India’s AIDS epidemic has decreased drastically in the last decade. Yet the numbers mask a worrisome trend: the deadly virus is highly concentrated in urban poor communities. Most vulnerable are sex workers and migrant laborers as well as their home communities—often in rural areas or neighboring countries. The physical, social and economic losses of AIDS are enormous: children are orphaned; sole breadwinners are taken from their families; heavy medical bills weigh on workers with no insurance; and proper treatment remains unavailable in subpar facilities. Not to mention the stigma that burdens people living with HIV, many of whom are ostracized by their families and communities. For this population, the circumstances and consequences have far-reaching implications.
An article on AIDS in Africa—where the deadly virus has dominated public health discourse for decades—explains the complexities of impoverished nations battling a health crisis of this magnitude: “While poverty is undoubtedly a crucial factor as to why health problems are so severe in Africa…political will of national governments is paramount, despite disheartening odds. Constraints such as social norms and taboos, or lack of decisive or effective institutions have all contributed to the situation getting worse.” In South Asia—and India, in particular—similar reasons are at the crux of the spread of HIV/AIDS among the urban poor.
The Poor at Risk
In December 2010, the Government of India’s National AIDS Control Organization (NACO) announced that adult HIV prevalence nationally declined from 0.41% in 2000 to 0.31% in 2009. The estimated number of new annual HIV infections declined by more than 50% over the last decade. It is reported that 1.4-1.6 million people are living with HIV in India, down from 5.5 million in 2005. While the news seems good, not everyone has benefitted. India has seen—as has the world at large— that the poor and marginalized are increasingly at risk. More than 87% of HIV/AIDS cases in India are due to heterosexual encounters. With widespread migration by single males, the urban poor—largely migrant laborers and women in brothels—increasingly account for a significant portion of HIV/AIDS cases.
Sex workers, largely teenage girls or younger from Nepal, are trafficked to the streets of India’s cities. One study found that more than 40% of Nepali sex workers tested HIV positive and that the number of the infected has increased 24-fold in the decade 1992-2002. Nepal is estimated to have only 75,000 cases—less than half the numbers in India—but health officials fear that without the services and counseling needed for these young girls as they repatriate, they could potentially spread the virus. “The high rates of HIV documented support concerns that Nepali sex trafficking may be a significant factor in both maintaining the HIV epidemic in India and in the expansion of this epidemic to its lower-prevalence neighbors,” says an article entitled “High AIDS Rate in Nepali Sex Workers Returning from India.” Labor migrants to India also account for Nepal’s HIV-positive population.
The clients of sex workers are equally vulnerable. Migrant laborers are part of the 258 million persons in India who do not live at their birthplace. Away from home for many months, the men engage in sex with partners other than their wives in “red light” districts where HIV/AIDS is prevalent. In 2008, the Population Council India, with funding from the Bill and Melinda Gates Foundation, conducted a study, “Patterns and Implications of Male Migration for HIV Prevention Strategies in Maharashtra, India.” The study found that there was high correlation between in-migration rates and prevalence of HIV in the study’s urban districts. In fact, the prevalence rate was double the national average. The study also found that HIV prevalence was not only high in in-migration urban districts, but also in out-migration rural areas. Male migrants passing HIV on to their domestic partners has been a pattern that has largely accounted for the spread of HIV to rural areas of India in recent years.
According to the Indian government, “…clients of sex workers are the single most powerful driving force in India’s HIV epidemic,” quotes Avert, an international HIV/AIDS charity based in the UK. These clients, says the site, are primarily long-distance truckers and male migrants. “Despite this risk, migrants have the lowest perception of risk in all high prevalence states. For example, in Andhra Pradesh, 60 percent of female sex workers believe they are at risk of HIV infection, compared with only five percent of male migrants.” This statistic reveals the lack of awareness around vulnerability to HIV/AIDS in these often conservative communities. Safe sex remains a taboo subject, and, as a result, the migrants see little risk in their behavior.
A Shift in Policy Focus
The international response to the global HIV/AIDS epidemic has made an important shift this year: the June 2011 United Nations’ Security Council Resolution on HIV/AIDS and General Assembly Political Declaration on HIV/AIDS announced that policy will “…reflect renewed political engagement and a changed strategy that focuses on highest risk populations, even though this may be more politically sensitive.” The Indian government has followed suit with a five-year plan to halt and reverse the epidemic in India by 2012. Understanding a particular need to work with vulnerable populations, the strategy includes integrating programs for prevention, care and support, and treatment.
