Hiv Aids

HIV/AIDS: Stigma, Discrimination and Prevention
Editor Prof. Gracious Thomas
School of Social Work

Indira Gandhi National Open University Maidan Garhi, New Delhi 110068
July, 2010
Indira Gandhi National Open University, 2010
ISBN: 978-81-266-4774-4
All rights reserved. No part of this work may be reproduced in any form, by mimeography or any other means, without permission in writing from the Indira Gandhi National Open University. Further information on the Indira Gandhi National Open University courses may be obtained from the Universitys Office at Maidan Garhi, New Delhi-110 068. Printed and published on behalf of the Indira Gandhi National Open University, New Delhi, by Director, School of Social Work. Print Production: Shri Kulwant Singh. Laser typeset by Nath Graphics, 1/21, Sarvapriya Vihar, New Delhi -110 016. Printed at :
Preface
The worldwide HIV/AIDS pandemic represents an intersection of medical and social problems virtually unique in modern history. The resulting convergence of challenges begins with the impact of the virus on the human body, best addressed by the objectivity of biological and medical science. Towards that end, medical providers have been assisted by researchers, epidemiologists, and public health educators in a host of governmental and non-governmental capacities. Striving to understand how, where and among whom the virus spreads, they have turned their attention to raising public awareness of risks associated with HIV, educating on methods of preventing viral transmission, encouraging testing, and maintaining systems needed for post-test counseling and partner notification. Virtual armies of professionals and volunteers have focused attention on improving access to barriers, educating those at risk regarding abstinence, and harm reduction associated with injection drug use. They have facilitated womens increased control over sexual exposure through development of microbicides, and tirelessly pursued the development of effective vaccines. Working together with pharmaceutical industries and government they have greatly increased medical option for treating HIV- related disease, and advanced the distribution and availability of medications worldwide. This book on Stigma, Discrimination and Prevention has twenty chapters focusing on various aspects of HIV/ AIDS, its nature, epidemiology, intervention strategies and issues pertaining to stigma and discrimination. HIV infected and the affected face discrimination from across the board. Even after two decades of living with HIV, there is widespread discrimination in most societies.
This volume will explain various aspects of stigma and discrimination in the context of HIV apart from describing other issues associated with HIV/AIDS. The first chapter: AIDS: Nature and Demography will give you a brief history and the various theories on the origin of HIV/AIDS. You will also read about the stages of infection of HIV/AIDS, its modes of transmission and the process of testing and diagnosis. The second chapter Social and Economic Implications elaborates on the impact of HIV/AIDS at different settings: family, community and at macro level. It also describes how HIV/AIDS causes irreversible damage to the human capital. The third chapter Socio-cultural Context of HIV/AIDS talks about the factors that are related to the spread of HIV/AIDS. It deals with gender issues, socio-economic and socio-cultural factors. The fourth chapter Testing of HIV/AIDS describes about HIV testing, various types of HIV testing and the guidelines to be followed while testing for HIV. In the fifth chapter Treatment and Care, Vaccine Issues you will read about the treatment of HIV/AIDS. You will have an understanding about the comprehensive treatment and care as well as the issues concerning AIDS vaccine. The sixth chapter Modes of Transmission and Prevention of HIV elaborates on the transmission of the virus through different routes and the types of preventive measures that are being taken to control the spread of HIV. The chapter on HIV/AIDS among Women and Children deals with issues of HIV/AIDS among women and children at risk of acquiring HIV infection as well as the rights of children suffering form HIV. HIV/AIDS in the Working Population of the Organised and Unorganized Sector is another chapter which discusses about HIV/AIDS among workers of organized and unorganized sector and the workplace policy on HIV/AIDS. You will also read about the
partnership of NGOs and the corporate sector in HIV/ AIDS prevention. In chapter nine HIV/AIDS Prevention and Control: Government and United Nations Initiatives you will read about the components of National AIDS control programme and the initiatives taken by the government of India and by various agencies of United Nations for prevention and control of HIV/AIDS. The tenth chapter on Social Work Intervention in Prevention and Control of HIV/AIDS describes different aspects related to HIV/AIDS like care and support, awareness, IEC, advocacy, policy planning etc. The eleventh chapter is on: Communication in HIV/ AIDS Prevention. As the title suggests, this chapter deals with the IEC strategies used for the control of the disease. It also talks about the challenges being faced in communication in context of HIV/AIDS, and the strategies used for some of the special population groups. Models of Behaviour Change is a chapter that throws light on the importance of change in behaviour of an individual to prevent the spread of the disease. This chapter explains that models of behaviour change and other considerations to behaviour change. The next chapter is on Counselling for HIV/AIDS: Nature and Process. There is an elaborate discussion on the nature and purpose of HIV/AIDS counseling, its stages and the skills required of a HIV counselor for addressing issues pertaining to HIV. It also examines the impact of values and attitudes of a counselor on HIV counseling. You will also read about the communication skills of a good counselor and characteristics of a good client. The fourteenth chapter is on Issues and Types of HIV/AIDS Related Counseling which describes special issues that emerge in the case of HIV/AIDS. This chapter mainly discusses about counseling in the context of Youth and children, injecting drug users, sex workers, etc. The chapter: HIV/AIDS and Legislation deals with the legal
aspects of HIV/AIDS. It throws light on some of the laws and legal policies for the prevention and spread of HIV/AIDS and rights of people living with HIV/AIDS. Still, we are faced with a seemingly relentless global health crisis. How, in the context of all this effort and remarkable progress, do we explain the alarming durability of the virus, and our inability to conquer it once and for all? In the last five chapters namely: (i) Theories and Models of Stigma and Discrimination (ii) Social Stigma: Universal and Culturally Specific (iii) Provider Stigma: Social Service and Health Care Providers (iv) Response Strategies for Social Workers and (v) Best Practices in HIV/AIDS Prevention and Education, we have discussed the frightening implications of stigma and discrimination as all-toohuman obstacles to ultimate success. Ironically, we will see that the personal and social attitudes shaping the response to HIV/AIDS have roots nearly as deep, though fortunately not quite as mysterious, as the virus itself. We have established a common language for describing the personal and social responses to HIV/ AIDS that have so powerfully shaped global efforts to date. Grounding them in theory, we have established how they manifest through religious, communal, and political practices, and are reinforced, intentionally and unintentionally by individuals and institutions which otherwise would have seemingly little in common. In the process, you will see how certain of these attitudes cut across cultural differences, though the particulars of their expressions may vary. You will also see that much good work has been done, and much more can be done, to deepen our understanding of the human side of a persistent viral pandemic. Social workers have many important roles to play in responding to HIV/AIDS. None may be greater than rising to the responsibility of becoming more aware of
our own contribution to the problem, then dedicating ourselves to removing yet another obstacle in the fight against this dreadful disease. The gratitude we owe to the many authors cannot be expressed in few words. We place on record our deepest appreciation to Professor Neil Abell and Ms. Nicole Cesnates of Florida State University, Dr. Archana Kaushik, Dr. Jyoti Kakkar, Dr. Rose Nimbiakkim, Ms. Nemthiangai Guite and Dr. Sonny Jose for their valuable contribution which I am sure will be of great interest to the professional social workers across the board. Professor Gracious Thomas Director, School of Social Work IGNOU, New Delhi
Contents
1 . 2 . 3 . 4 . 5 . 6 . Aids: Nature and Demography
Nemthiangai Guite
1 26 49 67 88 109
Social and Economic Implications

Archana Kaushik
Socio-Cultural Context of HIV and AIDS

Archana Kaushik
Testing of HIV/AIDS
Archana Kaushik
Treatment and Care, Vaccine Issues

Nemthiangai Guite
Modes of Transmission and Prevention of HIV

Gracious Thomas
7 . 8 .
HIV/AIDs among Women and Children

Gracious Thomas
137 160
HIV/AIDS in the Working Population of the Organised and the Unorganised Sector
Jyoti Kakkar
9 .
Hiv/Aids Prevention and Control: Governmental and United Nations Initiatives

Gracious Thomas
180
10. Social Work Intervention in Prevention and Control of HIV/AIDS

Rose Nimbiakkim
209
11. Communication in HIV/AIDS Prevention

Jyoti Kakkar
231
12. Models of Behaviour Change

Jyoti Kakkar
258 280
13. Counselling For HIV/AIDS: Nature and Process

Jyoti Kakkar
14. Issues and Types of HIV/ AIDS Related Counselling

Jyoti Kakkar
312
15. HIV/AIDS and Legislations

Gracious Thomas
337 362
16. Theories and Models of Stigma and Discrimination

Neil Abell
17. Social Stigma: Universal and Culturally Specific

Neil Abell
379
18. Provider Stigma: Social Service and Health Care Providers

Neil Abell
399
19. Response Strategies for Social Workers

Neil Abell
416 436
20. Best Practices in HIV/ AIDS Prevention and Education

Nicole Cesnales
AIDS: Nature and Demography

*Nemthiangai Guite
Introduction
Acquired Immunodeficiency Syndrome (AIDS) emerged as the most dreaded disease of the century. This is dreaded not because of the fact that death is certain, but it is also due to the stigma and social ostracism that is attached to its very name. AIDS continues to be a major concern of research, which requires broad ranging structural analysis of the overall health care sector as well as the social, political and economical forces that influence its shape and content both in the western world and in the developing countries. AIDS is just the tip of an iceberg of a host of social problems ranging from poverty, accessibility to adequate health care, disenfranchisement and discrimination. The time has come not just to say no to unwanted sex or unprotected sex or unwanted conception, it is time to say no to inequity, to discrimination and lack of choice. Human Immunodeficiency Virus (HIV), a lentivirus that belongs to the retrovirus group, is said to cause HIV / AIDS. Acquired Immunodeficiency Syndrome (AIDS) has emerged as one of the most serious public health problems in the country after first being reported in 1986. The initial cases of HIV/AIDS were reported among commercial sex workers in Mumbai and Chennai and injectable drug users in the northeastern states of Manipur. The disease is spread rapidly in the areas
* Nemthiangai Guite, University of Delhi, New Delhi
HIV/AIDS: Stigma, Siscrimination and Prevention
adjoining these epicenters. Currently Andhra Pradesh, Tamil Nadu, Maharashtra, and Manipur put together account for two-third of the total AIDS cases in the country. Today, 34.3 million adults and children worldwide are estimated to be living with HIV. The pandemic is most severe in sub-Saharan Africa, which has 24.5 million people infected with HIV-1, accounting for almost 9% of the total population in the 15 to 49 years age group. The latest UNAIDS and WHO estimates shows that there are 38.6 million people with HIV, 63.2% are in sub Saharan Africa, 21.4% are in Asia, 5.2% in Latin America, 4.1% in North America/Europe, 3.9% in Eastern Europe/Central Asia, and 2.2% in other parts of the world. Conservative estimates way back in 1998 show that eleven men, women and children were being infected per minute. More than 95% of all HIV infected people are now living in the developing world. In this chapter you will be basically introduced to the nature of HIV and AIDS, its history and origin, the epidemiology and demography of HIV/AIDS. We will also discuss how the understanding of the profile of the disease is important for social workers further intervention in preventing and controlling the spread of the epidemic.
Nature of Hiv/Aids
People have been warned to be conscious about HIV and AIDS for over twenty years now. AIDS has already killed millions of people, millions more continue to become infected with HIV, and there is still no cure. So AIDS will be around for a while yet. AIDS is one of the biggest problems facing the world today and nobody is beyond its reach. Everyone should know the basic facts about AIDS.
AIDS, Nature and Demography
Understanding HIV/AIDS The disease AIDS was first detected in 1981. AIDS (Acquired Immuno Deficiency Syndrome) is a medical condition. People develop AIDS because HIV has damaged their natural defenses against diseases. It is caused by a virus which was isolated and identified in 1983 as the Human Immunodeficiency Virus (HIV). HIV is a virus belonging to a family of viruses called retroviruses (known to mutate randomly) and lentiviruses (long acting i.e., once they enter the human body, the individual is infected for life and can transmit the virus to other). HIV can be passed from one person to another. Anyone can become infected with HIV through contact with the bodily fluids of someone who has already contracted HIV. HIV stands for the Human Immunodeficiency Virus. Someone who is diagnosed as infected with HIV is said to be HIV+ or HIV positive. HIV has a number of tricks that helps it to evade the bodys defences, including very rapid mutation. This means that once HIV has been contracted, the immune system can never fully get rid of it. There isnt any way to tell just by looking if someones been infected by HIV. In fact a person infected with HIV may look and feel perfectly well for many years and may not know that they are infected. But as the persons immune system weakens they become increasingly vulnerable to opportunistic illnesses, many of which they would have fought off easily in the past. The only reliable way to tell whether someone has HIV is for them to take a blood test which can detect infection from a few weeks after the virus first entered the body. A damaged immune system is not only more vulnerable to HIV, but also to the attacks of other infections. It would not always have the strength to fight off things that would not have bothered it before. As time goes by, a person who has been infected with HIV is likely to
become more and more ill often until, usually several years after infection, they become ill with one of a number of particularly severe illnesses. It is at this point in the stages of HIV infection that they are said to have AIDS indicative of the number of immune system cells left in their body dropping below a particular point. AIDS is an extremely serious condition, and at this stage the body has very little defence against any sort of infection. AIDS can only be acquired through the contact of body fluids from an infected person to uninfected person. HIV enters the human body and attacks the immune system; mainly infected certain cells called CD4 cells (or T4 cells). HIV is found in the blood and the sexual fluids of an infected person, and in the breast milk of an infected woman. HIV transmission occurs when a sufficient quantity of these fluids get into someone elses bloodstream. There are various ways a person can become infected with HIV. Stages of Infection When a person is infected with HIV, it usually takes about 3 to 6 months for the antibodies to show in a blood test. This period is commonly referred to as the window period. When a blood test detects the presence of antibodies, the person tested is referred as seropositive or antibody positive. During this window period an infected person can unknowingly infect others. The progress of HIV infection varies and should not be viewed as a definitive cycle of events. However, it is possible to identify the key elements of the clinical stages of HIV infection. They can be broadly classified into three categories. 1. Initial Symptoms of HIV Infection In the early stages of HIV infection (within weeks), the person may develop a flu like illness, similar to glandular
fever with symptoms of body ache, rash and swollen lymph glands. The person appears to get well after a few days. By this time the person may be considered a carrier capable of readily passing on the virus to another person. However, not all infected people (carriers) develop this kind of initial illness. 2. Asymptomatic HIV Infection Latent Period As with some other illnesses, this is a period in which the person who is living with HIV shows no apparent symptoms. This period, called the latency period, may range from several months to several years and differ from individual to individual. The person with HIV may look and feel healthy, and remains so for many years. But, the person can pass on the virus to another person even while he or she looks healthy. 3. Symptomatic HIV Infection People with HIV begin to feel sick with minor illnesses such as rashes, infections of the mouth such as oral thrush, loss of weight (about 10% of the body weight), persistent fever, night sweats, loss of energy and extreme tiredness, easy bruising and bleeding and prolonged diarrhea. This period of symptomatic illness is sometimes referred to as AIDS Related Complex (ARC) or as the period of active HIV infection. Transmission of HIV HIV is transmitted only when contaminated blood and body fluids come in contact with the blood and mucous membranes of healthy individuals. Semen and vaginal secretions, in particular, contain substantial concentrations of HIV. Though sweat, tears and saliva, are also body fluids, they contain very low concentrations of the virus and hence do not present a risk of transmission of HIV.
Ways in which one can be infected with HIV:

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Unprotected sexual intercourse with an infected person Sexual intercourse without a condom is risky, because the virus, which is present in an infected persons sexual fluids, can pass directly into the body of their partner. This is true for unprotected vaginal and anal sex. Oral sex carries a lower risk, but again HIV transmission can occur here if a condom is not used - for example, if one partner has bleeding gums or an open cut, however small, in their mouth.
Contact with an infected persons blood If sufficient blood from an infected person enters a healthy persons body, then it can pass on the virus.
Mother to Child transmission From mother to child HIV can be transmitted from an infected woman to her baby during pregnancy (HIV can cross placenta and infect the foetus), delivery (contact with the mothers infected blood) and breastfeeding (breast milk being fluid contain a certain concentration of the virus). There are special drugs that can greatly reduce the chances of this happening, but they are unavailable and cannot be afforded in much of the developing world.
Use of infected blood products If blood or blood product is contaminated, HIV can be transmitted during transfusion of blood or blood products. Therefore, blood from all donors should be screened. Similar precautionary screening should be done in case of organ or tissue transplants. Many people in the past have been infected with HIV by the use of blood transfusions and blood products which were contaminated with the virus in
hospitals, for example. In much of the world this is no longer a significant risk, as blood donations are routinely tested.
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Injecting drugs People who use injected drugs are also vulnerable to HIV infection. In many parts of the world, often because it is illegal to possess them, injecting equipment or works are shared. A tiny amount of blood can transmit HIV, and can be injected directly into the bloodstream along with the drugs.
It is not possible to become infected with HIV through:

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Sharing crockery and cutlery Insect / animal bites Touching, hugging or shaking hands Eating food prepared by someone with HIV Toilet seats
Test for HIV The body defends itself against each new viral infection by manufacturing proteins called antibodies. The presence of these antibodies is a positive indicator of infection. It is similar to HIV. However, after a person is infected with HIV, it can take up to 3 months for the antibodies to develop and detected. A person should be tested only after window period. To detect HIV antibodies in the blood, a number of different tests have been developed. Two of the most widely used tests are ELISA (Enzyme Linked Immuno Sorbent Assay) and the Western Blot Kit Test. However, a new method of detecting and identifying the virus in the blood called polymerase chain reaction (PCR), has been developed.
HIV facts and myths Around the world, there are a number of different myths about HIV and AIDS. Here are some of the more common ones: You would have to drink a bucket of infected saliva to become infected yourself . . . Yuck! This is a typical myth. HIV is found in saliva, but in quantities too small to infect someone. If you drink a bucket of saliva from an HIV positive person, you wont become infected. There has been only one recorded case of HIV transmission via kissing, out of all the many millions of kisses. In this case, both partners had extremely badly bleeding gums. Sex with a virgin can cure HIV . . . This myth common in some parts of Africa is baseless and totally untrue. The myth has resulted in the rape of many young girls and children by HIV+ men, who often infect their victims. Rape would not cure anything and is a serious crime. It only happens to gay men / black people / young people, etc . . . This myth is false. Most people who become infected with HIV did not think it would ever happen to them. They were proven wrong. HIV can pass through latex . . . Some people have been spreading rumours that the virus is so small that it can pass through holes in latex used to make condoms. This is untrue. The fact is that latex blocks HIV, as well as sperm, preventing pregnancy too.
History and Origin of HIV/AIDS

The origin of AIDS and HIV and the first cases of AIDS The origin of AIDS and HIV has puzzled scientists ever since the illness first came to light in the early 1980s. For over twenty years it has been the subject of fierce
debate and the cause of countless arguments, with everything from a promiscuous flight attendant to a suspect vaccine programme being blamed. So what is the truth? Just where did AIDS come from? Listed below are four of the earliest recorded instances of suspected HIV infection:
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A plasma sample taken in 1959 from an adult male living in what is now the Democratic Republic of the Congo. A lymph node sample taken in 1960 from an adult female, also from the Democratic Republic of the Congo. HIV found in tissue samples obtained from an American teenager who died in St. Louis in 1969. HIV found in tissue samples from a Norwegian sailor who died around 1976.
The first recognised cases of AIDS occurred in the USA in the early 1980s. A number of gay men in New York and California suddenly began to develop rare opportunistic infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did not yet have a name, but it quickly became obvious that all the men were suffering from a common syndrome. The discovery of HIV, the Human Immunodeficiency Virus, followed soon. While some were initially resistant to acknowledge the connection (and indeed some remain so today), there is now clear evidence to prove that HIV causes AIDS. However we have a research study led by Paul Sharp of Nottingham University and Beatrice Hahn of the University of Alabama, which made the discovery during the course of a 10-year long study into the origins of the virus. They claimed that this sample proved that chimpanzees were the source of HIV-1, and that the
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virus had at some point crossed species from chimpanzees to humans. They concluded that wild chimps had been infected simultaneously with two different simian immunodeficiency viruses which had viral sex to form a third virus that could be passed on to other chimps and, more significantly, was capable of infecting humans and causing AIDS. These two different viruses were traced back to a SIV that infected redcapped mangabeys and one found in greater spot-nosed monkeys. They believe that the hybridization took place inside chimps that had become infected with both strains of SIV after they hunted and killed the two smaller species of monkey. It has been known for a long time that certain viruses can pass between species. Indeed, the very fact that chimpanzees obtained SIV from two other species of primate shows just how easily this crossover can occur. Being animals ourselves, we are just as susceptible. When a viral transfer between animals and humans takes place, it is known as zoonosis. Below are some of the most common theories about how this zoonosis took place, and how SIV became HIV in humans: Controversial theory on the origin of HIV/AIDS
The Hunter Theory

