Women and the high risk

ALTHOUGH the human immunodeficiency Virus (HIV) and acquired immune deficiency syndrome (AIDS) are still considered the problems of "others", it is no secret that the infection is spreading in India. No respecter of social barriers, the virus has long ceased to be a problem of only commercial sex workers; it has infected monogamous women and children alike. In 2004, monogamous housewives accounted for over 22 per cent of HIV infection cases.

India, with four million known carriers, has the second largest number of HIV/AIDS patients after South Africa. The spread of the infection is attributed to low investment in public health infrastructure, high poverty levels, illiteracy and ignorance, strong gender biases, myths and taboos associated with the infection, and silence on sexuality.

The spread of HIV in the country varies with societal patterns, regions, States and metropolitan areas. Heterosexual behaviour is the most common way of HIV transmission, followed by the multiple use of infected needles by drug abusers.

Although the prevalence rate of HIV is low (0.8 per cent), the overall number of infected persons is high. The country has no system of collecting HIV testing information from the private sector, which provides 80 per cent of the health care. Thus, the official figures do not reveal the exact level of infection. Compounding this are the weaknesses in the surveillance system, the biases in targeting groups for testing and the non-availability of adequate testing services in several parts of the country. The limited statistics on the disease make it hard to map trends and identify new risk groups. But one frightening dimension is that women - especially vulnerable owing to their low socio-economic position even within households - are registering a higher rate of infection than men.

Globally, women below 25 are increasingly falling prey to HIV. In Sub-Saharan Africa, 12-13 women are infected for every 10 men. Even more disturbing is the fact that in 11 African countries the infection rate among women in the 15-25 age group is six times that of men.

In India, although HIV/AIDS is still thought to be largely concentrated in the high-risk populations including commercial sex workers, intravenous drug users, and truck drivers, surveillance data suggest that the epidemic is moving beyond these groups into the general population. It is also moving from urban to rural areas. In July 2003, Dr. Meenakshi Datta Ghosh, Project Director, National AIDS Control Organisation (NACO), agreed that HIV/AIDS no longer affected only high-risk groups or urban populations, but was "gradually spreading into the rural areas and to the general population". The majority of reported AIDS cases have occurred in the sexually active and economically productive 15-44 age group.

It is estimated that 39 per cent of the known HIV/AIDS positive cases in India at the end of 2002 were women. The effect of the rising HIV prevalence among women is seen in the increase in the mother-to-child transmission rate.

It is difficult to ascertain the exact number of children orphaned by AIDSs, but it could be high. In 2001, the number of such children was estimated at 1.2 million.

In a number of States HIV prevalence in pregnant (antenatal) women is over 1 per cent, according to data obtained by the screening of women coming to antenatal clinics (ANCs). Such prevalence rates are only relevant to sexually active women, but they provide a reasonable estimate of HIV prevalence in the general population in the respective State. According to NACO figures, in 2002 the antenatal prevalence rate in Andhra Pradesh and Maharashtra was 1.25 per cent; in Goa it had increased to 1.38 per cent in 2002 from 0.5 per cent in 2001; and in Karnataka it had increased from 1.13 per cent in 2001 to 1.75 per cent.

In Manipur, the transmission route of HIV/AIDS is no longer confined to intravenous drug users; the infection has spread to female sexual partners and their children. The antenatal prevalence rate in the State in 2002 was 1.12 per cent, and among drug users, it was as high as 39.06 per cent at three surveillance sites. The epidemic took off quickly among male drug users in Mizoram with some drug clinics registering HIV rates of more than 70 per cent among their patients in 1998. In 2002, the antenatal prevalence rate was 1.5 per cent. In Nagaland, where intravenous drug use has been driving the HIV epidemic, the antenatal prevalence rate was 1.25 per cent and the HIV prevalence rate among drug users 10.28 per cent.

When the surveillance systems in Tamil Nadu showed a rising HIV infection rate among pregnant women - the figure trebled to 1.25 per cent between 1995 and 1997 - the State government set up an AIDS society, which worked closely with non-governmental organisations (NGOs), to develop an active prevention campaign. The antenatal prevalence in the State was 0.88 per cent in 2002, although an infection rate of 33.8 per cent was recorded at the one surveillance site for drug users. By September 2003, Tamil Nadu had recorded 24,667 cases of AIDS, the highest number reported to NACO by any State.

According to Dr.N.M. Samuel, Head of the Indian Experimental Medicine and AIDS Resource Centre of the Chennai-based Dr. MGR Medical University, in India 20 million births occur every year with between 1 and 4 per cent of pregnant women testing HIV positive. In his paper, "Do women need microbicide", he quotes a study which showed that one out of every 12 pregnant HIV positive women who received anti-retroviral treatment (ART) gave birth to one HIV positive baby; the rate went up to three without ART.

Only 59 per cent of the women who tested positive returned for treatment. Drug affordability and accessibility continue to be obstacles to health care, and 43 per cent of women give birth at home with trained or untrained midwives.

According to Dr. Alan Stone of the United Kingdom Medical Research Council, women are most vulnerable to HIV infection. Women accounted for more than half the 5.3 million new HIV infections in 2000. Pointing to India, he said the STD (sexually transmitted disease) clinics in Chennai, Mumbai and Delhi had noticed a sharp rise (by over 60 per cent) in HIV cases in the past decade.

This brings to the fore issues of women's vulnerability, their decision-making power within the household, her control over sexual behaviour, and her socio-economic status.

Recently, the International Labour Organisation (India) published the results of a study it initiated to understand the socio-economic impact of HIV/AIDS on infected persons and their families. Conducted in collaboration with the network of People Living With HIV/AIDS (PLWHA) it underlined the adverse economic impact of HIV/AIDS and the trauma arising out of the stigma, discrimination and ostracism.

The study focussed on Delhi, Maharashtra, Manipur and Tamil Nadu, which recorded a high rate of prevalence of the infection. The most disturbing aspect of the findings pertains to the impact of HIV/AIDS on women. Conducted among 292 people, of whom 42 per cent were women, the study revealed that 74 per cent of the HIV positive women faced discrimination and underwent hardships, especially within the family of the husband, by whom they had been infected.

Although the majority of women were infected by their husbands, they were blamed for the husband's death. In many cases, the woman was accused of causing her husband's illness, and either disowned or driven out by her in-laws.

The children of infected parents are also heavily discriminated against; they are taunted, abused and not allowed to interact with other children. Over 35 per cent of the children were denied basic amenities and about 17 per cent had to take up petty jobs to augment the family income.

Education is considered an important tool for bringing about attitudinal changes. In keeping with this view, the study found that a relatively high level of education among the infected (and by implication their families) had an impact on the extent of discrimination the women suffered. Fifty-nine per cent of the postgraduate respondents faced discrimination compared to 74 per cent of those educated up to the school level and 71.42 per cent of those who were illiterate. Women were more vulnerable, with 17.21 per cent being illiterate compared to 11.18 per cent of the men. While 22 per cent of the men had college education, only 8 per cent of the women were in that category.

The study also indicated that the average monthly income of a PLWHA member was about Rs.1,117, whereas the average monthly expenditure was Rs.3,185. In many cases, this gap was met by loans or the sale of assets, leading to increased indebtedness, averaging Rs.4,818 a family. While medical costs varied in accordance with the stage of the illness, the fact that HIV-infected persons have to go in for regular check-ups underscored the economic impact of the infection.

The ILO study also reinforced the fact that women are at risk of HIV infection and are all the more vulnerable, as they have no say over sexual behaviour. Microbicides can be a saviour to most women who cannot say "No".