Spreading HIV/AIDS Awareness in a Culturally Sensitive Way in India

chillibreeze writer — Rajaratnam Abel

It is over two decades since the first case of HIV/AIDS was reported from India. During this period India has taken a number of steps to control the spread of the disease. Much of what India carried out was actually based on the advice given by experts from India and outside. The amount of money spent on HIV/AIDS is substantial. Then why is it that the country is still behind in its efforts to control the spread of HIV/AIDS? A proper understanding of what has gone on could still help India catch up.

Initial exclusive emphasis on the use of condoms to control the spread of HIV was probably the first major mistake. One of the very first messages on HIV/AIDS that came out was “Use condoms, stop AIDS”. Condom use as a technology fits in perfectly for controlling HIV/AIDS. Condoms were successful in the USA and Thailand and therefore considered appropriate for India as well. Unfortunately the experiences of other countries with condoms were promoted in India without adapting in anyway to the culture and traditions of India. Condoms became the sheet anchor of India’s intervention for many years and were promoted in an insensitive manner. In the early days condoms were even distributed to young people in colleges, a highly objectionable practice from a community perspective.

Little did officials realize the deep-seated animosity against the use of condoms in the community. Nearly six decades of condom promotion for family planning had resulted in very low rates of condom use by eligible couples in the whole country. Many women in India do not want their husbands to get into the habit of using condoms, as they fear this will encourage promiscuity. Men are often shy to obtain condoms publicly and there is also the general impression that the sexual satisfaction derived with the use of condoms is much lesser than without condoms. There were no research studies carried out on the acceptability of condoms. It was assumed that active public campaigns and social marketing would overcome these resistances. It just did not. Only very late did the country realize that there is a need for a comprehensive approach without excluding condoms.

In spite of the successful targeted interventions among truck drivers and commercial sex workers, the disease still started spreading to the general community. While the truck drivers received all inputs, their wives were left untouched, and therefore the full effect was not felt. Again the focus was on condom use and condoms were distributed in many roadside centers. The use of condoms by truck drivers went up. Surprisingly even without direct motivation many truck drivers became faithful to their wives. What an effect it would have had if along with condom distribution, they were also encouraged to be faithful right in the first instance! Condoms should have been encouraged only as the second alternative.

The second mistake was the approach to sexual behavior. Influenced by western thinking on sexual behavior and condom use, many Indian leaders were refusing to accept and even derided the strong cultural values of India. Precisely to avoid pre marital sex, girls are married off at a young age even today in spite of laws against early marriage. Probably it was the sexual behaviour of young people in the metros of our country and the sexually erotic sculptures of places like Khajuraho that influenced overseas experts to assume that sexual behavior patterns in India was similar to that in the West. Therefore even when success stories were coming in regarding sexual behavior changes in countries like Uganda, this was brushed of as not relevant for India.

The third major area where India floundered was in estimating the load of the disease. In the early stages of the disease experts indicated that time and money should not be wasted on estimating the load of the disease. The focus instead was supposed to be on interventions to prevent the spread, especially as there were no remedies available even if a person was diagnosed as HIV positive. Today when the disease has spread rapidly, every time India releases its estimate of the disease, it is received with skepticism and accused of under reporting. While great efforts have been made in recent years to obtain accurate data, it is often received with much more than a pinch of salt. One important principle of public health is the need for accurate information on the burden of any disease. This was not attempted till very late into the epidemic.

It was strange that in spite of repeated efforts, the funding organizations in the early nineties refused to consider educating the general community on HIV/AIDS. It was considered too costly and not effective. Only after the USA evolved a policy of not making grants for only condom based programs was there a shift to educating the entire community. Only now is the ABC concept (Abstinence before marriage, Being mutually faithful within marriage and Condom use if not A and B) being promoted. If along with the targeted interventions the ABC approach was also promoted, then the behavior change could have been phenomenal. Probably this was the fourth major mistake in the long-term perspective.

The next area relates to sexuality, especially among adolescents, as it is not adequately and appropriately considered in India. In the USA roughly 50% of young people have had sex before marriage. However based on some of the sex education programs in schools, there is an initial decline observed in this area. Studies have clearly indicated that premarital sex among young people in India is much lesser than that in the West, though there is a rural urban divide. Unfortunately in India it was assumed that even wholesome sex education would lead to promiscuity. There is enough evidence world wide that if sex education is provided in a sensitive manner, and with the support of the community, then the community will accept such education, promoting healthy sexual behavior among adolescents without leading to promiscuity.

India is way behind in providing sex and sexuality education for young people. Again whatever sex education has been taught has come around to promoting condom use, sometimes even demonstrating actual condom use. Unfortunately these are areas where there is strong community resistance still. Besides, there are so many more areas other than explicit sexual information that is needed for young people. These include an increased self worth and self esteem, negotiating skills, assertiveness, decision-making skills, vulnerability of young girls, the adverse consequences of unintended pregnancy among teens, and communication skills between parents and young people.

So when Maharastra recently decided against sex education among school children, it is because of the insensitivity to community perceptions on sex education. Some of the stated reasons for deciding against sex education are that the messages and pictures were too explicit. Human growth is shown with naked pictures of boys and girls. Indian Express presented as unacceptable by the community the following two sample essay topics for students: “If there were no condoms...” and “If there were no clothes...”. No wonder sex education is banned in three states.

Finally whatever communication strategies were implemented also had the same western bias especially relating to condom use. This made the community acceptance of even other good messages slow and incomplete. To control HIV/AIDS, behavior change is necessary. This is possible only with education presented in a manner acceptable to the community.

One of the most creative, well-budgeted and innovative HIV/AIDS education programs in India was based on the imaginary mascots Pulli Raja in Tamilnadu and AP and Balbir Pasha in Maharastra. The start of the communication created the ideal interest among people wanting to know who Pulli Raja was. The effective manner in which expectation was created on TV, on roadside billboard advertisements in strategic places, and in the print media maintained the suspense. But when for the first time the identity of Pulli Raja was revealed, it was a setting in which he had sex without a condom. That was the end of Pulli Raja. The public outcry was so vehement that the whole programme came to an abrupt end. What a wasted opportunity available to educate the people on the A to Z of HIV/AIDS!

If India is to succeed in its efforts to control the spread of HIV/AIDS in the country, those involved in making policies must take into account people’s sensitivities in any intervention. HIV/AIDS involves sexual behaviour, which is very personal and sensitive. If the community is involved right from the beginning, then condoms and sex education so vital to control the spread of the disease can be effectively communicated to the people in a sustainable manner, resulting in effective control of HIV/AIDS. However it must move in a comprehensive manner even beyond sex education and condoms and adapt the interventions in a manner acceptable to the people.

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