The most commonly accepted theory is that of the hunter. In this scenario, SIVcpz was transferred to humans as a result of chimps being killed and eaten or their blood getting into cuts or wounds on the hunter. Normally the hunters body would have fought off SIV, but on a few occasions it adapted itself within its new human host and become HIV-1. The fact that there were several different early strains of HIV, each with a slightly
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different genetic make-up (the most common of which was HIV-1 group M), would support this theory: every time it passed from a chimpanzee to a man, it would have developed in a slightly different way within his body, and thus produced a slightly different strain. The Oral Polio Vaccine (OPV) Theory Could production of the oral polio vaccine have contributed to the spread of HIV? Some other rather controversial theories have contended that HIV was transferred iatrogenically (i.e. via medical interventions). One particularly well-publicized idea is that polio vaccines played a role in the transfer. In his book, The River, the journalist Edward Hooper suggests that HIV can be traced to the testing of an oral polio vaccine called Chat, given to about a million people in the Belgian Congo, Ruanda and Urundi in the late 1950s. To be reproduced, live polio vaccine needs to be cultivated in living tissue, and Hoopers belief is that Chat was grown in kidney cells taken from local chimps infected with SIVcmz. This, he claims, would have resulted in the contamination of the vaccine with chimp SIV, and a large number of people subsequently becoming infected with HIV-1. The fact that the OPV theory accounts for just one (group M) of several different groups of HIV also suggests that transferals must have happened in other ways too. This indicates the fact that HIV seems to have existed in humans much much before the vaccine trials were ever carried out. The Contaminated Needle Theory This is perhaps an extension of the original Hunter theory. In the 1950s, the use of disposable plastic syringes became commonplace around the world as a cheap, sterile way to administer medicines. However,
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to the African healthcare professionals working on inoculation and other medical programmes, the huge quantities of syringes needed would have been very costly. It is therefore likely that one single syringe would have been used to inject multiple patients without any sterilization in between. This would rapidly have transferred any viral particles existing (within a hunters blood for example), from one person to another, creating huge potential for the virus to mutate and replicate in each new individual it entered, even if the SIV within the original person infected had not yet converted to HIV. The Colonialism Theory The colonialism or Heart of Darkness theory is one of the more recent theories to have entered into the debate. It is again based on the basic hunter premise, but more thoroughly explains how this original infection could have led to an epidemic. During the late 19th and early 20th century, much of Africa was ruled by colonial forces. In areas such as French Equatorial Africa and the Belgian Congo, colonial rule was particularly harsh and many Africans were forced into labour camps where sanitation was poor, food was scarce and physical demands were extreme. These factors alone would have been sufficient to create poor health in anyone, so SIV could easily have infiltrated the labour force and taken advantage of their weakened immune systems to evolved into HIV. A stray and perhaps sick chimpanzee with SIV might have made a welcome extra source of food for the workers. The Conspiracy Theory Some say that HIV is a conspiracy theory or that it is man-made. A recent survey carried out in the US for example, identified a significant number of African
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Americans who believe HIV was manufactured as part of a biological warfare programme, designed to wipe out large numbers of black and homosexual people. Many believe that this was done under the auspices of the US Federal Special Cancer Virus Program (SCVP), possibly assisted by the CIA. Linked in to this theory is the belief that the virus was spread (either deliberately or inadvertently) to thousands of people all over the world through the smallpox inoculation programme, or to gay men through Hepatitis B vaccine trials. While none of these theories can be definitively disproved, the evidence given to back them up is usually based upon speculation. Moreover, it ignores the clear link between SIV and HIV or the fact that the virus has been identified in people as far back as 1959. The Pattern of the Spread of HIV Infection: Global Scenario There are said to be a number of factors that may have contributed to the sudden spread of HIV, most of which occurred in the latter half of the twentieth century. They are listed as follows: Travel International travel has undoubtedly played a major role in the spread of HIV. Both national and international travel undoubtedly had a major role in the initial spread of HIV. In the US, international travel by young men making the most of the gay sexual revolution of the late 70s and early 80s, would certainly have played a large part in taking the virus worldwide. In India, the virus are supposedly spread along truck routes and between towns and cities within the country itself. Similarly, war bases of the US Army in Phillipines and Taiwan, where soldiers
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decamped, later evolved into brothels, hinting of a similar route of spread. We also witness an inadvertent growth of sex related tourism in destinations such as Goa, Thailand and Kovalam. Thus, the process of transmission in a global pandemic is simply too complex to blame on any one group or individual. The Blood Industry As blood transfusions became a routine part of medical practice, an industry to meet this increased demand for blood began to develop rapidly. In some countries such as the USA, donors were paid to give blood, a policy that often attracted those most desperate for cash; among them intravenous drug users (IDUs). During the early stages of the epidemic, doctors were unaware of how easily HIV could be spread and blood donations remained mostly unscreened. This blood was then sent worldwide, and unfortunately most people who received infected donations went on to become HIV positive themselves. Drug Use The 1970s witnessed an increase in the availability of heroin. It was the respective wars especially the Vietnam War, the civil war in the African subcontinent and later the other conflicts in the Middle East that stimulated a growth in intravenous drug use. This increased availability together with the development of disposable plastic syringes and the establishment of shooting galleries, where people could buy drugs and rent allied equipment, provided another route through which the virus could be passed on. Urbanisation, Migration and Alienation The rapid industrialization forced large populations to migrate from the rural to urban area and settlement in
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slums bordering the cities and industries. Moving away from primary groups into secondary groups has lead to alienation. Such moving away from the family, the absence of social control (community mores) and the inability to gain sexual gratification rendered individuals vulnerable to prostitution. Thus, brothels close to these squalors owing to the unprotected and indiscriminate sex too fuelled the epidemic.
Epidemiology
Definition of AIDS case WHO and National AIDS Control Organization (NACO) have given the definition of AIDS on the basic certain criteria which are given below: Clinical AIDS in an adult Positive test for HIV antibody detected by two separate tests using two different antigens and any one of the following criteria: 1 . a . b . Weight loss of greater than 10% of body weight or cachexia. Chronic diarrhoea of more than 1 month duration, chronic coughs for more than 1 month duration.
2 . 3 . 4 . 5 .
Disseminated, military or extra pulmonary tuberculosis. Neurological impairment that restricts daily activities. Candidiasis of the esophagus diagnosable, Dysphagia with oral candidiasis. Kaposis sarcoma.
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Clinical stage progression Stage I Stage II Stage III : HIV infection - asymptomatic/acute primary infection (sero conversion) : Early (asymptomatic) disease (CD4 count >500/mm3) : Intermediate HIV infection (CD4 200-500/ mm3)
Stage IV : Late stage HIV disease (CD4 50-200/mm3) Stage V : Advanced HIV Disease (CD4<50/mm3)
Clinical case definition for AIDS in Children At least two major signs associated with at least two minor signs in the absence of known cases of immunosuppression. Major Signs a . b . Weight loss or abnormal slow growth 1 . 2 . 3 . 4 . c . 1 . 2 . 3 . Failure to thrive; Recurrent/persistent diarrhoea of over one month duration; Recurrent bacterial infections, e.g., lower respiratory infection. Recurrent fever of over one month duration Candidiasis Tuberculosis Herpes Zoster
Minor Signs a . b . c . Generalized lymphadenopathy Oropharyngeal candidiasis Repeated common infection
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d . e . f .
Persistent cough for over a month Generalized dermatitis Confirmed maternal HIV infection.
Risk of Transmission Transmission dynamics reveal how HIV-1 spread in a population. Such an understanding helps in designing control program. The basic reproductive rate RO, is the average number of infectious contacts by one infected individual. An infectious contact is a person who would transmit the infection if his/her partner is non-infected. For an epidemic to occur, each infected individual must on an average make infectious contacts with more than one individual (RO must exceed 1). RO = B(C+D), where C is rate of partner change, and D is the infectiousness. This equation is affected by individual, social and psychological factors (partner selection, sexual and social network), family dynamics (type of family, economic conditions, etc.), community factors (type of neighbourhood, social capital, health services, etc.), and national and international factors (war, development and health policies) The problem of injectable drug use through needles has emerged as a serious problem firstly in Manipur and other North Eastern States and also in metropolitan cities such as Mumbai, Chennai, Kolkata and Delhi. The problem of HIV/AIDS has added a new dimension as sharing of injection equipment for narcotic drug use is one of the most efficient routes of HIV transmission and is considered to be much more risky than unprotected sexual contact. While most of the Injecting Drug Users (IDUs) are male, their female partners are not known to be in the habit of injecting drug use. The latter therefore suffer from the risk of sexual transmission from HIVinfected IDUs without their
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knowledge. It has also been noticed that majority of the IDUs are youth in their most productive age group of 15 25 years. Government therefore considers it as a serious issue and is committed to adopt appropriate strategies for preventing the risk of transmission through injecting drug use.
Demography and Prevalence of HIV/AIDS

Burden of HIV/AIDS
India has experienced a sharp increase in the estimated number of HIV infections, from a few thousand in the early 1990s to steeply increasing 3.5 million in 1998. 3.86 million in 2000, 4.58 million in 2002 and 5.21 million in 2004. In 2005, it was reported that there were 5.7 million people infected with HIV in India. With a population of over one billion, the HIV epidemic in India will have a major impact on the overall spread of HIV in Asia and Pacific and indeed worldwide. Globally India has the second lagest population in the world as far as numbers of HIV positive cases (2.5 million) are concerned. South Africa (5.4 million) ranks first. Controversy prevails regarding the absolute number of HIV cases in India. The UNAID in 2006 emphasized that India is having approximately 3.7 million HIV cases instead of 5.7 million. Recently, the Indian Government corrected the numbers and stated that it was 2.5 million and that estimates were calculated wrongly previously (NACO 2007). The following are the estimates of the AIDS epidemic in the country:
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The UN Population Division projects that Indias adult HIV prevalence will peak to 1.9% in 2019. There were 2.7 million AIDS deaths in India between
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1980 and 2000 as per UN estimates. As per projections, 12.3 million AIDS death will occur during 2000-2015, while 49.5 million deaths are expected to occur during 2015 50 (UN 2003). NACO reported 1,11,608 AIDS cases in July 2005.
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India is experiencing multiple epidemics. More than 100 districts have sentinel sites reporting sero prevalence of more than 1% among women visiting antenatal clinics. The epidemic is slowly moving beyond its initial focus among sex workers. Sub epidemics are evolving with potentially explosive spread among groups of injectable drug users (IDUs) and among Men having Sex with Men (MSM). It is now seen in all age group and sexual route is the major cause of transmission. The number of women are far on the increase. About 89% of the reported cases are occurring in sexually active and economically productive age group of 15 44 years. Recent research shows that many men are bisexual, i.e. they have sex with men as well as with women. In 2002, behavioural surveillance in five cities among men who have sex with men found that 27% were reportedly married, or living with a female sexual partner. In a study conducted in a low income group of Chennai in 2001, 7% men who have sex with men were HIV positive. 76% of the Indian population had heard of HIV/AIDS; the figure was 93% for urban males and 65.2 % for rural women. In Bihar, only 21.5% of the adult population and in UP only 27.6% had ever heard of HIV/AIDS. While 71% of Indians were aware of the sexual route of HIV transmission, only 18.6% of rural women had heard of the linkage. Attention and research currently focuses on areas with high recorded prevalence, but there is concern about what might
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be happening in the vast areas of rural India, for which especially there is little data.
l
The annual sentinel surveillance surveys have divided States and Union territories in India into four broad categories: High prevalence: Maharashtra, Tamil Nadu, Manipur, Andhra Pradesh, Karnataka and Nagaland States which have HIV prevalence rates exceeding 5% among groups with highrisk behaviour and 1% among women attending antenatal clinics in public hospitals. Moderate epidemics: Gujarat, Pondicherry and Goa, where HIV prevalence rates among population with high risk behaviour has been found to be 5% or more, while HIV prevalence remains below 1% among women attending antenatal clinics. Low prevalence: High vulnerable states: these states are where migration was rampant, and where weak health infrastructure existed. HIV prevalence rates among vulnerable population are below 5 percent and less than 1 percent among women attending antenatal clinics.
Vulnerable states: All other states and Union Territories fall into the low prevalence category. The HIV/AIDS situation in Different States Andhra Pradesh has one of the fastest advancing HIV/ AIDS prevalence rates in India. In 2002, the ANC prevalence rate was 1.25% and NACO has estimated that more than 400,000 people are living with HIV in Andhra Pradesh, the second highest number after Maharashtra State. This is 10% of the total HIV cases in India and ninety percent of the infections in the state occur through sexual transmission.
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HIV infection has increased noticeably in Goa in the past couple of years. The ANC prevalence rate increased from 0.5% in 2001 to 1.38% in 2002. This could be due to tourism. In Karnataka the mean prevalence among ANCs was 1.13 % in 2001 and 1.75% in 2002. In 2001 there were four districts with an ANC prevalence of 2 percent or more, and these are located in the southern part of the state, in and around Bangalore, bordering with Tamil Nadu, or northern Karnatakas Devadasi belt. Devadasi women are a group of women, who historically, have been dedicated to the service of gods. Over the years, this evolved into sanctioned prostitution as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. The geographical proximity of Manipur to Burma, and therefore to the Golden Triangle, has made it a major transit route for drug smuggling owing to its availability. However, the transmission route to the state is no longer confined to injecting drug users. It has spread further to the female sexual partners of IDUs and their children. The prevalence of HIV/AIDS in ANC cases in Manipur was 1.12% in 2002 and among injectable drug users at three surveillance sites, the HIV prevalence was extremely high - 39.06%. Similarly high prevalence of HIV among drug users was recorded in Mizoram (70%), Nagaland (10.28%) and Tamil Nadu (33.8%). Affected Population The majority of the reported AIDS cases occurred in the sexually active and economically productive 15 - 49 year age group. Although HIV/AIDS is still largely concentrated in at risk populations, including commercial sex workers, injecting drug users, and truck drivers, the surveillance data suggests that the epidemic no longer confined, but is moving beyond these groups
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in some regions and into the general population through bridging population. It is also moving from urban to rural districts. The epidemic continues to shift towards women and young people. It has been estimated that 38% of adults living with HIV/AIDS in India at the end of 2003 were women. In 2004, it was estimated that 22% of HIV cases in India were house wives with a single partner. The increasing HIV prevalence among women can consequently be seen in the form of increased mother to child transmission of HIV and paediatric HIV cases. Sex workers: Mumbai, the countrys largest brothel based sex industry, with over 15,000 sex workers poses a major challenge for HIV prevention. A study in Surat found that HIV prevalence among sex workers had increased from 17% in 1992 to 43% in 2000. Injecting Drug Users (IDUs): HIV infections among Injecting Drug Users (IDUs) first appeared in Manipur. Here, in the city, the level of HIV infection was 61% in 1994 and increased to 85% in 1997. In 1998, it stabilized around 80.7%. Injectable drug use is also a major problem in urban areas such as Mumbai, Kolkata, Delhi and Chennai. Recent survey data indicate that most IDUs had at some stage shared their needle and syringe. A majority of drug users are male. However, females are also involved and presented more HIV positives as compared to non drug addicts females. There is increased number of widows of addicts, many of them are HIV positives. Migrants: According to the 1993, National Sample Survey in India, 24.7% of the population had migrated, either within India, to neighboring countries or overseas. Applying this percentage to the mid 2003 population about 264 million Indians are mobile. Being mobile in itself, does not present a risk factor for HIV transmission.
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The migrants often live in unhygienic conditions in urban slums. Long working hours, relative isolation from the family, and geographical mobility may foster casual sexual relationships that make them highly vulnerable to STDs and HIV/AIDS. Migrant workers tend to have little access to HIV/STD information, voluntary counselling and testing, and health services. Regionalism, as well as cultural and language barriers cuts their access to such services. Returning or visiting migrants, many of who do not know their status, may infect their wives or other sexual partners in their home community. Truck Drivers: India has one of the largest road networks in the world and an estimated 2 to 5 million long distance truck drivers and helpers are part of this network. The extended period of time that they spend away from their families placed them in close proximity to high risk sexual networks, and often results in their increased number of sexual contacts. During their journeys the driver often stop at dhabas, roadside hotels that usually provide food, rest, sex workers, alcohol and drugs. They pick up the women, have sex with them and leave them at some other dhabas, where they encounter other drivers, get picked up and get used by other drivers and local youth. As a result truck drivers also play a crucial role in spreading STDs and HIV throughout the country.
Conclusion
The history of AIDS is a short one. As recently as the 1970s, no one was aware of this deadly illness. Since then the global AIDS epidemic has become one of the greatest threats to human health and development. At the same time, much has been learnt about the science of AIDS, as well as how to prevent and treat the disease.
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Although HIV and AIDS are found in all parts of the world, some areas are more afflicted than others. The worst affected region is sub-Saharan Africa, where in a few countries more than one in five adults is infected with HIV. The epidemic is spreading most rapidly in Eastern Europe and Central Asia, where the number of people living with HIV increased 150% between 2001 and 2007. AIDS is caused by HIV, a virus that can be passed from person to person through sexual fluids, blood and breast milk. Certain types of behaviour carry a higher risk of HIV transmission. People particularly vulnerable to HIV include injecting drug users, commercial sex workers (CSWs) and men who have sex with men (MSM). In many peoples minds, HIV and AIDS are closely linked with these groups, which can lead to even greater prejudice against people already treated as outsiders. Yet, the vast majority of HIV infections are transmitted through sex between men and women. Nearly half of all adults living with HIV are female. As a sexually transmitted infection, HIV particularly affects adolescents and young adults. Deaths of young adults have an especially damaging impact on their families and communities: skills are lost, workforces shrink and children are orphaned. Apart from inadequate funding, major obstacles in tackling the global AIDS epidemic include weak infrastructure and shortages of health workers in the worst affected countries. Political or cultural attitudes also cause significant damage; for example, some authorities oppose condom promotion, while others refuse to support needle exchanges for injecting drug users. Many are reluctant to provide young people with adequate education about sex and sexual health. Another very serious issue is stigma and discrimination. People known to be living with HIV are often shunned or abused by their very own community members,
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employers and even health workers. As well as causing much personal suffering, this sort of prejudice discourages people from seeking HIV testing, treatment and care. Based on recent trends it is likely that AIDS around the world will keep getting worse for many years to come. Millions more will become infected with HIV and millions will die of AIDS. Therefore, Social Work as a profession needs to focus more on the prevention and control of the epidemic by generating awareness and removing the various myths and misconceptions. We also need to adopt an approach where in the stigma and discrimination attached to the disease would be eliminated.
References
Bury, J., Morrison, V. & Mc.Lachlan, S. (1992): Working with Women and AIDS: Medical, Social and Counselling Issues. New York: Tavistock Routledge. Rushing, W.A. (1995): The AIDS Epidemic: Social Dimensions of an Infectious Disease. Westview Press. Senak, M.S. (1996): HIV, AIDS and the Law: A Guide to our Rights and Challenges. Insight Books. Sills. Y.G. (1994): The AIDS Pandemic: Social Perspectives. Connecticut: Greenwood Press. Thomas, G. (1997): AIDS, Social Work and Law. New Delhi: Rawat Publications. United Nations (1998): HIV/AIDS and Human Rights International Guidelines. Geneva: United Nations. UNAIDS/WHO (2000): Innovative Approaches to HIV Prevention: Selected Case Studies. Best Practice Collection. Geneva: UNAIDS. UNAIDS/WHO (2000): Protocol for the Identification of Discrimination against People Living with HIV. Best Practice Collection. Geneva: UNAIDS.

