which said, “Balbir Pasha roz savere kiske saath jaagtha hai? Amul Butter. Regular Product.” (“Who does Balbir Pasha wake up with every morning? Amul Butter. Regular Product.”)

Manjula as a character was the quintessential sex worker not only because of her attire and posture, but also because she embodied a long-standing belief: promiscuous sex workers, with their corrupted minds and contaminated bodies, were responsible for the spread of HIV to young, virile and monogamous men like Balbir Pasha. 

These tropes of the promiscuous sex worker and the innocent monogamous heterosexual man allow us to ask questions about the ways in which gender complicates HIV prevention and intervention programmes, a concern that continues well into contemporary times.

Sex/Gender and HIV

According to 2019 data from UNICEF, 75% of new HIV infections among adolescents were found to occur in women and girls aged 10-19 years. This trend holds true for Eastern and Southern Africa (83%), West and Central Africa (78%), Middle East and North Africa (55%), South Asia (53%) and Latin America and the Caribbean (53%). Further, fewer adolescent girls and women mention condom use with irregular partners.

What might account for the higher rates of HIV infection among women? A 2003 Gynaecology and Obstetrics paper by Tomris Türmen, then with the World Health Organisation, emphasises that women may be more vulnerable to HIV as compared with their male counterparts. According to the paper, two broad categories of factors may come together to increase women’s risk of contracting HIV infections: those that are biological, and those that are social and cultural.

Biological factors contributing to women’s increased susceptibility to HIV infections include the risk of vaginal tears and abrasions during sexual intercourse. Further, Türmen mentions that the presence of other sexually transmitted infections (STIs) increases the risk of HIV infection by up to ten times. Since most such STIs are “asymptomatic in women”, they might be unknowingly at a greater risk, Türmen argues.

Social and cultural factors complicate the biological vulnerability of women to HIV. Per Türmen, “women lack power and economic independence to negotiate safe sex and insist on condom use. Indeed those who exchange sex for income can seldom mention safe sex at all. We also know that women face domestic violence, at times made much worse by conflict or insecurity and most often bear the brunt of social stigma and discrimination”.

Women in sex work: Stigma and discrimination, HIV prevention and intervention

The first cases of HIV were identified in India in 1986 among female sex workers in Chennai. In the same year, the government of India set up the National AIDS Committee, which in 1992 instated the National AIDS Control Organisation (NACO) and the National AIDS Control Programme (NACP) to oversee and implement policies related to prevention of HIV transmission in India. The first phase of the NACP ran from 1992 to 1999.

In the second phase of the NACP, which ran from 1999 to 2006, “high-risk groups” were identified. These included female sex workers, “men who have sex with men” and “injecting drug users”. With the high-risk groups in place, the NACP set out on targeted intervention to prevent the spread of HIV in these groups, which included widespread distribution of condoms and counselling towards “behaviour change”. The “behaviour change” was presumably geared towards promoting safe-sex practices.

Meena Saraswathi Seshu, general secretary of SANGRAM, a rural NGO located in Sangli, Maharashtra, that works towards empowering people in sex work, told The Wire Science that “most interventions were designed to make female sex workers use condoms. They [female sex workers] were supposed to ‘protect’ the general population by using condoms with the ‘bridge population’(their clients)”.

According to NACO, “bridge population” consists of people who, “through close proximity to high risk groups are at the risk of contracting HIV”. The NACO identifies two key bridge populations – both seen as regular clients of female sex workers: “truckers” and “migrant labourers”.

Despite the widespread distribution of condoms, as Seshu has written previously, “the [state] could not shake off the perception that they did not use condoms and were therefore responsible for spreading HIV.” Further, she told The Wire Science that “private doctors refused to treat opportunistic infections[footnote]otherwise uncommon infections that are prevalent in people living with AIDS due to their compromised immune system[/footnote] and created tremendous panic in the general public”.

Under the ambit of HIV prevention, what began was a tale of gendered surveillance, incarceration and displacement, the ripples of which would continue to resonate for long.

