Mangala Bai of Athani village in Belgaum district of North Karnataka is HIV positive. So is Ragini from the same village. Both were sex workers and are now in their mid-40s. Ragini contracted HIV from a customer who refused to wear a condom. This is a standard problem for sex workers and one of the reasons that women are far more vulnerable to HIV in a society where men call the shots.
Data obtained from the Union Ministry of Health & Family Welfare (MH&FW) shows HIV infections have been on the rise among women. Of the 18 lakh HIV-positive cases reported between 2009 and 2016, two-thirds were women and six lakh of them were pregnant.
More than one and a half lakh women contracted HIV in 2016 alone. A substantial number of these women were pregnant: 35 per cent in 2010, and 50 per cent in 2016. There’s a steady and rapid rise that can be spotted. According to the National Rural Health Mission, the number of women who are HIV-positive has gone up from 80,000 in 2010 to 1.5 lakh in 2016.
A United Nations Development Programme report says HIV is more easily transmitted from men to women, and that male-to-female transmission during sex is twice as likely as compared to female-to-male transmission. The report notes that Indian women do not have control over their own bodies and they often do not have the right to decide when to have sex. Cultural norms and the attitudes rarely condone male proclivity for multiple partnerships and pre-marital/extra-marital sex also increases the woman’s risk of contracting HIV, according to UNDP.
Uttar Pradesh, Assam, Chhattisgarh, Madhya Pradesh and Jharkhand top the list of states with the highest number of women infected with HIV. The number of women with HIV went up from 40 per cent in 2010 to over 70 per cent in 2016 in these states.
Yet Union Health Minister JP Nadda said in December last year that India has successfully arrested the HIV epidemic, and can end it by 2030. “We have been able to script a success story. We can end the HIV/AIDS epidemic by 2030,” he said. “There was a 57 per cent reduction in new infections, and 29 per cent decline in AIDS-related deaths.”
However, government data also shows an increasing prevalence of HIV in most states including the states of the northeast. With the exception of Andhra Pradesh, Tamil Nadu, Jammu and Kashmir, Kerala and Manipur, all states have shown an increase in HIV positive cases during the period 2009-10 to 2015-16.
UP and Chhattisgarh numbers rose by more than 800 per cent. West Bengal by 712 per cent. And Maharashtra and Gujarat by more than 350 per cent. Other states that showed a rise were Jharkhand and Bihar.
Karnataka and Andhra Pradesh account for nearly half the number of HIV cases in the country. These two states along with Uttar Pradesh, Maharashtra, Gujarat and Tamil Nadu made up for 77 per cent of the HIV positive cases.
“Traditionally, there has been a high prevalence in Andhra and Karnataka but there has been a decline over the years,” said Dr Sathish Kumar, director of SAATHI, Chennai, an NGO that working on HIV prevention, care and support.
Six of the seven northeast states — Arunachal Pradesh, Assam, Meghalaya, Mizoram, Tripura, Nagaland and Manipur – also reported a rise in HIV infections among women.
A “high number of HIV positive in the northeast states is due to injective drug use habit,” said Kumar. “Drugs such as morphine are used by sharing needles. Those who contract the virus then transmit it to their sexual partners, who are mostly their wives.”
Rashmi Rekha Bhuyan, assistant director (Basic Services Division) of Assam State AIDS Control Society, says apart from more screenings (tests), outflow and inflow of migrants also account for the increasing numbers of HIV cases reported from northeastern states. Migrants and truckers are high-risk groups.
Despite the high HIV numbers, the Modi government cut funds allocated to prevent and fight the spread of infection by 22 per cent in February 2015 (to Rs 1,300 crore), leading to an outcry from AIDS activists and non-governmental organisations. The fund crunch hit HIV infection prevention and HIV awareness programmes though funding was restored in 2016 to Rs 1,700 crore, and then to nearly Rs 2,000 crore.
Funding had been cut because states with higher HIV counts — Karnataka, Andhra Pradesh and Tamil Nadu — had shown a decline in new cases since 2011. The government, however, overlooked data on smaller states.
“It is difficult to implement programmes. Without money, the NGOs cannot mobilise,” said Bhuyan. “In the ICTC (Integrated Counselling and Testing Centre) programme, there are new implementations and guidelines, but we cannot provide training due to the budget cut. New things are adopted by NACO [National Aids Control Organisation] but we cannot make them accessible for peripheral work.” Activities like capacity-building are done only when the fund is allocated on a regular basis. A lot of skill-based training has been cut down to function-based training. The four-day training has been reduced to one to two days of training.
However, to a question posed in the Rajya Sabha in December 2015, the Minister of State for Health and Family welfare, Nadda said budget allocation for 2015-2016 was in line with the absorptive capacity of the state ministries and departments.
Bhuyan said northeast states merit more funds because they are geographically-challenged. “Our challenges are totally different. There are places where there is no Internet connectivity and we will have to go there. Transportation is also difficult.”
There are reports that health workers were being laid off and services for prevention and control of AIDS were curtailed.
“The accountability of foreign funding many times appear to be slightly better than the accountability of Indian money,” said Dr Sajith Kumar, head of the Department of Infectious Diseases, Government Medical College, Kottayam, Kerala. “There is a deficiency in professional training. The government should provide more training to doctors and healthcare professionals.”
The HIV epidemic in India is termed “concentrated epidemic” (where five per cent in any sub-population at higher risk of infection) with most of the infected population limited to five core groups: Female Sex Workers (FSW), Men who have Sex with Men (MSM), Injecting Drug Users (IDU), transgenders, migrants and truckers. In UP, Maharashtra, Gujarat and Tamil Nadu, these core groups are high in numbers, especially migrants and truckers.
NACO puts HIV prevalence among FSW at 2.2 per cent; MSM, 4.3 per cent and IDU at 9.9 per cent. Others include transgender, migrants, truckers, silent sex workers and seasonal sex workers.
India has the third largest HIV epidemic in the world with a prevalence rate estimated at 0.26 per cent. This ostensibly small percentage is only because of India’s massive population (1.2 billion). This equates to 2.1 million people living with HIV. In the face of this, simply throwing money at the problem isn’t going to be enough. There needs to be supportive as well as preventive measures. Counselling is crucial to HIV management. Counsellors provide information about HIV/AIDS and facilitate behaviour change communication in the client. This is especially significant given a NACO report that almost a quarter of the people infected are unaware of their status.
One of the biggest hurdles to overcome is that of stigma and discrimination around the disease–a significant barrier preventing key affected groups and those at high risk of HIV transmission from accessing vital healthcare services. For instance, a 2011 sstudy in Andhra Pradesh indicated a significant association between police abuse and increased risk of HIV transmission and inconsistent condom use. And while new HIV infections in India have fallen by more than half since 2001, there’s still a long way to go.
** Names changed to protect their identity.