*Archana Kaushik
Introduction
There were about 34.3 million adults and children living with HIV/AIDS in 2001. In 52 countries, more than 1 percent of all adults carry the virus. The AIDS pandemic has claimed more than 18 million lives since it was first detected in the early 1980s. The pandemic is most severe in sub-Saharan Africa, with 24.5 million people infected with HIV in the region (WHO, 2006). Approximately 5 million people are living with HIV/AIDS in India today. Although Indias adult HIV-prevalence rate is low at about 0.8 percent, this converts into staggering numbers due to Indias enormous population. It is painfully clear that HIV/AIDS is not just another infectious threat to health. HIV/AIDS is destroying the traditional social fabric of the societies and is a threat to all aspects of sustainable development. Studies on impact of HIV/AIDS on demographic aspects indicate the classic population pyramid in developing countries will be radically changed with the advent of HIV/AIDS, within the next two decades. Never before has the world experienced death rates of this magnitude, among young adults of both sexes and across all social strata. It is hard to imagine how societies will be able to cope with such dramatic changes, where the old will have to care for their children and grandchildren, and where the youth will have to take responsibility for caring for family
* Dr. Archana Kaushik, University of Delhi, New Delhi
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members at a much younger age than they do today. Although the pattern and severity of the pandemic is not as drastic in other continents as it is in Africa, it is of concern to all societies and will remain so for the foreseeable future. In this chapter we would examine the impact of HIV/ AIDS on various aspects of social, political, and economic life, especially with reference to less developed countries. It is believed that HIV has influenced, most often negatively, the social institutions such as family and community relations. A look into the actual and probable devastation that HIV has brought about or would bring about, indeed would give us the necessary insight to reduce vulnerabilities associated with it and make us better equipped to deal with the infection, improve response, and strengthen social institutions. We would also look into some of the salient effects of HIV/AIDS, both direct and indirect, from the decline in productivity that result from early mortality, to increased burdens on households and states that stem from caring for infected persons. We would analyze the effects on households, the growing orphan problem and gender relations. We would also review a variety of economic effects, including on economic growth, on corporate firms, agriculture, health sector, and so on. It may be noted that for the purpose of the study, we may categorize the impact of HIV into socio-economic impacts, macro-micro-level implications, both of which are highly interlinked issues. Response to HIV infection at the level of households affect the supply of labour, which influence the responses of employers and workplace, which produce macro-level consequences. Similarly, the responses of national and international institutions determine the choices and alternatives available to individuals and families. Further, the impact of HIV/AIDS on economic institutions has the potential
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to influence many other institutions as well, including education, health care, government, and the law.
Household Level Impact of HIV

At the micro-level, economic constraints due to HIV infection are quite obvious and visible. Income losses, at the household level are on various accounts reduced work capacity, expenditure for treatment and care, reduced time to work and earn, caregivers inability to work full time, premature death of an AIDS afflicted member of the household, funeral costs and so on. At the household level, the most frequently felt impact of HIV is increased spending on treatment and care, even if the cost of anti-retroviral therapy is not taken into account. Stated otherwise, meeting the cost of management of opportunistic infections is quite an uphill task especially for families with financial constraints. Further, affordability of anti-retroviral drugs is not easy for most of the households affected with HIV/AIDs. The World Health Organization (2003) estimates that, of the six million people who currently need anti-retroviral treatment in the developing world, only 8 percent are receiving it. In Africa where more than half of the PLHA (People Living with HIV/AIDS) reside, this figure drops to 2 percent. When seen in the context of poverty, most of the HIV infected people would remain out of the purview of Anti-retroviral therapy that could elongate their lifespan. Next, HIV most often attacks the productive age group of 15 to 35 years, designated as youth. It consequently affects the ability to work and earn and there is substantial loss of earning and income of households having members infected with HIV. There is reduced earning due to frequent ailments and reduced ability to work due to the infection. Another dimension of this
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accentuated vulnerability is reduced employability due to stigma associated with the infection. So, people afflicted by HIV, face problems in getting job due to stigma and discrimination associated with HIV, and also retaining it because of deteriorating bodys health and immunity. In India, in consonance with many of the other developing nations, almost 93percent of the people are engaged in unorganized sector and more often than not, engaged in physically strenuous and hazardous jobs. With HIV infection, stamina and energy drops significantly and so significantly too affects the ability to work. Sunder and Singh (2006), in their research, confirmed that six states with high prevalence namely Maharashtra, Tamilnadu, Karnataka, Andhra Pradesh, Manipur, Nagaland have households affected on the economic front due to HIV. In economic terms, seriously affecting their capacity to earn as compared to no-AIDS. The medical condition of the people living with HIV/ AIDS reduce savings as treatment cost is manifold. In this context, it is important to note that the long term impact of HIV varies depending upon the initial economic condition of the households. So, the rich or the economically better off families have greater resilience in absorbing the economic shock brought by HIV infection and on the other hand poorer families may be pushed below poverty line while trying to cope with the crisis of infection. There have been many studies that indicate on higher work participation rate among the children and the elderly on account of lowering or the lack of work participation by the young HIV infected family member(s). Sunder and Singh (2006) in their study have found that families affected by HIV are under greater financial strain, often losing breadwinners and having less money to spend on education and health care of
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children. They often respond by taking their children out of school and adding them to the labour force, contributing to the abundance of unskilled labour and further accentuating the problem of child labour. Likewise, households affected with HIV may also change the skill composition of the future work force, as young people are forced to forgo education and training, in order to join the work force and contribute to household financial resources. There is rapidly growing number of AIDS orphans. According to the UN, the disease has resulted in more than 14 million AIDS orphans, since the epidemic began (Hagen, 2002) and this number is projected to increase to some 40 million in Africa by 2010 (Foster and Williamson, 2000). Orphanhood has adverse impact on children. In general, children who lose one or both parents to AIDS, are at risk of leaving school or falling behind their age group in school. Additionally, even before the parent dies, the child is required more in the household to help with domestic work. On becoming orphaned, some children stay home to take care of their siblings, and therefore do not go to school. The longterm effect is a loss of productive human capital. Researchers have also noted the deterioration in nutritional, health and educational status as the impact on the child of losing one or both parents. It has also been found that with the loss of the mother as caregiver, the health of orphans often gets worse. HIV can have a greater impact on children as the surviving parent is likely to die too if also infected, and because of the enormous economic burden due to a prolonged period of illness. Needless to add, the emotional impact of losing one or more parents to HIV/AIDS is distressing, and can be intensified if a child is abandoned (especially, once the cause of death of the parent is known). As AIDS is often associated with promiscuity, prostitution,
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or other unacceptable behaviour, the AIDS orphans get stigmatized and is alienated. These problems, along with economic difficulties, may force orphans to migrate to cities, joining the already large number of street children, who in turn become more at risk of HIV infection and transmission through sexual work and exploitation to secure their basic needs. Children, at times, after the death of one parent may have to live with step-parent(s), which has its whole gamut of consequences ranging from exploitation verbal, physical, sexual - at home, to desertion, and finally taking on urban streets. Many other AIDS orphaned children live with their grandmothers or in child-headed households, taken care of by older siblings. Grandmothers who have traditionally retired from active life are forced back to take up new child-rearing responsibilities and at times, even earn for livelihood. According to a study in Zimbabwe, the large majority of main caregivers were females over 60 years of age caring for their grandchildren (WHO, 2002). Further, studies conducted in Thailand, have found that AIDS victims return to their parental homes at late stages of the illness, imposing an unexpected burden of care on elderly adults (Knodel and Van Landingham, 2003). As older parents in developing countries commonly expect to rely on adult children for support, the loss of children also affects parents in the long-term. Rather than relying on their children, the elderly are finding themselves caring for children and grandchildren, causing extreme financial strain. Impacts on the health of elderly parents include, physical strain from care-giving, extra work required for needed expenses, as well as potential exposure to opportunistic diseases such as TB and a host of other physical illnesses (WHO, 2002). The effects of care-giving can vary across households, with most facing a decline in living standards due to
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the costly long term treatment, loss of income as the sick and their caregivers drop out of the workforce, funeral expenses, all of which can lead to debt and poverty (Danziger, 1994; WHO, 2002). Indeed, a study of household expenditure due to AIDS in Tanzania found that the cost of medical care and funerals exceeded the annual income of many households, largely due to the long duration of this disease. Further, the price of antiretroviral treatments as determined by pharmaceutical companies as well as the government subsidies will also be a strong determinant in the future impact on families. Caregivers also face many problems such as constrained relationships with in-laws, exhaustion due to care to HIV positive relative, stress of seeking additional sources of income, etc. (Magadi, 1992). Emotional strain, burnouts due to demanding care, psychological stress related to poverty, inability to care for ones children, and overall despair takes a heavy toll, particularly on mothers. Thus, we analyze that even if the families are doing their best to cope with crisis of HIV/AIDS, in future, the stress of caring for the growing numbers of people with AIDS as family members, may put the existing family structures under extreme pressure. Researches have shown that many families, with no assets to sell, are often forced to borrow substantial sums of money for the care and treatment of HIV positive relative, putting great financial strain on the households. As families are less able to save, less capital is available for investment, threatening the education and skill development of the children. Another reason for loss of income of the household is reduced work time of uninfected members primarily on account of providing care and support to the infected member. So, we see that presence of even one infected member has multifarious economic impact.
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Gender plays crucial role in defining the vulnerability to HIV as well as bearing the brunt of it. Gender inequality is further accentuated by AIDS. Females, biologically, socially and psychologically, are more vulnerable to HIV infection than their male counterparts. In traditional societies like India where mere discussion about sexual or reproductive health is a taboo, one can assess the amount of difficulty a woman faces in trying to enforce condom use to male partner, along with added pressure to have children. This makes it very difficult for many women to control their own sexuality, health, and well-being. Right now, limiting the scope of the discussion, we focus on the economic vulnerability of the women. Traditionally, money is not spent on the health care needs of females and they are socialized to remain apathetic towards their health concerns, particularly the sexual and reproductive diseases. Their need for economic self-reliance is hardly given any attention. Further, care for those affected by HIV/AIDS falls disproportionately on females and they usually operate as unpaid primary caregivers to those affected by HIV/AIDS, which takes a heavy toll on them physically, economically and psychologically. In many instances, women, the prime caregivers, are also infected with HIV, thus their health needs are regarded secondary. Providing long term care to HIV infected family member with scarce economic resources and ignoring the needs of their own ailing body, exhaust these women. It becomes all the more shattering when they have to face stigmatization, blame and abandonment from their own relatives and community people. Widowhood further brings economic hardship along with stigma and discrimination. Widows are also vulnerable to denial of legal rights to property or inheritance. Combined with blame and abandonment by in-laws, this can lead to the loss of shelter and any means of
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subsistence, resulting in poverty. This forces women to fend for themselves and their children by engaging in sex work for their familys survival. This in turn amplifies the risk of HIV spread as the societal discrimination and stigma discourages women from being tested and even telling family and others about their sero-status, leaving them without the much needed support and treatment. Gender discrimination and inequality not even spares young girls, who are likely to be the first ones to be taken out of school when economic constraints pinches the family affected by HIV. They have to care for younger siblings and, at times, may be pressurized to engage in sexual activities at a tender age, as men seek to marry younger girls to avoid risk of infection, and as girls needs to secure resources for their livelihoods. There is enough evidence that to show that AIDS has actually increased womens exploitation and abuse in myriad of ways. Presence of an HIV infected family member adds to the health vulnerability of other family members, though indirectly. HIV predisposes a person to tuberculosis, fungal infection, pneumonia and other communicable infections, which, especially, makes young children vulnerable to these infections. Lastly, the stigma and discrimination on account of AIDS are particularly severe in India and often at times, due to actual or even perceived fear of stigma and discrimination, individuals infected with HIV do not reveal their HIV status and deny themselves healthcare services. This indeed makes the situation all the more precarious. Experiential and empirical data bring out that many people with HIV in need of medical attention travel a long way (often away from their residence) to access healthcare services far off from their place of residence in order to maintain anonymity and also not
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to let their neighbourhood and community know about their sero-status, which indeed is not a cost effective proposition.
Sectoral Impact of HIV

The impact of HIV pandemic has gone beyond the households affected with the infection and it has started influencing sectors like health, tourism, agriculture, transportation and industry. In this unit let us analyze impact of HIV on some of the prominent sectors, to begin with the agriculture sector, which has the highest unskilled labour intensity. Agriculture sector: There is widespread agreement that HIV/AIDS exacerbates economic vulnerability. HIV/ AIDS is assumed to bring the proportions of devastation similar to those such as droughts and floods, thereby threatening the sustainability of rural communities. Loss of labour power due to AIDS destroys family life as well as agricultural patterns. Researchers argue that households with infected adults generally experience a decline in agricultural production and may opt for shift in cropping patterns requiring less labour and financial inputs which in turn may result in reduced food production and quality. In addition, decreased labour input in crop production due to increased rate of morbidity and mortality among labourers, the area under cultivation may be reduced. The costs of taking care of chronically ill relatives or orphans substantially lowers the capacity to utilize appropriate inputs (seed, fertilizer, etc.), which lowers the crop production. Further, HIV/AIDS infected/affected households tend to switch cropping patterns that demand lesser labour inputs even compromising with the better returning long duration crops.
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Poverty adds to AIDS vulnerability to many fold. It lowers the income and food purchasing-power of households and HIV/AIDS lowers household food and cash crop production. Small farmers may have to mortgage or sell off their piece of land for want of money. When they are left with no money to make initial investment for crop production, they often migrate to urban centers. Another pull factor for migration is better healthcare infrastructure in urban areas. Cities often provide hostile environment to these migrants and many, especially women, are left with no choice but to engage themselves in sex work for survival. These factors further accentuate transmission of HIV infection. With increasing numbers and proportions of workforce in agriculture giving into morbidity and mortality due to AIDS, this primary sector shrinks in meeting the requirement of food production of the nation and contributing its share to GDP. Education: HIV/AIDS would threaten educational institutions by precipitating a shortage of both teachers and students. The direct effects of the disease on the health and numbers of teachers and students are perhaps most obvious. The effects may be classified to be on the demand side or supply side. Impact that lower the demand for education may be listed as - the premature mortality of women of reproductive age due to AIDS reducing the number of children ever born. HIVinfected children dying of AIDS reduces the number of primary school enrollees. The economic burden of an HIV-infected parent may reduce the ability of households to afford school fees and uniforms or force children to engage in income-generating activities and food production instead of attending school. Children (particularly females) may be needed to provide care for sick relatives. Orphaned children may not attend school if they do not receive financial and social support from
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the extended family. Orphaned children as well as HIV positive children may not attend school if they feel stigmatized or are subject to discrimination. The educational performance of children from HIV-infected households may also suffer, leading to higher rates of drop out. HIV-infected young adults have a shortened time horizon (if they know they are infected) and are less likely to pursue higher education. Further, it is anticipated that the teaching manforce may be impacted vide a disproportionate loss of teachers to AIDS mortality, creating a shortfall of educated manpower, raising pupil-teacher ratio. High rates of absenteeism among HIV-infected teachers and absenteeism due to care of sick relatives and funeral attendance drains on the efficiency of the education system. The epidemic may have disparate effects on rural areas as HIV-infected teachers in rural areas may request transfer to urban areas to access medical care. But higher rates of HIV infection in urban areas may create shortfalls in urban areas. The quality of education declines as less experienced and less qualified teachers are hired to fill vacancies. Teacher morale may be affected by the loss of colleagues, and by the increased work load their absence creates, which in turn lowers the quality of education. Health: Health services play a crucial role in AIDS prevention, care, and treatment. While in the developed nations, the health care system has taken prime responsibility for providing palliative care for AIDS patients, in heavily affected developing countries such formal care is almost non-existent. Instead, households, families, and kin are the primary caregivers of people afflicted with HIV/AIDS. Nonetheless, the epidemic has had an obvious and profound effect on the healthcare institutions in the developing world. Demands for public health education and treatment can place burdens on
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health care institutions that shift infrastructure, personnel, and financial resources away from meeting other basic healthcare needs. HIV/AIDS-focused health care centers funded by foreign charities will siphon skilled medical labour away from state-run hospitals and clinics by offering higher salaries, leading to acute staffing deficits. In response to the pandemic, the state may reallocate resources meant for providing essential social services such as potable water, sewage services, educational facilities, childhood vaccination programmes and other developmental infrastructure. In most developing countries, there is acute scarcity of supplies, infrastructure and resources and organised responses to AIDS are dramatically taxing the healthcare systems even when additional resources have been provided by foreign donors. Research studies have shown that many healthcare workers are at risk of burning out, and that patients with other ailments may be suffering as time and scarce resources are dedicated to AIDS patients (London, 2003). Thus, high budgetary allocation for the health sector, is done at the cost of some other sector. Most of the countries are allocating big share of the public health expenditure on prevention, care and treatment of HIV. When compared with a hypothetical no-AIDS scenario, the huge budgetary allocation on HIV could have been utilized on other crucial aspects such as poverty alleviation, education and infrastructure development of the country. Market Economy: HIV/ AIDS has general impact on markets as it reduces substantially the number of consumers as well as their financial resources. There are myriad direct costs for firms and employers whose workforce is drawn from a population with high HIV prevalence. These costs include lower productivity due to poor health, absenteeism and sick leave; absenteeism of ill workers or workers with infected family members;
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absenteeism by healthy workers attending the funerals of co-workers; health claims and cost of treatment; pension and retirement claims; funeral costs borne by employers; the costs of training and recruiting workers meant to replace the ill and dying, instability due to increased turnover, recruitment as well as escalated training costs. There are indirect costs to firms of HIV/ AIDS including the psychological effects on uninfected workers that may result in lowered morale due to high turnover, fear of death, and loss of interest. Responses to direct and indirect costs may vary, but include voluntary and mandatory testing of current and potential employees, provision of health care and anti-retroviral drugs (either directly or through a health plan), as well as awareness generation programmes. It may be noted that these responses of the corporate sector may not be entirely humanitarian, as firms realize that it may be less expensive to provide drug treatment than endure the costs of a sick workforce with a high mortality rate. Pre-employment HIV screens are illegal, but firms sometimes use them to reduce HIV-related costs by avoiding the hire of infected employees. Some firms may respond to these costs in less compassionate ways, by terminating employees found to be infected, limiting or eliminating health insurance coverage, and changing the terms of retirement pensions. At times, individual firms tend to reduce the costs on account of HIV/AIDS to individual firms by shifting responsibility for dealing with the impact of AIDS on their workforce onto families and households, communities, governments, and other organizations. High prevalence of HIV may lead to shortage of skilled labour and often makes both types of labour skilled and unskilled more costly and less productive. Status and skill level of the infected workers determine, to some extent, the response of the firm; companies may provide
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treatment cost, health care and other benefits to highly skilled and professional workers, while limiting these benefits or even terminating the services of unskilled or semi-skilled infected employees as it is more difficult to replace skilled and qualified staff due to a general shortage of skilled workers. In addition, HIV holds the potential to erode the skill base of future workers, as young people leave school to engage in economically productive activities to support their family which has lost a breadwinner to AIDS. HIV infection can change the cost of acquiring human capital, which may lead organizations to depend on a generation of new workers with lower skills. Armed Forces: Infection rates among the armed forces have been found to be higher than in the general population. It may be attributed the following factors: the military forces are highly mobile, face frequent dislocation, are prone to casual sex and are deployed in socially disrupted and conflict zones that make the armed forces indulge in risky behaviours. It suggests that the spread of the diseases in the armed forces will have both direct and indirect impacts on national and regional security. Further, high rates of prevalence may weaken the army, and may reduce the ability of the nations to engage in local and regional peace-keeping activities.
Macro-level Impact of HIV