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Taking the example of Maharashtra, Seshu told The Wire Science that female sex workers were easily identifiable “due to the brothel structure and the red-light districts”. As a result of their visibility, it was easy for the police to raid these brothels at the behest of anti-trafficking groups. Even distribution of condoms by NGO workers, especially to sex workers engaged in more informal forms of the profession, became a challenging task since the police often saw the presence of condoms as “evidence to pick up sex workers,” she added.

Further, once picked up, sex workers – especially those living with HIV – were at a risk of state-sanctioned incarceration. Even as recently as 2021, a Mumbai court ordered the detention and “brainwash” of a sex worker living with HIV lest she “pose a great danger to society”. Seshu has also written previously about how these police raids often led to the displacement of sex workers from the red-light areas (for instance, in the case of Kamathipura, Mumbai’s largest red-light district); these displacements have led to the loss of livelihood and employment for women, who have often had to return to more precarious form of sex work.

“The most negative consequences of this targeting was that marginalised populations were forced to go further underground and were not reachable,” says Seshu, continuing, “we lost many lives to fear and lack of confidence in the system.”

The medical establishment and the public health system only complicated this picture. Along with the inability of the healthcare system to provide people in sex work treatment for opportunistic infections and STIs, Seshu mentions that, in the past, “civil hospitals refused to do any surgeries on people suspected to be living with HIV”. The worst hit were sex workers and pregnant women (who undergo regular HIV testing as a part of the pregnancy monitoring process). 

“They were routinely tested and rejected from services, including delivery and medical termination of pregnancies,” Seshu told The Wire Science.

Married women: Invisible and at risk

In 2006, Suniti Solomon, one of the doctors who had identified the first cases of HIV in India, co-authored a paper that mentioned “the prevalence of HIV among sex workers has more or less stabilised because of targeted interventions, increased condom use, and empowerment strategies that encourage sex workers to demand safe sex from clients”. 

“Meanwhile, housewives with single partners are gradually accounting for a larger proportion of infections,” it added.

How did the “housewife” become the “new face of the epidemic in India”, as Solomon et al.’s paper claims? The authors write, “These monogamous women are primarily put at risk by the extramarital sexual behaviour of their husband, from whom their infection is most probably acquired.”

Previous research has highlighted the role that patriarchal social norms and domestic violence plays in the increased susceptibility of women in monogamous heterosexual marriages to HIV infections. For instance, when researchers interviewed in 2003 women and men in two slums in Chennai, they found that social norms “sanction men’s extramarital affairs” and “encourage women’s submissiveness”, making it difficult for women to initiate conversations around their husbands’ promiscuity. This in turn impacted their knowledge of their husbands’ sexual health, increasing their risk to HIV.

Further, women also reported having to agree for sex with their husbands even when they were unwilling due to the sword of domestic violence lurking on their heads. “Many women reported that in order to avoid violence, they acquiesced to sex, even if it placed them at a higher risk for an [STI],” the authors of the 2003 paper write. 

Finally, a risk of domestic violence meant that women could not negotiate condom use, which further increased their chances of contracting HIV.

The authors, thus, point out a fundamental flaw in the HIV prevention and intervention approach: the singular focus on practising monogamy and using condoms, without recognising the social context in which certain groups emerge as more vulnerable than the rest. Thus, they argue that while public health initiatives around condom distribution and safe-sex practices are necessary for prevention of HIV spread, they are not sufficient unless they also work towards social and economic emancipation of women.

Despite the recognition that women in monogamous heterosexual marriages are at a risk of acquiring HIV, they remain invisible to the HIV-AIDS prevention and intervention programmes. For example, the NACP phase V, set in motion in 2021 and expected to run till 2026, continues to not include women in monogamous heterosexual marriages as a group at a high risk of contracting HIV infection.

Notably, pregnant women do find a mention in the NACP-V strategy document, but only in the context of preventing vertical transmission[footnote]transmission from mother to foetus[/footnote] of HIV and other STIs. It has been previously argued that the sole focus of HIV prevention and intervention programmes on pregnant women ranks the needs of women as “secondary to those of their foetuses”.

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Violence undergirds not only women’s increased susceptibility to HIV infections, but also the unfair consequences they face once diagnosed. Leena Menghaney, a lawyer who works on public health and is currently with the access campaign at Médecins Sans Frontières, revealed to The Wire Science that “women who tested [HIV] positive faced a much higher level of stigma and violence in society. They were extremely vulnerable to losing their residence, whether it was from the landlord, the parents or the partners”. 