As part of this plan, the government will need to lend greater support to private partners to develop micro-insurance schemes for people living with HIV. The poor often have no access to insurance, and families can be crippled for generations by one member’s mounting medical bills. If insurance is available in India, most of the products have HIV/AIDS prevention clauses. Schemes for poor HIV patients will not only need to be made available but developed with particular sensitivity to a virus with major stigma. Opportunity International’s MicroEnsure in Africa learned that in areas with low life expectancy and high rates of HIV, the mutual guarantee of their group lending model “was quickly eroded” because members were reluctant to include women who either had AIDS or were suspected of having AIDS. “By providing insurance against the death of the borrower, the group no longer had to worry about paying back the loan of a deceased group member and as a result we saw that these women that had AIDS could be included back into the groups and be provided with loans.”
In 2008, in Karnataka, India, the NGO Population Services International (PSI) launched the first-ever medical insurance for people living with HIV in India. “The fight against HIV has reached a new milestone,” says an article on the new scheme. PSI says one of their initial obstacles was mobilizing members. Most of the potential clients were daily wage workers for who the premium was unaffordable. “We had to convince them that even for a cup of tea, one has to spend INR5, so if they forego little expenditures everyday and save INR5-6 (US$0.1-0.12) per day, it would be possible to save the required amount,” says Asha Ramaiah of the National Women’s Forum and founding member of Karnataka Network of Positive People.
“The PSI project reflects a perfect example of how public-private partnership can be used to address HIV/AIDs. Besides, it also serves to encourage other insurance providers to enter the relatively new field of community-based health insurance,” says the article announcing the scheme.
Nirman’s Approach in Dharavi
In Dharavi, alternatively known as kutty Tamilnadu—meaning “Little Tamil Nadu”—there are 15,000-20,000 single male migrants from Tamil Nadu, a majority of whom are originally from the state’s Tirunelveli District. The one-square mile slum is estimated to have 300,000-400,000 migrants from Tamil Nadu, according to Nirman, an NGO working with this extremely poor community.
The men primarily work in the garment, construction or food industries and earn INR50-80 (~US$1-1.75) for a 12-14 hour shift. To address HIV/AIDS vulnerabilities in this community, Nirman has launched a project called Aaruyir, in collaboration with the South Asian Research and Development Initiative (SARDI), a Delhi-based labor support organization, and with support from USAID/FHI. The project is being implemented in association with the Center for People’s Education (CPE) at Tirunelveli, Tamil Nadu.
Aaruyir is a uniquely designed initiative and one of the few that operates in collaboration with a source-point NGO—in the migrants’ home district—as well as in the destination area, such as Mumbai. Nirman’s outreach activities address some of the key challenges in the fight against HIV/AIDS in India: behavior change communication that is sensitive to the often conservative communities through street plays, posters and hand-outs; sensitizing the community to dealing with a person living with HIV; and developing messaging that is careful not to stigmatize the migrant workers as carriers of the virus but as a group that has increased vulnerability to HIV/AIDS. The NGO operates a drop-in center in the community and also focuses on condom promotion and distribution.
In an area devoid of services and counseling for people exposed to HIV—particularly in slum areas—NGOs such as Nirman and Population Services International have been pioneers. The Indian government will need to devise more collaborative approaches with these organizations as they ramp up efforts to meet the deadline of eliminating HIV by next year. Though the government should keep ambitious eradication goals at the fore, policy implementation must look carefully at the particular needs of this emerging trend in the spread of HIV among the urban poor. After all, the region as a whole is relying on India to make a large-scale impact on the HIV/AIDS problem that has been spilling over its borders.
The responses will need to take into account the effects of the current situation—support for people living with AIDS, children orphaned due to AIDS or families without a father’s income—as well as the prevention of further spread. One innovative pilot project being explored is the biometric smart card, which stores the medical history and treatment of a patient and can be accessed by any hospital with a data reader. The cards were being specifically designed for people living with HIV who often wanted to visit treatment centers away from their home districts for fear of being stigmatized. Programs like these are needed not just in the high-risk areas of India’s cities, but also in the rural areas and neighboring countries that migrants come from. This complicates an already burdensome problem, but as the world has seen from the Africa epidemic, any other response than a large-scale, coordinated effort is much more costly to society with the massive loss of human life.