One of the most direct macro-level effects of HIV/AIDS is on the demographics size and structure of population. Demographers have projected that HIV/AIDS may fundamentally change the age structure of heavily affected societies by hollowing out the middle of the age distribution (Bongaarts, 1996). The population structure will change from the typical age pyramid into
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a chimney-shaped structure because the HIV/AIDS epidemic affects youth the most. This age group of youth, 15 to 35 years, would primarily be squeezed in the agepyramid due to the pandemic, affecting the traditional population structure. The effect of HIV/AIDS on the size of populations is primarily influenced by two factors: AIDS-related mortality as well as changes in fertility that can be attributed to HIV. The sharp decrease in numbers of children reflects child mortality due to HIV/ AIDS as well as a reduction in the number of live births due to adult mortality and reduced fertility in HIV infected women. Most of the severely affected countries, especially in the African continent, are already seeing significant reversals in development indicators due to the HIV pandemic. Therefore, while HIV/AIDS is commonly understood to be a medical or public health problem, it is becoming clear that, in terms of its causes and consequences, the pandemic is deeply embedded in the social, political, and economic processes that shape the development of nations. Accordingly, successful responses to the pandemic depend not only on the development of medical treatment and behavior change, but also on political will, cultural understanding, the preparedness and capacity of heath care systems and the achievement of broader development goals. However, the massive influx of funds required to accomplish the provision of HIV treatment will certainly require the reallocation of funds from other health and non-health related purposes such as defence, infrastructure, education, and economic development. So, for most developing countries, realizing the Millennium Development Goals (MDGs) of eliminating HIV/AIDS would be quite tough proposition.
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Researches that compared the existing with AIDS scenario to a hypothetical no AIDS scenario, have brought out that the pandemic is likely to decrease overall economic growth, decline the rate of progress in almost all the sectors (primary, secondary and tertiary) and depress productive output (also differentially in the sectors that supply more unskilled workers) as a result of worker morbidity. It would also influence foreign investment as the comparative advantage of investment in developing nations is the availability of cheap labour. The cost of an HIV-infected workforce and its consequences (as discussed above) make the proposition much less attractive for international investment, and may lead to capital flight into regions with lower prevalence. With rapidly increasing proportion of HIV positive people, there is an increased pool of infected individuals, which enhances the risk of transmission to the uninfected population, if precautions are not taken. This also implies a growing cost of care and treatment of a constantly increasing number of infected persons over longer periods of time, in terms of providing antiretroviral drugs. In this regard it may be noted that in developed nations of North America, Europe and Australia HIV has become a chronic ailment like diabetes, thanks to accessibility and affordability of antiretroviral therapy. However, fruits of these biomedical advances have not been able to reach to the overwhelming majority of those who require it, mainly in developing nations. As a consequence, developing countries would be taking many more years in transforming HIV infection from a fatal illness into a chronic condition for most of its PLHA. Researches suggest that the economic impact of HIV on developing countries will be substantial. Impacts are not only the morbidity and mortality of HIV infected people which may result in shortened life-expectancy
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but also include a loss in human capital even among non-infected youth as they are forced to forgo education for early participation in labour market in order to care for the sick, thereby losing on skill acquisition and educational development. McPherson (2003) has pointed out that a major consequence of HIV infection is the shortening of decision horizonsa person who has HIV/ AIDS is unlikely to plan for the future by saving or obtaining education, and decisions will be made in reference to the present. By extension, the aggregated effects of these shortened horizons in communities with a high prevalence rate are likely to have implications for everyone, including the uninfected, in ways that may have dire consequences for the economy of the nation as a whole. Researches predict that the much higher level of disease does seriously threaten economic growth, with expected economic relationships distorted, including a decline in GDP per capita. Unfortunately, the regions with the highest HIV prevalence also tend to be underdeveloped, and have unstable economic conditions, corruption, red-tapism and less-thandemocratic governments, poor social security, meager infrastructures, and unskilled labour (UNAIDS, 2003). Countries hard-hit by AIDS would be having much difficulty in creating and maintaining many of the elements essential to economic development, including a large, skilled, productive labour force, an attractive environment for investors and a population with income to spend on consumer products. A substantial number of studies have examined the past and future impact of HIV/AIDS on specific countries. The general consensus is that although quantifying the impact is difficult, the potential damage is great, especially in countries with high-prevalence. Nations with high HIV prevalence are also burdened with the costs of prevention, treatment and mitigation of the
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impact of AIDS, especially when employers are able to effectively shirk the burden. On the contrarily, if employers are forced to bear these costs, countries are likely to have a difficult time attracting investment (Lewis 2002). This means that in addition to the more direct impacts of HIV on development as discussed earlier, nations have fewer resources available to fund economic development initiatives, including crucial elements such as infrastructure, education, and training, as scarce resources are directed to mitigate the consequences of AIDS. All of these factors further threaten a nations ability to pay off debt and attract investment, which are especially vital to the economic development necessary to give nations the ability to reduce poverty and prevent and treat AIDS. Some of the indirect effects of HIV/AIDS on national economies come from the projected demographic impact on population growth. Because the disease sickens and kills during key working and childbearing years, it will affect the workforce not only in the present and nearfuture, but according to demographic projections, for decades to come. About 90percent of Indias reported HIV cases are among 20-45 year-olds, the most economically productive segment of the population. If HIV continues to spread at the current rate, India could experience a diminishing labour pool, which could, in turn, affect in the long term, economic prosperity, foreign investment, and sustainable development. Next, let us look at the impact of treatment. It is observed that most of the infected people in Africa, where the epidemic has been most disastrous, are without access to modern therapies. Even within regions and nations, access to these treatments is uneven. In the wealthy United States, with a sophisticated and well-developed healthcare infrastructure, there is inequality in access to current anti-retroviral treatments, with the poor and
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minorities being at the disadvantage (AIDS Alert 1999, 2002). In many of the Sub-Saharan African countries, the meager proportion of people, who have access to anti-retrovirals, are disproportionately urban, wealthy and well connected. A key difficulty is that even though foreign funds for ART drugs are available, many of the hardest-hit countries have weak healthcare infrastructures making accessibility a major issue for most of the needy infected people. Lack of transportation facilities and high expenses make it difficult for most of the PLWHA to access far off hospitals and clinics for ART. Healthcare institutions are themselves understaffed and undersupplied, and coupled with stigmatized attitudes towards PLWHA, their functioning gets constrained further. The AIDS epidemic has weakened an already fragile health care system, which is even less equipped to implement treatment programmes for HIV/AIDS, even when funds are available. Further, the aggregated impact of large numbers of HIV infected workers may have other effects on other levels of the economy. Regions with high HIV prevalence do not attract foreign investment, thus, further exacerbating the problem of poverty. The macro-level economy is quite interconnected with household decision-making and outcomes. One of the key effects of AIDS tends to be an increase in migration, as rural livelihoods become untenable, creating strain for urban labour markets and instability in the provision of food through agriculture. All these factors create a vicious cycle of poverty, further accentuated by HIV infection, lack of sufficient resources for poverty alleviation programmes as well as HIV mitigation interventions, which further deepens the vulnerability to poverty and HIV infection in future generations too. The States role in these situations is also limited by poor economic
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conditions and scarce resources being transferred for care and treatment of HIV infected population. Researchers have identified poverty as the epidemics primary social determinant. Poverty leads to vulnerability. Poverty leads to riskier behaviours, either by favouring transactional sex, or by driving migration. For example, increases in poverty and food insecurity may increase malnutrition, which catalyses the advancement of HIV infection. Further, poor infected people cannot afford the cost of ART and hence expect the state to provide it free of cost or at highly subsidized rate. Providing anti-retrovirals to people who need them is essentially throwing them in a lifeline, and once given, it is nearly impossible to take them away. Thus, extending this treatment to people who cannot afford to provide it for themselves comes with obligations, and creates dependency for a large number of people on the government and/or foreign aid for the rest of their lives. This kind of dependence adds to the vulnerability as availability of ART is subjected to fluctuations in voluntary donations, foreign aids, political motivation, commitment and leadership (see: de Waal 2003). The economics of providing ART from a health budget perspective and the potential impact on companies and households, productivity growth, structural changes, addressing inequalities and delays in progress and development of the nation is quite significant.
Conclusion
The pandemic of HIV is widely acknowledged to be the most severe health crisis of modern times. HIV continues to spread at alarming rates throughout the world, and India is one of the most badly affected countries. In this unit, we have discussed some of the socio-economic consequences of HIV/AIDS in developing countries, with special reference to India.
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At the household level, loss of income due to incapacity to work, expenditure on treatment, low employability due to HIV associated stigma and discrimination, gender issues, strains in care giving especially to women and elderly were discussed. Migration and commercial sex are among the commonly adopted strategies by the families affected with HIV. Children infected and affected by the epidemic are likely to have less access to formal education and intergenerational knowledge transfer. At the sectoral level, the chapter covered impact of HIV on health sector and discussed how poor healthcare infrastructure further adds to the problems of PLHA. People engaged in agricultural work switch to less labour intensive crop production, and are often left with little resources and manpower to provide required inputs. HIV has widespread implications. Impact of HIV on education sector was discussed from demand as well as supply side. Impact of armed forces was also covered briefly. Fewer children access education and so also are the teaching force affected. The chapter discussed at length the impact of HIV on corporates and firms. Employers bear the cost of losing employees to AIDS, training newly recruited ones, bearing health expenditure and funeral costs. Lastly, we discussed macro-level impact of HIV, which includes decline in progress and development of the nation as scarce resources are reallocated for the treatment and care of HIV infected population. Costs of the epidemic include increased expenditures for health care, prevention and education programmes, costs of caring for dependents of the ill and deceased, providing ART and increased spending on funerals. There would be drastic change in demographics due to mortality to AIDS, mainly affecting the young population. HIV/AIDS epidemic threatens the already vulnerable economies and political systems.
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References
Bloom, D. & Lyons, V.J. (1993): Economic Implications of AIDS in Asia. New Delhi: UNDP. Dane, B.O. & Levine, C. (1994): AIDS and the New Orphans: Coping with Death. Connecticut: Auburn House. Halett, M.A. (1997): Activism and Management in the AIDS Crisis. Binghamton, N.Y. The Harrington Park Press. Leukefeld, C.G. & Fimbres. M. (eds.). (1989): Responding to AIDS: Psychosocial Initiatives. Silver Spring, MD: National Association of Social Workers Overall, C. and Zion, W.P. (1991): Perspectives on AIDS: Ethical and Social Issues. New York: Oxford University Press. Rushing, W.A. (1995): The AIDS Epidemic: Social Dimensions of an Infectious Disease. Westview Press. Sills. Y.G. (1994): The AIDS Pandemic: Social Perspectives. Connecticut: Greenwood Press.