Further, “there were challenges for women to actually tell their partners about their HIV status without worrying about the kind of violence or emotional abuse that would elicit against them,” she added.

Discrimination against transgender persons 

Understanding the ways in which gender complicates the public health discourse around HIV also requires us to engage with the concerns raised by transgender persons, who, like female sex workers, have been identified as a high-risk group by the NACP.

In the early days of the HIV intervention programmes, the category of “men having sex with men” subsumed within it several transfeminine identities. In later phases of the NACP (III onwards), transgender persons were recognised as a separate group called “TGs”. However, as has been previously pointed out, this disaggregation didn’t take into account the various cultural trans identities which couldn’t be translated directly into English (e.g. kothis, hijras, dhuplis, etc.)

Further, like women in monogamous heterosexual marriages, “inserting partners” or “panthis” in “men having sex with men” relationships continued to be seen as a low-risk group, leading to them being neglected by the HIV prevention and intervention programmes.

Thus, HIV prevention and intervention programmes sustained themselves upon a gendered and discriminatory backbone, where people from marginalised communities, like female sex workers and transgender persons, were seen as vectors of the disease, thus requiring constant surveillance and segregation. At the same time, the programmes ended up insidiously constructing a monogamous and desexualised image of women and femininity. Insulated from the complications of social and political realities, state-sanctioned public healthcare systems continued to drive marginalised people further into the margins.

Contemporary hopes, contemporary despairs

Menghaney told The Wire Science that the HIV prevention and intervention programmes changed “all the thinking around public health”. 

She said, “we had traditional programmes, like tuberculosis, which basically treated a patient as someone who needed to be told what to do. And then came the HIV [prevention and intervention] programmes where people said ‘no, we know what to do’. ‘You just have to give us the resources; we will ourselves do prevention and adherence; we will ourselves deliver services, including tests’”.

According to Sankalak, a publication by the NACP that documents the status of the National AIDS Response, HIV infections and mortality resulting from the same have declined in India by 46% and 76% respectively. However, the publication also mentions that the prevalence of HIV among high-risk groups remains disproportionately large.

In 2017, at the same time when the government of India put into force the HIV and AIDS Prevention and Control Act, the Ministry of Broadcasting and Information also banned condom ads from 6 am to 10 pm citing indecency. With licences of several NGOs cancelled under the draconian Foreign Contribution Regulatory Act (FCRA) 2010, community-driven HIV prevention and intervention programmes are faced with a crisis. In 2022, several groups in the country erupted in protest as government health centres fell short of antiretroviral (ART) drugs.

“It surprises me to no end when the Government declares that they have been able to reduce HIV,” Seshu told The Wire Science, adding, “the Government dumped these communities with the responsibility to ensure condom use and monitored them closely through the targeted intervention programme. And yet there is no public acknowledgement of the contribution of these communities in the HIV prevention and intervention programme.” (Emphasis supplied)

Seshu also argues that the government has “abandoned” the rights of vulnerable communities “once they realised that a medical model would work”. As a result, along with condoms, police atrocities also find their way into the lives of sex workers.

According to Menghaney, there are “larger global challenges” at play. The success of the HIV prevention and treatment programmes, she says, lies in the local and global networks that affected communities forged, which now appear to be “falling apart”. 

More importantly, she told The Wire Science that “the Global Fund to fight Tuberculosis, HIV and Malaria is moving away from middle-income countries.” Already in India, for instance, ART treatment is now being driven by domestic funding. The Global Fund’s condition – that affected communities will be involved in planning prevention and treatment programmes – is the key reason why governments like India, for example, have kept representatives of affected communities in the room when priorities are being set, Menghaney added. 

So, Menghaney asks, “What will the transition be like after the Global Fund completely removes itself from the HIV picture in countries like India?”

According to Seshu, other problems complicate the picture of reduced funding. 

“The worst is that the government expects workers to work without pay while increasing surveillance, the reduction in the rights-based approach, and the continued discrimination of vulnerable groups at the hands of the public healthcare system,” she says.