*Archana Kaushik
Introduction
It may be noted that at the biological level, all human beings are equally vulnerable to HIV infection. It means that if exposed to the virus, through sexual intercourse or through blood products, any average person can develop HIV infection. There is no innate biological resistance to HIV infection. Thus, there is equality of biological probability to HIV infection among all human beings. Further, a person indulging in any of the identifiable risky behaviours (such as unprotected penetrative sex with infected partner, sharing infected needles with injecting drug users, transfusion of infected blood, etc.) increases the individuals chance of HIV infection. HIV requires specific, visible and identifiable actions/ behaviours for transmission to occur. However, it may be noted that individual behaviour is connected to societal norms, expectations, values, conflicts, processes and responses. Therefore, it is very important to study these socio-cultural factors that accentuate vulnerability to HIV infection. Certain noteworthy factors accentuating HIV vulnerability may well be described socio-cultural construct of masculinity and feminity, poverty, migration, infrastructure, accessibility to information and services, political will, and so on.
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Vulnerability to HIV infection may be categorized at various levels - at the individual level it is illustrated in terms of sexual preferences, awareness level and indulgence in risky behaviours; programmatic vulnerability refers to the extent to which the services meet individual needs; and societal vulnerability encompasses the socio-cultural and economic factors that create risk-inducing circumstances namely poverty and migration catalyzing HIV transmission. The discussion on socio-cultural context of HIV would remain incomplete if gender construct and associated values, traditions are not included. Since, you would be getting an opportunity to study vulnerabilities associated with gender in the futher Blocks. Here, in this unit, these topics would be described only briefly. Let us take a look at some of these factors at length in these subsequent sections.
Socio-cultural Milieu
Certain socio-cultural factors that influence vulnerability to HIV infection may be categorized as follows, although, in reality, it is quite difficult to differentiate and segregate the collective impact of these dynamic variables. Culture of silence: The socio-cultural milieu of Indian society does not encourage the overt communication about sexual issues. These issues are NOT supposed to be discussed; talking about sex is a taboo. Parents, teachers and other adults often do not tell the children and adolescents about sex and sexuality. The only source of information they have is their peer group who are not capable of providing scientific and accurate information. The half cooked information or lets say misinformation, is compounded by myths and misconceptions that indeed add to the vulnerability to
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sexually transmitted infections including HIV. A myth such as having sex with a virgin will cure STDs is often illogical and is of disastrous consequences. Changing family patterns, functioning and roles: Forces of social change such as urbanization, industrialization, modernization and globalization have brought about significant changes in the family patterns and functioning. The nuclear family system is replacing joint families; alternate family patterns such as single parent families, women headed families, childless families are becoming increasingly visible in the society. Family cohesion is decreasing and family disintegration is on the rise. The familys role to provide solace, comfort, recreational opportunity, protection, catharsis of pent of emotions is increasingly being taken over by outside agencies such as peers, colleagues, recreational clubs, television, cinema and the like. Monogamy and faithfulness of marriage partner cannot be ensured as, extra-marital sex is on the rise often in a clandestine manner,. All these factors increase the risk of HIV infection. Sex at workplace: Forces of social change described above have also brought change to the workplace culture, ethos and patterns. Especially in cosmopolitans and metropolitans, workplace is characterized by cut throat ruthless competition, fast pace of work, pressures to meet deadlines, little time to relax and rest, late working hours, resulting in excessive stress and tension and lack of time and energy to be spent creatively with family members. Career oriented families are emerging where both husband and wife are equally aspiring to quickly ride the ladder of success, may be at the cost of decision to remain childless. Corporate life, BPOs have given the opportunity to both sexes to mix freely and be together for longer working hours. At workplace, casual sex is becoming quite common for various reasons like
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for many it acts as a stress buster, for some it is opportunity to meet unfulfilled the needs due to failed marriage and for others it may be the price to be paid for out of turn promotions and other incentives. This makes people more vulnerable to HIV infection. Men buying sex: Data project that almost 85percent of HIV infection are through unprotected sex, which includes men buying sex or having sex with commercial sex workers. Men across the world buy sex for various reasons - wanting to avoid emotional involvement, lack of sex or not enough sex in marriages, wanting to experience power, variety or certain kinds of sexual experiences, thrills, loneliness or old age. These men are usually ordinary citizens and not sexual deviants. In societies with equitable gender relations, men respect the right of their wives or partners to refuse sex and visiting sex workers is like a safety valve that lessened the strain on their modern relationships. In some societies, going to a sex worker is often a mark of the onset of manhood, with young boys being taken to brothels by their peers. Young boys generally visit sex workers for experimentation and for learning skills of sexual intimacy, which increases the risk of HIV transmission. In patriarchal societies, where rigid sexual segregation, silence and taboo around sex are the norms, where sex is limited to procreation and there is lack of communication on sexuality with spouse. Visiting sex workers is considered as the only possible way of getting close to women without upsetting social norms. In societies like India, males buying sex often have highly moral positions on women; they consider sex workers as bad and promiscuous women but do not think it incongruous or immoral for themselves to visit sex workers. Sociologists are of the view that act of men buying sex is a kind of safety valve where men could get rid of their excess sexuality, thus preventing them from
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attacking good women (in other words chaste traditional wives and daughters). Attitude towards sexuality: In societies like India, socialization process, in myriad of ways, tend to develop negative attitude towards sex, sex organs and sexuality. A culture of silence and the lack of accurate information regarding sexual anatomy and physiology make adolescents ignorant about sexuality, developing a negative emotional attitude toward sex organs and matters related to sexuality. It is not uncommon for adolescents to perceive their sexual organs as dirty and to refrain even from looking at them. Such negativism is particularly very common among females, and to certain extent with the males. As a consequence, many myths crop up around sexual issues making adolescents and youth prone to reproductive tract infections (RTI) and sexually transmitted infections (STI). Adolescents are likely to be curious and yet ill-informed, with sources of knowledge being peers or unscientific literature, which may cause irreparable harm later in life. Many adolescents adopt high risk behaviour due to the numerous myths and lack of skills especially ability to deal with peer pressure effectively. Thus, ignorance about sexual functioning and STI, unhealthy curiosity about sex, peer pressure and lack of appropriate skills may facilitate transmission of STI/HIV, particularly in the backdrop of low levels of literacy. Adolescence and vulnerability: Research findings show that, most often than not, adolescents and youth, both males and females, display an abysmal lack of knowledge on sexual health issues. Also, adolescents initiating their sex life early are more likely to have multiple and high risk partners, and are less likely to use condoms. Further, experimentation with alcohol and drugs are associated with high-risk sexual behavior. Media arouses sexual interest but does not provide
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accurate information about sexuality. Youth may not be candid about their sexual experiences out of fear of stigma and labels especially in case of same sex behavior. Young people often lack information they need to affect safe, healthy decisions; this may lead to serious consequences such as teenage pregnancy and childbirth, unsafe abortions and STIs including HIV, to mention a few. Violence on women as the mark of manhood: Studies have indicated that violence on women, both physical and sexual, has been a predominant aspect of social construct of manhood. It is equally noteworthy, that even many of the women accept being victims of violence and treat manifestations of violence as socially accepted behaviour of men. Beating, sexual coercion, marital rape are some of the violent behaviours that threaten the physical as well as mental well-being of perpetrator as well as victim, including increased risk of HIV infection. Thus, a womans vulnerability is far more than her male counterpart.
Gender Issues
The then UN Secretary General Kofi Annan had very rightly articulated that today, AIDS has a womans face (2003). Gender roles and relations directly and indirectly influence the vulnerability to HIV infection, as mentioned below: Biological Vulnerability: Physiologically, susceptibility to HIV infection among women is more than double than men due to a larger mucosal surface area of the vagina being exposed during heterosexual intercourse, coupled with the fact that semen has a higher concentration of HIV than vaginal fluid. Adolescent and young women, initiating their sex life at early age, are for obvious reasons at a higher risk to HIV infection. In the Indian
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context, cultural practices such as child marriages, early marriages, as well as forced marriages, increase this risk. Marriage as Vulnerability: Research studies have shown that more than four-fifths of HIV positive women worldwide had contracted infection from their husbands or primary partners. Lack of knowledge, combined with their inability to negotiate condom use, places women, whose husbands have multiple partners, at risk of HIV infection. In fact, it was noted that more than 90percent of women infected with HIV in India were married and monogamous. Studies have indicated that sexual coercion in marriage is widespread in India. Research done on married couples in Mumbai found that women commonly have sexual relations against their will and many husbands believe that sex is their right in a marriage. Also, women respondents generally did not report condom usage. Women in coercive sexual situations have little ability to negotiate safer sex and are highly vulnerable to STI/HIV. Notably, Indian law does not consider marital rape an offense. Even in situations where women perceive that they are at risk, negotiating condom use requires overcoming their traditionally submissive role and image in sexual relations as well as a cultural emphasis on fertility. Next, the role of women as care-providers also makes them vulnerable as there have been innumerable instances of HIV-positive men (called HIV crooks) marrying women without informing them of their HIV status, in order to have someone to care for them in their illness. Socio-demographic Factors: Certain socio-demographic factors further compound these vulnerabilities. Factors such as illiteracy (35 percent females and up to 72percent rural women illiterate as per 2001 census) and exposure to mass media (40 percent women have no exposure to
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mass media) affect womens knowledge of HIV. On an average, women in India marry at 19.7 years of age and a significant proportion of them become pregnant during their first year of marriage. As mentioned earlier, younger women are biologically more susceptible to HIV infection. Sexual violence, exploitation, child sexual abuse and trafficking of women and children are other gendered experiences that females face in their life cycle, increasing their vulnerability to HIV. Gendered Power Relations and Information Accessibility: Cultural taboos on sex related matters signify that women are usually less informed or ignorant about spread of HIV infection and its prevention. Data indicates that 95 percent of Indian women do not have comprehensive knowledge about ways of preventing HIV/ AIDS (National Family Health Survey, 2005). Majority of women have maintained that they had no knowledge of sex-related issues until they got married and many got to know of HIV only after being infected (see UNIFEM, 2005). As a consequence, awareness level of women is much lower than their male counterparts with respect to HIV infection. Awareness being low, expecting safe behaviour is out of the question. Gendered power dynamics also underlie sexual relations. The imbalance of power within the home curtails a womans ability to negotiate the terms of sex and thereby increases her vulnerability to HIV. Reportedly, women have difficulty discussing sexual relations with their husbands, including contraception. Societal pressure on motherhood and fertility impedes use of barrier contraceptives for women of reproductive age thereby increasing their chances of STI/HIV. Although media campaigns are slowly breaking taboos, societal norms still largely dictate the extent to which programmes can directly address sexual behaviour.
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Economic Vulnerability: Patriarchal social structure is characterized by womens economic dependence on men, which also results in skewed distribution of economic resources to their disadvantage. In the context of HIV/AIDS, women, as caregivers and/or as infected, have to work harder to meet the medical expenditure of the infected males in the family, while ignoring and postponing their own treatment needs. Chronic malnutrition, which has its roots in socialization practices as per patriarchal social norms, render a womans body weaker to fight against the infection. Also, economic disadvantage creates barriers in accessing information about HIV/AIDS, making the poor more vulnerable to infection. More often than not, women face economic hardship in accessing and utilizing healthcare services, which includes transportation cost, foregoing daily wages and so on. This economic dependence also forces them to exchange sex for survival. Studies have shown that poverty is overwhelmingly the root cause of women bartering sex for economic gain or survival. Violence and Vulnerability: The reality of many womens lives is that vulnerability to domestic violence and HIV coexist domestic violence directly and indirectly exacerbates vulnerability to HIV and HIV status increases vulnerability to violence. Sexual coercion or violence in marriage most likely occurs without condom use, and thus increases womens vulnerability to STIs and HIV. Quite obviously, violent sexual acts such as rape are likely to result in vaginal tearing or lacerations, thus dramatically increasing the risk of contracting an STI or HIV. In addition, fear of violence or abandonment often prevents women from discussing fidelity with their partners or asking their partners to wear a condom. Further, accusations of infidelity are closely correlated with incidents of domestic violence. On the other hand,
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studies have brought out that sero-positive married women are subject to emotional abuse, violence, stigma within the home and community and even abandonment. Reportedly, women are accused of infidelity and/or thrown out of the home, on being tested positive. Life stories of women living with HIV demonstrate them being discriminated against and facing violations of their human rights as a result of their HIV status. Women are generally blamed for their husbands infection, subject to beatings and torture, neglect and discrimination within their home, denied of inheritance and property rights, have their children taken away from them, are unable to access health care or legal support, and ultimately are deserted by marital and natal family, especially after the death of an HIV positive husband. Access to Health Care Services: Due to certain sociocultural factors, females have less access to health care including HIV/AIDS services, than their male counterparts. Salient reasons are a culture of silence on sex issues; women cannot avail services, and they generally keep on ignoring and denying their health concerns, which in the case of HIV infection becomes dangerous and may shorten their life-span. Further, actual perceived stigma and discrimination related to HIV; healthcare infrastructural lacuna; shortage of trained medical staff, more specifically females and particularly in rural areas limits access. As discussed earlier a lack of knowledge about availability of health services, in the background of illiteracy and limited exposure to media also hinders utilization of health services by females. Data reflecting the fact that nearly 40percent of people living with HIV in India are women, while only 25percent of beds in AIDS care centres are occupied by women, confirm the presence of above mentioned factors.
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Stigma and Discrimination: In a number of societies, like India, women are mistakenly perceived as the main transmitters of sexually transmitted diseases (STDs). In patriarchal social structure women are at the disadvantage in terms of resource and power distribution and it is easier for the society to blame them despite the fact that they are only victims. The differential treatment of sero-positive men and women can be traced back to skewed power structure prevalent in the society. Men are likely to be excused for their behaviour that resulted in the infection, whereas women are not. In India, for example, the husbands who infected their female partners may abandon them blaming them for transmitting infection. It is often said that if AIDS doesnt kill a woman, stigma will.
Socio-economic Determinants
With respect to transmission dynamics, there is now sufficient epidemiological evidence of social determinants that play a significant role in enhancing the vulnerability to HIV infection. Salient ones are: poverty, migration, awareness levels, infrastructure and State capacity. Let us understand these factors in some detail in the context of HIV/AIDS. Poverty is one of the most compelling factors that force people to indulge in risky behaviours, which act as contingent condition to HIV infection. There are certain impeding factors that make poverty as crucial force in putting people at risk of HIV infection. First, poverty greatly accelerates peoples vulnerability by restricting access to information and services. Many people living below poverty line do not know the meaning and implications of their sero-positive status and many others die of AIDS without having slightest of knowledge about it. Second, lack of resources for subsistence forces
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women to sell sex for survival. With inability to find any other occupation, many women below poverty line resort to sex work as the only option for a living. Third, poverty creates a vicious cycle of illiteracy, lack of skills, unemployment and underemployment, ignorance and inhibited access to information and services for development. Fourth, poor people migrate to other places with better livelihood options. Migration has traditionally been a survival strategy for people, especially those below poverty line. This phenomenon indeed makes a person vulnerable to HIV infection, as discussed below. Migration: People, more often than not, migrate to urban centres in search of better livelihood options. In South Asia, annually, more than 200 million people are estimated to migrate within and between countries in the region, in desperate search for a better life. There are many push factors leading to migration such as poverty, landlessness, low agricultural productivity, marginalization, lack of opportunities for employment and growth, domestic or community conflict, political unrest, natural calamities, war, terrorism, and so on. Likewise, better opportunities for livelihood, education and growth due to urbanisation and industrialization, increased access to information, improved system of mobility and communication are some of the pull factors that lure people to migrate to urban centres. With growing mismatch between pockets of economic activity and deprivation brought about by the new global economic order, migration is on the rise. Then, how process of migration accentuates the vulnerability of people to HIV infection? Most often than not, migrants have rosy picture about the places of destination, with little or no knowledge about the complex mix of vulnerabilities that await them on the way. Reportedly a large number of migrants face an acute risk of exploitation, physical violence, sexual
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abuse and socio-political marginalization, alienation and discrimination. A recent study by UNDP demonstrates that HIV is a manifestation of the inequalities and deprivation faced by migrants. Hostile and lonely environments, separation from families, lack of access to information and services and social support systems can lead to social and sexual practices that make them more susceptible to HIV exposure. At the individual level, migrants may face isolation, loneliness, exploitation, hardships, and hostility from host societies, separation from family and partners, strains in relationships, and the like. For men, gender related norms and economic needs force them to migrate without their families in search of work, creating situations that foster multiple sexual relationships that may lead to HIV infection. At the source, there is increased single parent households and extra burden on women who stay behind. And, when the migrants return they may infect their wives. These factors make the social environment conducive for HIV to thrive. As the epidemic spreads wider, the link between migration and HIV is emerging stronger than ever before. However, it may be noted that migration in itself is not a vulnerability factor for HIV, but it is the unsafe process of migration that creates conditions of vulnerability. HIV/AIDS can be a Driving Force of Migration: People living with HIV/AIDS (PLHA) may be driven to migrate or leave their homes because of stigma and discrimination they face, lack of sufficient health services and non-availability or poor access to treatment. Further, at times, migrants hide their HIV status due to the fear of stigma and discrimination, and thereby transmit the infection further. Utilization of Health Services: Many migrants live in indeterminate state, having no stay or work permit in the host country and live in constant fear of deportation.
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Any contact with official government agencies, even if related to health matters, increases the fear of being reported to the police and is, therefore, often accompanied by suspicion. This factor, combined with the hardships of daily life, makes providing HIV testing, care, support and treatment particularly challenging for these populations. Added to this, migrants, particularly from poor economic background, are often working individuals, subject to poor and unstable living and working conditions, and often face language barrier and acute cultural differences at destination places. Such conditions usually mean that they have limited access to reliable and culturally appropriate information on HIV/AIDS and health services. Social Service System: There is a seemingly unrelated but strong relation between the health infrastructure and HIV transmission a poor public health system amplifies the spread of STI and HIV. Reportedly, STIs greatly enhance HIV transmission by up to 100 folds while effective diagnosis and treatment of STIs can decrease HIV incidence by 40 percent. Thus, lack of STI diagnosis and treatment services would be a significant determinant of HIV epidemics. This provides a direct link to policy level implications and health care infrastructure available to people and, of course, the budgetary allocations on public health. Inadequate funding of healthcare may lead to unsafe practices such as re-use of needles and syringes, denial and delay in providing treatment to HIV patients, limited availability to ART and PMTCT medicines and the like. Wide-spread AIDS-related stigma and discrimination in healthcare settings force sero-positive people to hide their status and thereby limit access to treatment. Likewise, lack of access to clean water and electricity are hypothesized to favour the spread of HIV due to poor hygiene, thus weakening the immune system of the poor.
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Role of Mass Media: Two decades ago, messages were mostly aimed at raising awareness about how AIDS was transmitted and they did so by creating fear through messages such as AIDS kills. Consequently, stigma and discrimination became rampant as people started avoiding, isolating and rejecting PLHA from almost all walks of life. Fear of stigma and discrimination became so overpowering that people hesitated to get tested. At times, PLHA hide their sero-status and even do not maintain safe behaviours, thereby infecting others. Human Trafficking: In South Asia, human trafficking has increased drastically over the past few decades. Apparently, trafficking takes place for various purposes like domestic labour, organ transplant, forced labour, organized begging, adoption, sex work, forced marriage and so on. Traffickers are mainly organized networks, recruitment agents, relatives, parents, guardians and husbands. Even though males are trafficked, most often the victims are young girls and women from poor and illiterate families. Irrespective of purpose of trafficking, sexual exploitation is constant. Trafficking reduces freedom of choice, access to information and accelerates vulnerability to HIV manifolds. Disasters: Though seemingly unrelated, disasters enhance vulnerability to HIV. Floods, cyclones, droughts, earthquakes, land slides are common in India - 65 percent of the landmass in India is prone to earthquakes, 40 million hectare land is prone to floods (12 percent of the total land in India), 8000 km long coastline with two cyclone seasons (8 percent of the total land) show the vulnerability of huge population groups living at these places. These apart, manmade disasters such as fire, accidents, terrorism, etc., accentuate vulnerability to HIV. These disaster situations lead to forced migration due to disaster. People may have to stay in rescue and rehabilitation camps and
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are in shock, grief, insecurity, due to heavy toll of life, tearing down of infrastructure, major loss of livelihood, which has far reaching economic and social consequence. In such situations poor are more vulnerable and many women have to engage themselves in commercial sex. Such an environment is a breeding ground for HIV transmission. Tourism: Every year millions of tourists, from within the country and abroad, visit places of tourism. Though tourist spots are places of high socio-economic transactions, often times they are also risk zones in terms of HIV transmission. Research studies have shown that tourism is also associated with high rate of risk behaviours (casual unprotected sex, men having sex with men, injecting drug use and pedophilic relationships). Many times, tourists show impulsive behaviours, while the host population exhibit compulsive behaviours. Tourists do not, generally, share the ethos, values and cultural norms of the host community and are driven by enjoyment, experimentation and freedom. On the other hand, host community is often afflicted with poverty and deprivation and hence vulnerable to exploitation and HIV transmission. People/Occupations with High Mobility: Armed forces, business communities, and a variety of new-age jobs due to globalization demand high mobility as job requirement. These people have to leave their families for longer duration of time and may indulge in forced/ casual/commercial sex in order to avoid loneliness, frustration, alienation, insecurity and the like. Unnatural sexual practices are also on rise among these population groups. All these situations make the individuals involved at high risk of HIV.
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Conclusion
Biological vulnerability to HIV is equal among all human beings. There exists certain social factors that put specific population groups into more risk than others. In this chapter, we discussed the socio-cultural determinants of HIV infection. A culture of silence due to taboo with regard to any sort of discussion on sex and sexuality makes adolescents vulnerable to HIV. Lack of adequate information along with prevalent myths and misconceptions about sexuality, masculinity and feminity has the capacity to fuel the spread of HIV pandemic. Social change reflected in family structure and functioning, workplace culture and our attitudes and behaviours also accentuate HIV vulnerability. Feminization of HIV is a new phenomenon. A patriarchal social structure, skewed power relations, gender roles and expectations, gender associated violence along with biological vulnerability speed up the HIV spread. Stigma and discrimination and care giving issues with regard to gender vulnerability were discussed. Socio-economic determinants such as poverty, illiteracy, unemployment along with gender discrimination leads to migration, provide fertile grounds for HIV spread. Migrants are inhibited to access information and healthcare system. At the place of destination, factors such as exploitation, loneliness, alienation, insecurity, home-sickness all these factors drive migrants to indulge in risky behaviours and render them vulnerable to HIV infection. Back at home, they infect their spouses and sex partners. Lack of adequate healthcare infrastructure also inhibits care and treatment of migrants. Tourism and human trafficking are also highly linked to transmission of the pandemic.
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References
Bor, R. & Elford, J. (1994): The Family and HIV. London: Cassell. Dane, B.O., Miller, S.O. (1992): AIDS: Intervening with Hidden Grievers. New York: Auburn House. Overall, C. and Zion, W.P. (1991): Perspectives on AIDS: Ethical and Social Issues. New York: Oxford University Press. Rushing, W.A. (1995): The AIDS Epidemic: Social Dimensions of an Infectious Disease. Westview Press. Sills. Y.G. (1994): The AIDS Pandemic: Social Perspectives. Connecticut: Greenwood Press.
Testing of HIV/AIDS
*Archana Kaushik
Introduction
HIV infection has a unique status in the galaxy of diseases. HIV status brings with it stigma, discrimination, isolation and alienation, not only to the person affected but also to his/her family and relatives. Therefore, HIV testing means a lot to any person suspected to have it; a positive result is perceived to be no less than a death sentence. However, ignorance is not bliss in this case. Getting HIV test is very much needed for reasons more than one. First, it would help the medical management and treatment of HIV and related ailments. Doctors are in a position to give proper medical advice in order to prolong the AIDS stage. Secondly, HIV testing, often anonymous, ensures blood safety through blood donation. This would minimize HIV transmission through infected blood transfusion. Thirdly, anonymous HIV testing is done in sentinel surveillances in order to monitor the trends of HIV prevalence, which, in turn, helps in evaluating the existing interventions and designing the future programmes for prevention, diagnosis and treatment of HIV infection in the specific population groups as well as in the general population. Fourth, HIV testing and knowledge about ones own sero-status helps a person plan personal as well as familys future, if the result is positive. The counsellors would provide information
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regarding maintaining healthy and positive life style and prolonging life span. Fifth, HIV testing may induce behaviour change and prevent further transmission through counselling process. Motivating the client for partner notification is an important aspect of the posttest counselling process. Sixth, for anxious clients who get negative test results, it brings peace of mind of individuals who have been or are indulging in high risk behaviour(s). They would be eventually be dissuaded from unsafe practices and risky behaviour. Seventh, HIV testing is also helpful in identifying asymptomatic individuals, who are engaging in high risk behaviour, so that they do not suffer a sudden break down during the AIDS phase and so that life can be extended. Eighth, HIV testing would help those testing negative to be careful in future, and ensure that they do not indulge in risky behaviours through motivation during counselling. Ninth, HIV testing of pregnant woman can reduce the chances of parent to child transmission to a large extent, if proper medication is taken in. Finally, HIV testing would also help in prophylaxis in the hospitals and reducing the chances of healthcare functionaries from getting HIV infection. All these benefits of HIV testing are sidelined due to rampant stigma and discrimination prevalent against HIV positive persons. Lack of a conducive social environment, drive many HIV positive persons to hide their sero-status and infect others. Therefore, much emphasis is given on confidentiality in HIV testing and declaration of its results. In subsequent sections, we would be learning about these aspects in the form of guidelines and protocols to be followed during HIV testing. HIV testing may be mandatory in certain situations or voluntary in most cases. It may be anonymous as in the case of surveillance studies and blood donations, or distinctive and specific, when done voluntarily. Let us
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first understand different types of tests available, and their characteristics necessary in order to ascertain the HIV status of an individual.
Hiv Testing
The only way to ascertain if an individual has HIV is to take an HIV test. HIV status cannot be diagnosed through symptoms, as HIV and AIDS symptoms are not specific, and may be indicative of many other illnesses, which is why an HIV test is the only way to receive a definitive diagnosis. Generally blood is the body fluid taken for testing of HIV. The test shows the presence or absence of human immuno-deficiency virus in the body. There are mainly three types of HIV tests - the first type of test is the HIV Antibody Test; the second is the Antigen Test; and the third type is called the PCR Test. One of the most popular HIV Antibody tests is the ELISA Test. ELISA is the acronym for Enzyme-Linked Immunosorbent Assay. It is the standard HIV test that looks for antibodies in a persons blood. When HIV (which is a virus) enters a persons body, special proteins called antibodies are produced. Antibodies are the bodys response to an infection. An antibody test is the most common type of test used to diagnose HIV in individuals. Although HIV antibodies appear in blood within 2-8 weeks after infection, they usually become detectable only after 3 to 12 weeks with the assays that are available currently. This period following the entry of HIV into the body and the appearance of detectable levels of antibodies with the available test kits is called the window period. So if a person has specific antibodies against HIV in their blood, it means they have been infected with HIV. However, there are only two exceptions to this rule. First,
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babies born to positive mothers retain their mothers antibodies for up to 18 months, which means they may test positive on an HIV antibody test, even if they are actually HIV negative. This is why babies born to positive mothers may receive a PCR test after birth (about this test you would learn subsequently in this section only). Secondly, some people who have taken part in HIV vaccine trials may have HIV antibodies even if they are not infected with the virus. ELISA is a commonly performed screening test. Screening assays must detect all positive sera, that is, should be highly sensitive even if some false positive results do occur. Standard HIV antibody (ELISA) tests are at least 99.5% accurate when it comes to detecting the presence of HIV antibodies. This high level of sensitivity, however, means that their specificity (ability to distinguish HIV antibodies from other antibodies) is slightly lower. Therefore, results of a screening test are never used as the final interpretation of HIV status, and individual is never identified on the basis of one screening assay as technical errors can occur. The serum reactive in screening assay is subjected to confirmatory tests (as per policy and strategy of testing) to be classified as reactive in repeated assays. Therefore confirmatory tests are recommended, which may be ELISA itself or Western Blot or PCR, rapid tests like latex, red cell, comb test, line test, dot-blot assays. In general, in resource-poor settings with relatively high prevalence, a second ELISA test may be used to confirm a diagnosis. The second test is usually a different commercial brand. When two tests are combined, the chance of getting an inaccurate result is less than 0.1%. It may be noted that as per the WHO guidelines, a threekit ELISA test is used in government hospitals, three kits of different brands so as to ensure correct results to the maximum levels.
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Any HIV positive result given by an ELISA test must, therefore, be confirmed using a second test. Secondary tests include: Western Blot Assay It is one of the oldest but most accurate confirmatory antibody tests. It is complex to administer and may produce indeterminate results if a person has a transitory infection with another virus. Indirect Immunofluorescence Assay It is just like the Western blot, but uses a microscope to detect HIV antibodies. Line Immunoassay It is commonly used in Europe. It reduces chances of sample contamination and is as accurate as the Western Blot. Among these tests, Western blot test is used as a confirmatory test in most of the countries. This test can separately detect antibodies to various HIV proteins. If several types of antibodies are detected then the result is positive; if no antibodies are detected then the result is negative. If the test appears to show only one or two types of antibodies then the result is called indeterminate or inconclusive. There are two main reasons why this can happen. First, it may be that the person has only recently become infected with HIV, and has not developed antibodies. Second, the test may be showing a weak reaction to other antibodies unrelated to HIV. An indeterminate result indicates that further testing is required. Either the Western blot may be repeated a few weeks later, or a different test (such as PCR) may be used. The risk of a false positive during confirmatory testing is extremely tiny - around 1 in 250,000 for the Western blot, for example. Rapid test: A rapid HIV test is also an antibody test. The advantage of a rapid test is that you do not have to return to get your test result - results are usually
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available within a few minutes or hours. Rapid tests are single-use and do not require laboratory facilities or highly trained staff. This makes rapid tests particularly suitable for use in countries with limited resources. Though the test is rapid at providing results, it is still an antibody test, so it is advisable to wait for three months after any risk behaviour before taking it. This makes rapid tests very suitable for VCT in resource poor countries. They are rapid, easy to perform and do not require sophisticated equipment, technical expertise and are mostly cost effective. Some of them, particularly comb tests, line tests, etc., are also discriminatory for HIV 1 and HIV 2 antibodies. The second type of test is an antigen test. It is also known as P24 antigen test. Antigens are the substances found on a foreign body or germ that trigger the production of antibodies in the body. The antigen on HIV that most commonly provokes an antibody response is the protein P 24. The P 24 antigen is a protein that is part of HIV. During the first few weeks after someone becomes infected with HIV, p24 is produced in excess and can be detected in the blood serum (although as HIV becomes fully established in the body it will fade to undetectable levels). P24 antigen tests are sometimes used to screen donated blood, but they can also be used for testing for HIV in individuals, as they can detect HIV earlier than standard antibody tests. Some of the most modern HIV tests combine P24 and other antigen tests with standard antibody identification methods to enable earlier and more accurate HIV detection. Because the p24 test can detect HIV infection before the HIV antibody test can, it is used for diagnosing HIV early in the course of infection. It is usually recommended that this test is taken 3-4 weeks after possible exposure to HIV.
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The third type of test is a PCR test. HIV tests that detect the genetic material of HIV itself (rather than antibodies or antigens) are known as PCR tests. PCR stands for Polymerase Chain Reaction. The whole process of extracting genetic material and testing it with a PCR test is referred to as Nucleic Acid-amplification Testing or NAT. PCR tests detect the genetic material of HIV itself, and can identify HIV in the blood within two or three weeks of infection. PCR tests come in two forms: DNA PCR and RNA PCR. Babies born to HIV positive mothers are usually tested using a DNA PCR because they retain their mothers antibodies for several months, making an antibody test inaccurate. Blood supplies in most developed countries are screened for HIV using an RNA PCR test, which can produce positive results several days before a DNA test. Both types of test can be used to measure the amount of virus that is present within a persons body (referred to as viral load tests). When a person already knows that she or he is infected with HIV, they may also have a viral load test to detect HIV genetic material and estimate the level of virus in the blood. This can be performed using either an RNA or DNA PCR test. PCR tests are not often used to test for HIV in adults, as they are very expensive and more complicated to administer than a standard antibody or P24 test. However, they may be offered in special circumstances, or by private clinics where patients are willing to pay. NAT generally gives positive results much sooner than standard antibody testing, making it useful in situations where early diagnosis is necessary. An RNA PCR test will produce a positive test result within two to three weeks. A DNA PCR test will provide positive results within three to four weeks (sometimes sooner). False positive results are more common than false negatives due to the PCR Tests sensitivity; hence, all positive
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results must be double checked using a standard antibody test. Most people develop detectable HIV antibodies within 6 to 12 weeks of infection. In very rare cases, it can take up to 6 months. It is extremely unlikely that someone would take longer than 6 months to develop antibodies. Getting tested earlier than 3 months may result in an unclear test result, as an infected person may not yet has developed antibodies to HIV. The time between infection and the development of antibodies is called the window period. During the window period, people infected with HIV will not yet have antibodies in their blood that can be detected by an HIV test. However, the person may already have high levels of HIV in their blood, sexual fluids or breast milk. People can transmit HIV to another person during the window period even though they do not test positive on an antibody test. Further, it is also important that one is not exposed to further risk of getting infected with HIV during the window period. The test will be accurate only if there are no other subsequent exposures between the time of possible exposure to HIV and the test. A negative test at three months will almost always mean a person is not infected with HIV. If an individuals test is still negative at six months, and they have not had unprotected sex or shared needles again in the meantime, it means that they do not have HIV, and will not therefore go on to develop AIDS.
HIV Testing: Types and Ethical Issues Involved

HIV testing has become a delicate issue for reasons more than one. Associated stigma and discrimination has given HIV a unique status. People, after being tested HIV positive, face wide discrimination in their family,
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community, work place and even at healthcare institutions. Researches have shown that in hospitals, treatment of suspected cases of HIV is postponed till their test results are out and if they are sero-positive, they may have to face denial of treatment. Surgeons would decline from any invasive procedures on suspected and confirmed HIV positive persons, physicians would not even touch them, paramedical staff would show revulsion and detestation and through direct and indirect cues and signs the HIV status of the patient would be disclosed to all. Positive HIV test results have brought much of exploitation, dehumanizing treatment, overt discrimination and oppression to people. Hence, many hide their sero-status, others maintain anonymity by accessing far off health services avoiding the nearby ones. Initially, doctors would order for HIV test of their suspected patients and without any information, consent or counseling, the patients were forced to get their test done, which would initiate an unending process of stigma, discrimination and oppression. However, NGOs and socially enlightened people had filed Public Interest Litigation (PIL) against the health care institutions for uninformed and mandatory HIV testing followed by discrimination and denial of further treatment in myriad of ways. This mandatory testing of persons suspecting of carrying HIV infection have created much hue and cry in the country. Testing for HIV, which is merely a biological test, has developed ethical, moral and legal dimensions. Testing without explicit consent of the patients i.e. mandatory testing has proved to be counterproductive in the long runs in the control of HIV epidemic. Mandatory testing can drive the target people underground and make it more difficult for launching intervention. The Government of Indias take on this
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was that there is no public health rationale for mandatory testing of a person for HIV. On the other hand, such an approach could be counterproductive as it may scare a large number of suspected cases from getting detected. People would refrain from knowing their sero-status and getting information, counseling to take appropriate measure to improve their quality of life. When people go undetected, transmission of HIV in the community would be assume proportions no less than a fire in a forest. Therefore, HIV testing carried out on voluntary basis with appropriate pre and post-test counseling is considered to be a better strategy, and in consonance with the national policy on HIV testing as well as the WHO Guidelines. The government has maintained that HIV testing should be a part of overall comprehensive preventive and promotive programmes. Testing by itself does not result in behavioural changes that can restrict transmission of HIV to others and therefore, testing should be a part of total control programme providing social support, means and skill to reduce or eliminated risk behaviour. The policy guidelines of the government on HIV testing maintains that
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No individual should be made to undergo a mandatory HIV testing No mandatory HIV testing should be imposed as a precondition for employment for providing health care facilities during employment. Adequate voluntary testing facilities with pre-test and post-test counselling should be made available through out the country in phased manner. There should be at least one HIV testing centre in each district of the country, for voluntary testing in the Government Sector. No citizen will be forced to undergo an HIV test;
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The main ingredients of Voluntary Testing are Informed consent after pre-test counselling, confidentiality and post-test counselling at the time of disclosing of positive as well as negative results. HIV testing for the purpose of confirmation of the sero-status of an individual must always be undertaken after pretest counselling and informed consent. Testing without informed, written and explicit consent, has proven to be counter productive and has driven the HIV positive individuals underground. This makes prevention and intervention more difficult. Pretest counselling also enables the individuals to face the HIV test results (refer for details in next block). As per the government policy and international guidelines, the confidentiality of the test results (both negative as well as positive) should be strickly maintained in most cases. This is to respect the privacy and rights of the individuals and to protect them from discrimination, victimization and stigmatization. The test results, the name or the identity of the individuals, and such other details must never be divulged loosely. The test report must be placed in a sealed envelope marked confidential and must be submitted to the clinician who requisitioned the test. The records in the laboratory must be kept secure to prevent access by unauthorized persons. The results are never to be communicated via telephones/fax/emails, etc. Confidential testing means that the results of any HIV test performed will not be revealed to anybody except designated clinic staff, and in some cases, specific public health officials. Confidential testing will usually require a person to give their details (name, age, address) to the clinic performing the test. They then have to contact or return to the clinic after to get the results (unless a rapid test is used). The clinics are legally bound to not reveal personal details and test results. Private doctors also perform HIV tests. In case an individual does not
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want their name associated with their test, anonymous HIV testing may also be offered. Anonymous testing can either be ensured by a patient giving a false name and address (which can create difficulties if a person tests positive and needs to be informed), or can be specifically requested. Anonymous unlinked HIV testing is a form of testing used worldwide for research and surveillance purposes, most commonly among pregnant women. Blood samples taken routinely for other tests are additionally tested for HIV. No personal information is taken and there is no way of linking the test results back to the person being tested. The results have no direct individual use but can provide important information for estimating HIV prevalence and incidence. Though National AIDS Prevention and Control Policy unequivocally said there should be no discrimination in matters of employment to an HIV positive person and that they should be guaranteed rights enjoyed by other members of society, many employers fire their employees on being detected HIV positive, even if their sero-status does not hamper in their job responsibility in any ways. One Constable had approached the Andhra Pradesh Administrative Tribunal, stating that though he cleared the written tests and was provisionally selected for the post of Sub-Inspector, but was denied promotion only because he tested positive for HIV. The Tribunal had rejected his claim going strictly by the Andhra Pradesh Revised Police Manual, which prohibited entry of persons who are HIV positive into government service. He appealed before the Andhra Pradesh High Court, which allowed his claim. Even the Ministry of Labour maintained that it was wrong to deny employment or promotion to anyone just because he had tested positive for HIV, sero-positive persons should be guaranteed equal rights to education and employment as other
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members of the society. National AIDS Prevention and Control Policy also assert that HIV status of a person should be kept confidential and should not in any way affect his right to employment, position at workplace, marital relationship and other fundamental rights. There are some of the knotty issues associated with HIV testing. One of them is partner notification. Though international guidelines stress that counsellors can only motivate and persuade the sero-positive clients to notify their sex partners about their HIV status, they shall not notify clients partners themselves. However, in India, the Supreme Court, in response to a case filed by an HIV positive widow whose husband hide his seropositive status at the time of marriage, questioning who is responsible for this, gave the verdict it is the responsibility of the healthcare workers to notify the partner if the clients do not do so. It seems to be a breach of confidentiality but is needed to save the life of many women whose only risk behaviour is their marriage. There are situations when rights of PLHA come in conflict with those of their partners. It is the right of the PLHA to decide who needs to know his HIV positive status. However, if he decides not to notify his partner, then it would be injustice to his partner. Further, doctors also claim that they need to know the HIV status of the patient for his/her treatment. Relatives or caregivers, in the hospital, also insist to know the sero-status of their patient. However, responding to such precarious issues, the NACO guidelines indicate that only partner notification is a must, while medical staff, doctors and nurses, need to observe universal precautions. If there is a need to break confidentiality at the time of partner notification these steps should be followed: first encourage client to tell on his own to his partner about his HIV positive status; if he is adamant not to disclose,
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then warn and if he still does not notify, then counselor should inform. Another knotty issue whether or not children should know their status as well as their parents HIV status. It is recommended that as soon as possible, children should be informed about their own HIV status as well as that of their parents, and that parents themselves should inform the child. Children are able to absorb the shock if parents themselves notify them. In situations where they come to know from outside sources contoured with stigma, labeling and derogation, it has found to have detrimental effects on children.
HIV Testing Sites, Procedures and Management

As seen in earlier sections, HIV test is not merely a biological or pathological test. It involves many complexities, dilemmas, moral and ethical concerns, legal issues, human rights and social justice. In this context, let us first understand the sites for HIV testing. In most countries, there are many places for testing of HIV. It is recommended that one gets the HIV test done at a health clinic or at a specialist HIV/AIDS Voluntary Counselling and Testing (VCT) site. At these sites, often doctors, trained counsellors, and other health professionals are available to provide required inputs. HIV testing is done in the pathology labs in hospitals, private labs, dispensaries and so on. However, NACO has initiated establishment of Integrated Counselling and Testing Centres (ICTC) at various places, where people can come and get their HIV test done after informed consent and proper counseling with surety of confidentiality. The ICTC is an extremely important component of HIV/AIDS care, prevention and control programme. Its services are holistic and integrated as
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it serves as an entry point for HIV counseling, testing, treatment of opportunistic infections, ART, psychosocial support and referral to appropriate services. According to NACO guidelines, the ambiance and infrastructure of ICTC should be conducive for the client to confide in the counsellor and undergo testing. ICTC should be easy to locate and there should be proper sign boards and use of symbols for non-literate clients. Its name should be non-stigmatized one, easily understandable and preferably in local language. The waiting area should be in close proximity to the counselling and blood collection site. It should be well lit and with adequate ventilation and sufficient sitting space. It should have toys for children accompanied by parents, books, posters, brochures, IEC materials to provide information related to STI/HIV. There should be two separate rooms for counseling one each for the male counselor and the female counsellor. The rooms should be sound proof so as to ensure confidentiality. Further, core staff should comprise of ICTC manager, counsellors and lab technicians. Guidelines insist that qualification for counsellors should be masters in the discipline of social work or psychology, with counselling as a separate paper and essentially with practical exposure to counselling/casework. Let us briefly look at the procedure for counselling and testing. The client on reaching the centre is registered, and he/she is given a personal identification number/ digit (PID). Client is administered pre-test counselling during which he/she is informed about HIV, how it spreads, how it causes disease, window period, possible need for testing, implications of positive and negative test results, false negative and false positive test, the risk behaviours, the treatment, and services available. This information is updated and is conveyed to the client in a language understood by him/her. On the basis of
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knowledge gained, the client makes informed decision to either undergo HIV testing or not. If the client agrees, a written informed consent is given to him/her for signing. The next step is the collection of blood sample as per the blood collection guidelines, and the client is asked either to wait, if there is facility/time to do rapid testing. Otherwise, the client is issued a paper with his/her PID Number and requested to collect the report on a specified date, usually by the third day. Generally, at ICTC, the rapid HIV testing is performed in accordance with the guidelines. Results are interpreted and report is prepared as negative, positive or indeterminate. Necessary entries are made in the relevant registers. The client comes to collect the report, which is given during post test counseling. In case of the report being negative, the counselling is aimed at reducing the chance of risk behaviour. The client is also educated regarding strategies of risk reduction. In case the test result is positive, the client is provided psychosocial support and is informed about availability of treatment and other services. This is done to help the client cope with the positive result and in order to give him/her hope. Importance of safe behaviour is stressed again to prevent secondary transmission of HIV. In case, the result is indeterminate the client is called for repeat testing after 14-28 days. In case, the result continues to be indeterminate, the client is referred to National Reference Laboratory for further testing. If required, the client is referred to ART Centre. In case the female client is pregnant, she is referred to PPTCT centre for further management. All the records are maintained at the ICTC as per the guidelines, and confidentiality of test is maintained. The client is counselled to get the spouse/children tested for HIV. The client is provided referral as per the requirements.
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It is generally recommended that the HIV test is done in a health care setting. However, in some countries home sampling kits are available. With a home sampling kit, a person can take a sample (usually a blood sample) and then send it to a laboratory for testing. A few days later the person phones up a special number, gives their individual identification code, and is given the result over the phone. If the result is positive then a professional counsellor will provide emotional support and referrals. For home sampling, the major advantages are convenience, privacy and anonymity. However, the major disadvantage of this approach is lack of opportunity for pre-test and often post-test counselling, where client is prepared for test results and also provided useful information with regard to prevention of transmission of HIV and its management. Now-a-days, HIV test kits are also available for testing at home. It maintains confidentiality and anonymity, but without any scope for counselling. Reactive test results must be confirmed by further testing at a clinic. If purchased over the internet, there could be no guarantee regarding the genuineness of test kit nor the accuracy of the test results. In the event of an incorrect result, there may be no legal recourse. Currently, HIV testing is done in serum/whole blood and plasma. In some countries other body fluids like urine, sputum, etc., are also used. In India, other than blood and blood products, HIV testing on urine and saliva have not been evaluated nor validated. In recent times, a large number and wide range of rapid tests of high quality have become available and are currently being used worldwide in various situations like emergency cases, points of care like VCTC, ICTC, PPTCTCs, etc. Different types of rapid tests are: dot blot assay, lateral flow assay, dip-stick, comb test, etc. Their
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advantages are follows: they are easy to perform, very rapid, requires no complex equipment and only limited infrastructure. Some assays can be stored at room temperature, such tests have wide temperature range stability, can be used at remote peripheral labs and in situations when same day results are required. Management of waste generated by rapid test is easier to dispose off. Tests Related to Management of HIV: Many pathological tests are conducted on PLHA for assessing their health status depending upon the types of ailments cropping up in the body. As you are aware, out of a wide range of opportunistic infections, a few may afflict the health of PLHA. Depending upon the symptoms, doctors suggest certain pathological tests for the PLHA such as tests for Haemoglobin, ESR, tuberculosis, bacterial and fungal infections, and so on. However, one specific test done on PLHA is CD4 count test that needs mention. Now, let us attempt to understand what the CD4 test is. It may be reiterated that HIV attacks type of immune cells called the T-helper cells. These cells carry a protein called CD4 on their surface, which HIV uses to attach itself in the body. The T-helper cells play an important part in the immune system by helping to coordinate all the other cells to fight illnesses. A major reduction in the number of T-helper cells can have a serious effect on the immune system. HIV damages many T-helper cells and as a result, there are fewer cells available to help the immune system. A CD4 test measures the number of T-helper cells (in a cubic millimetre of blood). Someone uninfected with HIV normally has CD4 count between 500 and 1200 cells/mm3. In a person infected with HIV the CD4 count declines over a number of years. Doctors often use test of CD4 count as a parameter to appraise health status of PLHA and even to take decision regarding when to start antiretroviral treatment for HIV.
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In most of the countries, generally the CD4 test is used to determine when a person should start treatment. Though there is variation between the guidelines on initiation of ART between different countries, treatment is generally recommended when the CD4 test indicates a count less than 350 cells/ mm3. When this happens, other factors may also be taken into account, such as viral load and opportunistic infections. The World Health Organisation (WHO) has a method of describing the different stages of HIV disease based on clinical symptoms, known as the WHO staging system for HIV disease and is useful for healthcare settings with poorly equipped medical facilities. The table below shows the WHO guidelines to starting treatment in countries with limited resources, based upon the stages of HIV disease and whether a CD4 test is available or not.
WHO clinical staging 1 2 3 Primary HIV infection Clinically asymptomatic stage Symptomatic HIV infection CD4 testing unavailable Do not treat Do not treat Treat Consider treating if CD4 count is below 350 start treating before C D4 c ou n t fa ll s below 200 Treat irrespective of CD4 count CD4 testing available Treat if CD4 count is below 200
Progression from HIV to AIDS
Treat
Before ART is initiated basic clinical assessment is generally carried out. This includes determination of existing medical conditions (such as hepatitis, TB, pregnancy, injecting drug use and major psychiatric illness), assessment of current medications (including traditional and herbal medications), weight
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measurement and assessment of patient readiness for therapy.
Conclusion
In this chapter we learnt about various types of testing like testing of antibodies (ELISA, Western Blot, rapid tests), test of P24 protein linked to HIV virus and PCR test to detect presence of virus and/or its load in the body fluid. Antibody test because of its cost effectiveness, accuracy, specificity and sensitivity is considered to be the standard one and is widely used in voluntary screening of HIV. PCR is costly but is not dependent on window period for its accuracy. Likewise, P24 test also detects presence of virus in early periods of infection. Mandatory testing has had boomerang effect, because, of associated stigma and discrimination, suspected people declined from testing. Voluntary testing associated with pre-and post-test counselling is considered ideal and is recommended in the NACO policy on testing. Pre-test counseling provides needed information, prepares individuals for the results and is a platform for taking informed consent. Post-test counseling aims at behaviour change, adopting healthy, safe life style and linkage with needed services. Partner notification is a delicate and sensitive issue if client is unwilling to disclose his/her sero-status to his/her sexual partner. The Supreme Court issued a directive making it the duty of healthcare functionary to inform the partner of the client, if he/she after persuasion does not do so. Children should also be informed about their sero-status preferably by their parents as early as possible. Integrated Counseling and Testing Centres are popular sites of HIV testing, management and care. Adequate procedures are in place to ensure confidentiality and
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conducive environment to clients coming for testing and care. Testing at these sites is considered better than home testing. Next, certain pathological tests such as CD4 count tests are important, so as to manage health status of sero-positive clients.
References
Greene, K., Derlega, V.J., Yep, G.A. & Petronio, S. (2003): Privacy and Disclosure of HIV in Interpersonal Relationships: A Sourcebook for Researchers and Practitioners. New Jersey: Lawrence Erlbaum Associates. OBrien, M.E. (1992): Living with HIV: Experiment in Courage. New York: Auburn House. Kalichman, S.C. (1998): Preventing AIDS: A Sourcebook for Behavioral Interventions. New Jersey: Lawrence Erlbaum Associates. Edgar, T. Fitzpatrick, M.A. & Vicki, M.S. (1992): AIDS: A Communication Perspective. New Jersey: Lawrence Erlbaum Associates.
Treatment and Care, Vaccine Issues

*Nemthiangai Guite
Introduction
For the first decade and a half after the discovery of HIV there was neither a cure nor any treatment available. The mutative nature of HIV makes it difficult to invent a vaccine, a cure or for that matter an appropriate treatment. HIV attacks the immune system, which defends the human body against pathogens. When the balance tilts against the immune system, the people living with HIV/AIDS (PLHA) become more susceptible to opportunistic infections (OIs). With the bodys immune system incapacitated to defend itself against OIs, the PLHA ultimately succumbs to them. In this chapter we will examine how with the introduction of combination ARV (Anti-Retroviral) therapy in 1996, HIV became a manageable disease for the vast majority of PLHAs. However, the prohibitive costs of the drugs and the necessary monitoring tests make ARVs unaffordable for most PLHAs, especially those living in developing and least developed countries. In developed countries, the cost of ARVs has been borne mostly by the State and partly through insurance. As a result, there has been a marked decrease in the number of deaths on account of HIV in the past 10 years. On the other hand the number of deaths in developing countries due to HIV continues to spiral. As HIV largely affects the young and productive populations, economies
* Dr. Nemthiangai Guite, University of Delhi, New Delhi
Treatment and Care, Vaccine ISSUES
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in some countries have been affected by the HIV pandemic. We will also discuss on how the expanding access to treatment provides an incentive for people to come forward to be voluntary tested for HIV. Even as ARV treatment and treatment for OIs helps suppress the disfiguring symptoms of AIDS, it also helps allays peoples fears of contracting the fatal disease. As a social worker we need to develop a cumulative effort which would be to break the barriers of stigma and discrimination, which need to be overcome for effective prevention strategies. Comprehensive HIV/AIDS care is therefore the need. Different disciplines ranging from medical care to social support are needed. Social workers can work in settings such as clinical care and nursing care; in providing counselling and psychosocial support to individuals; generating opportunities for employment or financial support; locating appropriate housing in appropriate neighbourhoods; providing care and support of orphans and widows; as well as training in the care and prevention for home caregivers, etc.
HIV/AIDS Treatment
The first line of management for a PLHA is ensuring her/his healthy lifestyle. The second is the treatment of OIs. The most occurring OIs in India are Tuberculosis, Candidiasis, Cryptosporidiasis, Herpes Zoster, Toxoplasmosis, Bacterial Pneumonia, Cryptococcal Meningitis, PCP and Kapasis sarcoma; all of which are treatable and curable. As the viral count increases and the immune system is compromised, it becomes essential to try and restore the balance by lowering the viral load in the body of a PLHA. ARVs do this, enabling PLHA to live longer, healthier lives.
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Anti-Retroviral Therapy The first drug discovered in 1987, acted in the reverse transcriptase enzyme so that pro-virus DNA would not be formed. Since then, various drugs acting on the reverse transcriptase have been discovered. Two groups of drugs: 1) Nucleoside Analogue and 2) Non-nucleoside analogue were discovered and used until 1998. These were the drugs, which acted on the enzyme protease, which helped in the maturation of m-RNA to mature virions. These drugs were known as protease inhibitors. In effect, the anti-retroviral drugs, acts on the various stages of the life cycle of the virus in the human body stopping the replication of the virus; nevertheless, it does not get the virus out of the human cell where they are firmly integrated. However, these drugs remain very costly, and the Government of India has pledged to support provision of drug program with the help of DFID, Clinton HIV Initiative, USAIDS, and other funding agencies. The WHO, in 2002, included ARVs in its Model List of Essential Medicines. This list presents, a list of minimum needs for a basic health care system, listing the most efficacious, safe and cost effective medicines for priority conditions. The ARVs included and also available in India are as follows: 1 . Reverse transcriptase inhibitors () i Nucleoside analogue: AZT (azidothymidine, zidovudine) 100 mg each tablet; DDC (zalcitadine) 75mg each tablet; Stavudine 100 mg. tablet each; Lamivudine 150mg. tablet each; Didanosine; Di deoxyadenosine (ddA).
(i Non-nucleoside analogue: Nevirapine 200 mg. i) tablet each; Delavirdine, Sustiva, thiobenzimidazoline derivatives.
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2 .
Protease Inhibitors () Saquinavir (SQV) i (i Ritonavir (RTV) i) (i) Indinavir (IDV) ii ( v Nelfinavir (NFV) i)
Currently 107 government hospitals are providing ART and CD4 count test free of cost. ART is also available for children in 87 centres. In addition, ART is also being provided by the private sector. National AIDS Control Programme (NACP)-III has scaled up this service to a large number of people through effective public-private partnership as well as community partnership. The WHO has also release guidelines for a public health approach to the scaling up of ARVs in resource limited settings. According to the National Guidelines for Clinical Management of HIV/AIDS, nearly all these drugs are available in India. There has been some debate over the efficacy of combination ARVs. However, it is now accepted that ARVs reduces viral replication, prevent the emergence of resistance and, ultimately, prevent treatment failure for a significant amount of time. ARVs thus lead to improved rates of mortality and morbidity, prolonged lives and improve the quality of life. Different views have been posted on when ARVs should be commenced. In order to provide uniformity the WHO has issued guidelines, which lay down when ARVs should be started. Treatment of HIV-related opportunistic infections As the immune system becomes increasingly damaged by HIV, it becomes more susceptible to opportunistic infections. These infections would usually be fought off by a healthy immune system, but a low CD4 cell count means opportunistic infections such as PCP (a type of pneumonia) can be life-threatening. If one of these
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illnesses becomes a serious problem, antiretroviral treatment may be advised immediately. Treatment should only be started once the person is ready. A lot of commitment is needed, since following a drug regime can be quite demanding and in most circumstances, the treatment will have to be taken for life. Once it is decided that treatment should be started, doctors will advise of the various HIV drugs and combinations available, which might be most suitable. Some opportunistic infections are easier to treat than others. Effective treatment depends on health services being able to procure, store, select and administer the necessary drugs and to provide related treatment, care and diagnostic services to monitor health status and treatment response. A few opportunistic infections and symptoms such as candidiasis of the mouth, throat or vagina (thrush), herpes zoster (shingles) and herpes simplex can be managed effectively through home-based care. In a home-based care setting, diagnosis is made by observing symptoms. Some opportunistic infections may be diagnosed by observation or using a microscope, and treated where there is minimal health infrastructure. Such infections include pulmonary tuberculosis and cryptococcal meningitis. In a setting with reasonable infrastructure, the facilities available include X-ray equipment and culture facilities. Using these, opportunistic infections such as extrapulmonary tuberculosis, cryptosporidiosis, isopsoriasis, PCP and Kaposis sarcoma can be diagnosed and treated. Opportunistic infections such as Toxoplasmosis, MAC and Cytomegalovirus infection can be diagnosed and treated in places with advanced infrastructure. Treating these infections is often impossible in resource poor countries. Many developing countries lack the advanced equipment and infrastructure (such as CT scanning) needed to treat these complex infections.
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Comprehensive Treatment and Care

In this section we will discussed on various critical issues that needs to be considered while providing comprehensive treatment and care to HIV patients. We will talked about comprehensive treatment and care which consists of a number of different elements, including voluntary counselling and testing (VCT), food and nutrition, support for the prevention of onward transmission of HIV, follow-up counselling, protection from stigma and discrimination, spiritual support, the provision of antiretrovirals (ARVs), treatment of STIs, management of nutritional effects, prevention and treatment of opportunistic infections (OIs), traditional treatment, palliative care, preparing for death, family and orphan support. Therefore in this section we will specially focused on the role of Social Workers while providing comprehensive treatment and care, considering the fact that people suffering from HIV/AIDS have differing needs according to their stage of infection Critical issues for treatment programmes The following issues need to be considered before, during and after providing treatment and care not only to the PLHAs but to their family members as well:
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Counselling, testing, and treatment awareness
HIV counselling and testing is particularly important as a starting point for access to other HIV/AIDS-related services. If a person does not know they are infected, they cannot get any treatment or care. In most cases, people are diagnosed HIV positive only when they are already seriously ill. At this point, there are fewer opportunities for cost-effective interventions. Therefore the Social Worker should, in addition to providing enough
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HIV counselling and testing facilities to meet demand, it is important to encourage people to use these services. Raising awareness of the benefits of treatment provides people with an incentive to learn their HIV status, and so should help to increase demand. However, in many societies fear of stigma and discrimination remains a serious barrier to testing. The Social Worker should work diligently to help overcome this problem, by moving towards offering every patient an HIV test as a routine part of health care, regardless of symptoms. Before starting ARVs, a PLHA must be counselled and the treatment should be started only after obtaining voluntary informed consent from the client. All the factors must be considered to determine whether ARVs can be sustained lifelong, and also to ensure that there is availability of alternate drug regimens in the event of treatment failure.
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Helping people to meet programme requirements
As a social worker we should understand that in order to help patients, who are most likely to benefit from antiretroviral treatment, it may be necessary, for example, to arrange transportation in order to help people meet these requirements. Also, the treatment strategy may require people to find the support they need to cope with the demands of treatment, whether it be from friends, family or support groups. Those who have alcohol dependence, substance abuse, or depression, need to be helped to overcome their problems before they start treatment. One of the main obstacles in accessing health care in general is the cost involved. The same insurmountable barrier exists for PLHAs who try to access ARVs. The Indian pharmaceutical industry took the lead in lowering prices of ARVs resulting in a world wide decline in prices. Despite this, the cost of ARVs coupled with the cost of monitoring tests is
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approximately Rs. 4,000 per month for the first line of treatment per month, making the treatment inaccessible for most PLHAs in India.
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Nutrition
Even in the absence of treatment, someone who has HIV is likely to remain healthy for longer if they have an ample and nutritious diet. The need for good nutrition also applies to those who are receiving treatment, especially because some of the drugs should be taken on a full stomach, and moreover, little is known about the effects of antiretroviral on malnourished people. Furthermore, if someone lacks an adequate food supply, they are less likely to be able to adhere to a daily treatment regimen. Hunger is a much more immediate problem than the threat of AIDS, and desperate people may even resort to selling their drugs to feed themselves and their families. For all of these reasons, we should consider nutritional support to be a key component of AIDS treatment programmes.
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Treatment for other infections
By the time someone reaches the stage of HIV infection at which treatment is required, they are often suffering from opportunistic infections such as Tuberculosis and Candidiasis. Treatment centres must be able to provide medication for these infections as well as the underlying HIV infection. Social workers must also educate patients regarding the possible harmful interactions between antiretroviral and other pharmaceutical drugs as well as alternative therapies.
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Reliable supply chains
Antiretroviral drugs can stop working if they are not taken every single day. It is therefore essential to maintain an uninterrupted supply of medication, from
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the factories where the drugs are made all the way down to the rural villages where they are needed. This difficulty exists in India because of the chronically weak and unreliable distribution systems for all kinds of medicines. Transport and communication networks too are often very poor. Social Workers needs to develop initiatives to remedy this situation or network with those international agencies which have taken initiatives in this regard, which include the AIDS Medicines and Diagnostics Service (AMDS), whose partners include UN agencies, USAID, the Clinton Foundation and various other non-governmental organizations. AMDS collects and distributes information about drug pricing and supply chains, as well as providing technical assistance to supply chain managers.
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Trained Staff
Shortage of trained staff is one of the most serious problems facing antiretroviral treatment programmes. One reason for the paucity of health workers in poor countries is the international poaching of doctors and nurses by the cash rich Europe and North America. Skilled professionals are lured abroad by better working conditions and much better pay. This migration satisfies the needs of the rich countries, but drains resources from nations that can ill afford to lose the workers on whom they had spent so much money for training. In response, as a social worker we should be working hard to expand recruitment and training schemes and try to influence policy makers.
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Treatment Adherence
Ensuring thorough follow-up care is not only important on an individual level (as the drugs are only effective if taken everyday for life), but is also important on a public health level, since it reduces transmission of drug
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resistant HIV. Therefore a major challenge for social worker is ensuring adherence, as unfortunately not all PLHAs can benefit from ARVs treatment. A significant number cannot tolerate ARVs because of toxicity and/ or due to drug resistance. Once ARVs are commenced, they have to be continued for life.
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Universal Access
It is relatively easy to provide treatment where there is good infrastructure in the form of voluntary testing centres in antenatal clinics as well as the availability of medicines. It is much harder to move into rural areas and reach people who have little or no contact with health services or community organizations or NGOs, or to reach marginalized groups such as refugees, prisoners and injecting drug users. Social Workers need to look for innovative ways to reach the most underserved population groups as they strive for universal access. One example is the use of mobile outreach services to take drugs from treatment centres to outlying communities on a regular basis.
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Traditional Healers and Medicine
Social Workers need to understand that, traditional treatments for HIV/AIDS can be attractive as they are accessible, culturally appropriate and acceptable. They may also be affordable in resource poor countries like India. However, there is little evidence that such therapies are safe or effective in treating HIV infection. Whilst some of the traditional treatments may be helpful, others may do more harm than good. Traditional medicine should not replace more proven modern treatments if they are available. However, in the absence of such treatments, traditional medicine can be promoted as a feasible option if it relieves pain and makes the patient feel better. So also, traditional healers especially
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faith-healers, exorcists, magic-men may be integrated as first line contact points who may encourage interface with the health services. End of Life Care Palliative Care End of life care is an important part of palliative care. In many resource poor countries, the existing health infrastructure is inadequate to provide care in a hospital for people who are approaching the end of their life. Often, the only option available for care of people with AIDS is care at home, and even when hospital care is available this may not be what people want. Whether in a hospital, hospice or home, palliative care aims to provide comfort and support for people who are terminally ill and, ultimately allow them to die with dignity. This can involve controlling pain, treating symptoms such as diarrhoea and vomiting, relieving psychological or spiritual anguish, and also supporting families and caregivers. Preparing for Death It is often believed that it is not appropriate to talk about the fact that somebody is going to die, and that mentioning death will in some way hasten it. However, for those who wish to discuss death, an open discussion, ideally from early diagnosis, can help dying people to feel that their concerns are heard, that their wishes are followed, and that they are not alone. Most people yearned to be assured that they will be remembered. Encouraging friends and family to share stories or memories of the persons life makes the person feel loved and cared for. People nearing death, are frequently afraid of dying in great pain. Social workers or carers should be able to reassure patients that pain relief will be
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carried out up to the point of death. Another great worry is what will happen to patients dependants after they die. Where ever possible, the social worker should make plans for dependants and partners. Although it can be distressing to discuss such issues, formulating plans may help reduce anxiety. Negotiating a will can also prevent family conflict and ensure that partners and children are not left destitute. This is particularly important in India, where property grabbing is a widespread phenomena. Practical issues to be discussed before death include:
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custody of children family support drafting up a will funeral costs future school fees
Emotional issues to be discussed before death could include:

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resolving old quarrels, especially with close relatives capable of providing social support assuring the patient and family members that they are loved sharing and shaping hopes for the future especially for children who are left behind bidding goodbye to caregivers and providers
Family and orphan support Looking after someone with HIV can be very daunting and distressing task for family members, partners and friends. And the need to offer counselling to partners and families following the death of a family member or friend is often overlooked, particularly in resource poor
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countries. Counselling can help a person to discuss their loss and to mourn appropriately. The process of grieving may last many months, and possibly even years. Further still, family members may have unresolved fears about HIV infection for themselves, social workers can helped to come to decisions about HIV testing. However, for some people a single counselling session may be sufficient to clarify their thoughts and relieve them off their feelings and reassure them that they are coping as best as they can under the given circumstances. Other people may need several sessions. Some people may even never completely come to terms with a loss, particularly that of a child. The impact of the loss of life differs across families and communities. An even more distressing fact is what happening to a childs life, she or he loses a parent. More than 15 million children under 18 have lost one or both parents to AIDS. Caring for these children affected by HIV/AIDS requires concerted action at all levels. In the countries hardest hit by HIV/AIDS, care for orphans lies often with their extended families or communities.
Issues Concerning AIDS Vaccine

Public health officials have placed enormous hope on the potential of an HIV vaccine to bring the global HIV/ AIDS epidemic under control. For decades, vaccines have proven to be among the most powerful and cost-effective disease prevention tools available. Vaccines if discovered, will also have potential advantages over existing HIV prevention interventions; they can reach populations that otherwise have limited access to health care and especially prevention services, and they need not depend on consistent and sustained behavior change by millions of individuals.
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An HIV vaccine capable of controlling the pandemic would need to satisfy several criteria. It would need to be effective against multiple strains (or clades) of HIV, especially those predominant in developing countries. It would have to be made accessible to at-risk populations throughout the world, including populations with minimal ability to purchase the vaccine. And it would have to be deliverable in developing countries with rudimentary health care infrastructures. Each of these priorities presents special challenges to scientists and policymakers. Yet numerous scientific, ethical, public policy issues and challenges remain before a vaccine can reach all those who need protection from HIV. In the next section of the unit we will discuss the various issues concerning the vaccine, ranging from ethical to accessibility and try to locate social workers role in the whole process. The Status of Research Vaccines against HIV are being developed, and remain in various stages of clinical trials, yet none have proven effective till date. It is important to conduct research to find an effective vaccine because:
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The availability of a safe, highly effective and accessible preventive HIV vaccine would be a valuable complement to other preventive interventions, significantly contributing to the interruption of the chain of transmission of HIV. Well conceived HIV immunization strategies could reach populations where other interventions are not sufficiently enough. Research on preventive HIV vaccines is providing new information on the possible use of vaccines as therapeutic interventions, to be used in association
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with anti-retroviral therapies (ARTs), which could lead to its lowering in the cost of the treatments and to an increase in their long term efficacy. The candidate vaccines need to be tested on healthy human volunteers through sequential phases. Phase I and II trials provide data on the safety of the candidate vaccines and on their ability to induce immune responses specific to HIV. These trials are done among small numbers of volunteers (50 200 per trial). Depending of the results obtained, candidate vaccine can proceed to large scale phase III trials, to obtain their efficacy in inducing protection against HIV infection or AIDS. For scientific reasons, Phase III trials are done in populations with high incidence of HIV infection, involving thousands of volunteers. Since 1987, more than 30 HIV candidate vaccines have been tested in approximately 60 Phase I/II trials, involving more than 10,000 healthy volunteers. Most of these trials have been conducted in the United States and Europe; several have also been conducted in developing countries such as Brazil, China, Cuba, Haiti, India, Kenya, Peru, Thailand, Trinidad and Uganda. The results have confirmed the safety of the vaccines, and have provided important scientific information to develop newer generations of candidate vaccines with better ability to induce anti HIV specific immune responses. Nearly all vaccines are based on being able to induce a strong enough CTL (Cytotoxic T-Lymphocytes) response to afford protection. The best vaccine would be the one which can stimulate both antibodies and CTL response. Some of them are:
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AIDSVAX, a gp 120 based vaccine that has reached to Phase III clinical trials.

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CTL inducing vaccines which can prime the CTLs to target a range of viral proteins and not just those on the outer surface of the virus. Unlike neutralizing antibodies, it will not stop an infection, but by killing infected cells, the CTLs can hold down viral load in the body. A recombinant adeno-associated virus (rAAV) acts as vector (harmless virus) carrying three genes of the HIV subtype C, the strain that is common in India and South Africa. These viral vectors are capable of infecting cells naturally, and evoking an immune response. Modified Vaccina Ankara (MVA) acts as vector, and it carries six HIV genes that have been optimized to match those strains circulating in India. Sub unit vaccine: a vaccine that contains only part of the virus or other microorganism. HIV subunit vaccines produced by genetic engineering are referred to as recombinant subunit HIV vaccines.
The WHO-UNAIDS HIV Vaccine Initiative is collaborating with national authorities, laboratories and scientists working with HIV vaccine development and evaluation across the different continents. Incentives for Private Sector Involvement Despite the urgent public health need, HIV vaccine research is at best a questionable financial investment; private sector pharmaceutical and biotech companies, which play a critical role in vaccine design and manufacture, have not raced to develop a vaccine for HIV. The scientific challenges are daunting, and the development timeline is long, expensive, and unsure. In addition, the vast majority of people who need an HIV vaccine live in developing countries, where there
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are few resources to pay for health care or vaccines. This concern about the lack of a paying market in developing countries discourages private companies that fund HIV vaccine research from investing in research on products particularly suitable for lower-income countries. The lack of private sector enthusiasm for HIV vaccine research is troubling for public health advocates because much of the expertise to develop and manufacture vaccines rests in private sector companies. A range of incentives can be proposed by social workers to encourage private sector investment in HIV and other priority vaccines. Issues for Trial Participants It is likely that multiple large-scale trials of several HIV vaccines will be necessary before a highly effective product is identified. These trials will involve thousands of volunteers around the world over several years. Clinical trials of HIV vaccines raise important concerns about participant protections and research ethics. Some HIV vaccine candidates may engender an antibody response in vaccines, causing trial volunteers to test positive on standard HIV antibody tests even though they are not truly infected with HIV. In the India, a positive HIV test result could lead to severe discrimination in health insurance and to social stigma. The simple fact of participating in an HIV vaccine trial may cause someone to be labeled a high-risk individual, a gay person, or a drug user. It is incumbent upon researchers to ensure they have adequate protection in place to warn trial participants about these risks and assist them if they should encounter problems. Confirmatory testing technology that can distinguish between vaccine-induced infection and actual infection
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should be accessible to all those enrolled in vaccine trials. Ensuring Access to an HIV Vaccine Developing an AIDS vaccine does not guarantee its use. For example, the highly effective vaccine for hepatitis B has been available in the industrialized nations for over 17 years, yet this vaccine has only recently become accessible in much of the developing world. Health advocates and public health officials agree that it is unacceptable for an HIV vaccine to follow the standard decade or longer delay between licensing in rich countries and availability in developing countries. Ensuring simultaneous access to an HIV vaccine in rich and poor countries alike involves many challenges. Since, HIV vaccines employ advanced technology, and may be expensive compared with current vaccines, a major issue is the severely limited health care resources in poorer countries for purchase of HIV vaccines. In addition, marginal health care infrastructures in many developing countries will render it difficult to distribute a vaccine. And vaccination programs will have to be adapted to reach the risk groups that need an HIV vaccine most urgently. Current immunization programs in developing countries focus on reaching children, but it is sexually active adolescents and adults that will most immediately need a vaccine for HIV. A part of the challenge will be to involve many countries reluctant to acknowledge that young people are sexually active. Still more challenging is to reach the highly mobile or displaced populations with a vaccine. There are several proposals for accelerating access to HIV vaccines in the developing world. International organizations including the World Bank are considering establishing purchase funds to buy HIV and other
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vaccines. These funds could be financed with donations from industrialized governments and major foundations. Governments could also encourage tiered-pricing structures, in which vaccine purchasers in industrialized countries pay a significantly higher price for the vaccine than poor countries and aid organizations. IAVI has developed innovative intellectual property agreements with its research partners that will facilitate more rapid access to HIV vaccines in developing countries. Elected officials, other policymakers, and public health leaders in these countries will also need to make acquisition and distribution of HIV vaccines a priority.
Conclusion
The most effective treatment programmes are those that are truly community-led. Governments, health providers and non-governmental organizations should strive to mobilize all sectors of society to achieve the fastest possible rate of expansion in terms of HIV allied services. This means harnessing the united strengths of community organizations, faith-based groups, employers, families and people living with HIV themselves. The issue of AIDS as is the case with other illnesses, is very much developmental one. There is an urgent need to develop an integrated understanding of medical and developmental issues. The need to forge multi sectoral and integrated initiatives for AIDS is of much importance as for other illnesses. The virtual non-existence of the General Health Services has crucial implications for care. The infections that affect the AIDS patients and require care and treatment for prolonging a productive life are illnesses that affect all. Adequate access to an effective GHS with a working referral system would
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ensure sufficient and affordable treatment to mitigate suffering. The intangible inputs of responsiveness, empathy, technical effectiveness of care and confidentiality especially in the case of AIDS, are critical elements that need to be fed into the training of medical personnel. For many years, the assistance provided to people living with HIV in poor countries has largely consisted of homebased palliative care and helping people to prepare for death, and some support organizations still regard this as the only help they can give. There is therefore a real need to change attitudes to let people know that, with sufficient effort, treatment can be provided to save lives even in the least developed places on earth. Despite all the challenges inherent in HIV vaccine development and delivery, a preventive vaccine for AIDS remains the best hope to end the global epidemic. Researchers, public health leaders, governments, private organizations and companies, and affected communities must work together closely to accelerate research and delivery of HIV vaccines that can stem the tide of new infections throughout the world.
References
Aggleton, P. Davies, P. & Hart, G. (1992): AIDS: Rights, Risk, and Reason. London: Falmer Press. Dane, B.O. & Levine, C. (1994): AIDS and the New Orphans: Coping with Death. Connecticut: Auburn House. Douglas, A. & Philpot, T. (1998): Caring and Coping: A Guide to Social Services. London: Routledge. Greene, K., Derlega, V.J., Yep, G.A. & Petronio, S. (2003): Privacy and Disclosure of HIV in Interpersonal
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Relationships: A Sourcebook for Researchers and Practitioners. New Jersey: Lawrence Erlbaum Associates. Masi, D.A. (1990): AIDS Issues in the Workplace: A Response Model for Human Resource Management. New York: Quorum Books. OBrien, M.E. (1992): Living with HIV: Experiment in Courage. New York: Auburn House. Reamer. F.G. (1991): AIDS & Ethics. New York: Columbia University Press.

*Gracious Thomas
Introduction
There are several ways in which one can get infection with HIV. Understanding the routes of HIV transmission, will help us to avoid the spread of HIV. In other words, understanding how HIV passes from one person to another will enable us to protect ourselves. It will also help us to plan and implement programmes for the prevention and control of HIV/AIDS. Persons infected with the HIV can pass on the virus to those who are not infected. Most transmission occurs from patients who are without any symptoms of AIDS. Therefore, it is essential that everyone becomes aware about the transmission of HIV/AIDS. It is also important to know who can get infected, and how one can get infected. HIV is usually present in all body fluids, tissues and organs. HIV has been found in almost all body fluids such as blood, genital secretions (semen, cervical and vaginal), saliva, tears and breast-milk. The HIV/AIDS virus can pass on to an individual only through three routes. These are: () i sexual exposure
(i contact with HIV contaminated blood and blood i) products, and;

* Prof. Gracious Thomas, IGNOU, New Delhi
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(i) mother-to-child during pregnancy, childbirth, as ii well as through breastfeeding
HIV Transmission through Sexual Activities

Sexual activity, whether homosexual or heterosexual, is the major route of transmission of the HIV throughout the world. The virus can be transmitted by any penetrative sexual act in which HIV-infected semen, vaginal or cervical secretions or blood is introduced into the body through a breakage in the mucosa. Penetrative Penile-Vaginal Intercourse Penetrative Penile-Vaginal Intercourse (or sexual intercourse) is the most common form of sexual activity. Transmission of HIV from men to women and from women to men is well documented. However, transmission rate through heterosexual contact is reported to be higher among females. The transmission from men to women is fairly well understood. Semen from an infected man contains HIV that is most likely associated with infected lymphocytes. HIV introduced into the vagina must make its way into the lymphatic to initiate viral reproduction. Small breaks in the linings of vagina are presumed to be portals of entry to the lymphatic. Women are more susceptible to infection than men after a single exposure to HIV. This difference may be because the vaginal mucosa has a larger surface area and the vagina acts as a vessel for the seminal secretions. The seminal fluid has a greater contact time with the vaginal mucosa. Moreover, small cuts or breakage in the vaginal mucosa can go unnoticed. Other factors that increase the transmission during sexual intercourse are the presence of ulcers on the male and female genitalia. Women who have infections in their pelvic organs are more prone to develop
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infections. Chemical irritation of the vaginal mucosa that occurs due to use of barrier contraceptives may increase the chance of the women getting infected. Although male to female transmission clearly occurs, the means of transmission of HIV from women to men is less clearly understood. Penile-Anal Activity Penile-Anal Activity (or anal sex) implies penetration of penis into the anus. Such sexual activity found to be most common among men having sex with men (MSMs) appears to be the primary means by which HIV is transmitted. This is sometimes referred as rectal activity and in turn often leads to tears or breakage in the lining of rectum. The rectal mucosa being delicate, any breakage in the rectal lining makes it easier for HIV to enter into the lymphatic system. Laboratory studies suggest that cells that line the rectum may also become directly infected with the virus. Surveys of the homosexual populations indicate that a partner who inserts his penis into the anus of another partner (active partner) seems to have a lower chance of becoming infected, when compared to the partner into whose anus the penis is inserted (passive partner). When such acts are undertaken without any physical barriers, it must be considered as high risk for transmission of the virus. Usually penile-anal activity is not recommended even between a mutual faithful husband and wife on health grounds. It is against dignity for the man to force his wife to agree for penile-anal sex against her will. Every human act whether in public or private has its implications on the behaviour and character of the individual. One must have regard and respect for every human being including a sex worker.
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Oro-genital contact Oro-genital contact implies contact between the mouth and genitals. The role of oral-genital sex as a route of transmission of HIV is poorly studied in populations other than homosexuals. It is because individuals who engage in oral genital sex rarely do so to the exclusion of other forms of sexual contact. It is difficult to attribute transmission of HIV to oral sex and not to other types of sexual exposures. The possibility of transmitting HIV from the vagina to the mouth seems possible, although it is not documented. Similarly, the feasibility of transmitting of HIV from the mouth to the genitals is unclear. One may however speculate about possible routes of transmission in any type of oral-genital contact. HIV bearing lymphocytes present in semen could contact damaged mucosa in the mouth and allow the entry of HIV into tissue. Likewise, traces of menstrual blood or vaginal discharge containing HIV could serve as medium for transmission of infection from the genitals to the mouth. Although HIV is present in the saliva, usually it does not infect, as the dose of virus (viral load) is so low, much below the threshold necessary to transmit the infection. Moreover, saliva also contains an enzyme that inhibits the virus. Hence, it does not easily transmit the infection. Oral sex is very rare amongst most people in the Indian sub-continent for various reasons. Some of the facts include: i ) Over 70 per cent people live in rural areas in small houses along with several family members (children, joint family, etc.), where privacy for intimate sexual activities is limited.
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i) i
Almost half the populations in most urban areas live in slums which comprise a small room without any privacy and safety.
ii Most men and women from the above mentioned i) categories return home tired and wanting rest after a days work. They eagerly wait for darkness to set in so that their sexual urges can be satisfied in fleeting moments. i ) Most people in India are not exposed or oriented to v various forms of sexual activities described above owing to their conservative background - familial, cultural, religious, educational, traditional and social. v ) Husbands and wives hardly ever talk to each other on sex and sexuality.
It may be noted that very few studies have been conducted on the sexual behaviour of people in India. Therefore, most of the concerns discussed in this unit may not be relevant for most people. However, adequate information on various aspects with regard to sexual activities which are risky in nature need to be made known so that the last person in the country is enabled to take the necessary precaution to avoid transmission of STDs and HIV/AIDS. Prevention of Sexual Transmission Commercial sex workers (CSWs) and the female population in general, should not be seen as a commodity available for sexual pleasure. Our tradition, our culture, our social norms, our religious beliefs, our philosophy and our valve system dissuades misuse or abuse of human beings. The Indian tradition believes that every human being is created with a definite purpose and order. Various religious traditions celebrate each birthe as an affirmation of Gods indulgence with man. Another
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response is the belief that espouses that without a woman, a man is incomplete; similarly, without a man, a woman is incomplete. The religious scriptures clearly state from the beginning of creation, God made them male and female. For this reason, a man shall leave his father and mother and be joined to his wife, and the two shall become one flesh. So they are no longer two, but one flesh. Therefore what God has joined together, let no one separate. This reminds us that if we remain faithful to our spouse and avoid sex outside marriage, transmission of HIV through heterosexual activities can be prevented. Alternative Sexual Activities It is a fact that some people are also involved in same sex relationships. It is observed that the sexual activities carried out by people involving the same sex are highrisk activities. Apart from oral and anal sex, people are also involved in sex with animals (known as bestiality). These are all unhygienic activities and also downgrade the dignity of human beings. It is certainly not healthy for a society to promote such activities. It is true that there are vices in every society. For example kleptomania is an undesirable activity and is regarded as a crime before society. At the same time, we are also awared that it is a psychological sickness. Therefore, instead of condemnation, we need to approach the problem with a different understanding. Similarly, due to one reason or the other, a person may be motivated or attracted towards the same sex. The family background and social environment in which one has been nurtured can certainly influence a person to develop such inclinations. Such persons need understanding and assistance from every quarter family, friends, society, religion as well as emotional and psychological support. Instead, it can be disastrous
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to encourage a person to develop and maintain unhealthy practices, which have already become threats to our society. HIV and Eunuchs Our society is known for sheltering and promoting the third sex-the eunuchs. Very little research has been conducted on this large population consisting of over a million eunuchs. However, available information indicates that very few, not even one per cent of the eunuchs are born eunuchs in the country. People do come into the world as blind, deaf, dumb, mentally retarded etc. Quite similarly, a very small percentage is also born without proper organs. Somehow, for reasons beyond comprehension, our culture permitted the eunuchs to organise their own communities. This has prompted them to propagate their population. Since born eunuchs are very limited, the best approach is to catch and castrate young boys and young men. Thousands of such castrations take place every year in India. Since many of these castrations are done outside medical environment, many of the castrated males die of infection. A conservative estimate shows that about 75 percent of the castrated persons die of infection. The eunuchs are held in high regard by some sections of our society. It is a known fact that eunuchs provide sexual satisfaction to those who have normal sex organs. There are reported to indicate that eunuchs provide anal and oral sex to their customers. This is therefore is a matter of great concern in India, considering the possibility of HIV transmission through such activities of these eunuchs.
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Sperm Donation and HIV Sperm donation and artificial insemination are practices that are product of modern science and technology. With the advent of HIV, one needs to be extremely careful while seeking medical intervention for such practices. Pre-marital Sex Sexual activities among adolescents, street children, drug addicts have no formal sanction of our Indian society. Our society generally permits sex only within marriage. Studies in India indicate that approximately 16 to 20 per cent of the adolescents engage in pre-marital sexual activities. This is indicative of the extent of risk behaviour prevailing among the adolescents. Another concern is the fact that this includes a sizeable population of children living on the streets, away from the social control exercisable by way of the family. Prisoners and HIV Prisoners too have a high prevalence of HIV infection and AIDS. HIV infection rates among this group are difficult to determine accurately due to various reasons. Intravenous drug use and homosexuality are the predominant risk behaviours commonly found in prisons. The Indian Penal Code prohibits sodomy. The very same logic, is worry fully, used as a shield to even restrain the distribution of condom among prisoners. A country like Israel permits the spouse of the prisoners to visit him/her once a week so that they are able to continue the monogamous relationship and avoid same sex relationship. But in India we are yet to evolve a suitable strategy. Much less is our inclination to create awareness among policy makers, keeping in mind our socio-cultural religious values.
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Behaviour Modification The safest and surest way to avoid HIV is to mend ones behaviour in terms of sexual activities. It is extremely unfortunate that whatever information disseminated in our country apparently advocates only one message use condoms to have sexual intercourse. Where are our traditional, cultural, social and religious values which always gave us one and only one message: No sex before marriage; have sex after marriage, that too, only with ones own spouse. If we are faithful to ourselves, then we dont need a condom to protect ourselves against HIV / AIDS / STDs. If we remain faithful to our spouse there is no question of getting infected with HIV. The old saying . History repeats itself seems to be proving true in this regard. It is man who thought and developed social and behavioural norms in the society in terms of family life, marriage, and sexual restriction. The advancement of science and technology and propagation of the freedom theory have overpowered the societal norms giving way to vulgarity. Man has once again been shown his place and reminded of his fragility and limitations, by the AIDS pandemic. Studies across the globe show that over 75 percent of HIV transmission takes place through sexual activities. Quite certainly, such sexual relations most often occur outside marriage. Therefore, it is high time that everyone involved or intending to involve in sex outside marriage, need to modify his / her behaviour to avoid getting infected with HIV. Whatever be the occasion, one should avoid sex outside marriage, if one wants to avoid risking ones own life. A women is somebodys mother, sister, daughter or wife. Similarly, a man is somebodys father, husband, brother or son. Let this thought remind people every time they want to be involved in sex with a person outside marriage.
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Condom Use The present policy to promote condom use patiently among school children, is undertaken with such tenacity as if it is the only method to prevent HIV/AIDS. This being an idea borrowed from foreign countries where sexual freedom is an accepted norm has been met with stiff resistance. It has proved wrong in the Indian context, as it is a society which has not accepted the theory of freedom of sex, nor even sex outside marriage. As a result, all efforts to bring about awareness and proposals for AIDS and sex education have met with strong opposition. In fact most parents and teachers disagree with the very idea. One of the possible reasons is that the policy makers almost ignored the feelings of the people. Studies across the world indicate that the condom, if used correctly, offers a substantial degree of protection against acquiring HIV infection. HIV transmission, despite condom use is rarely attributable to a failure of the condom itself and is more often attributable to their incorrect use. Three principal type of condom failure occurs: breakage, leakage and improper use. Each of these types of failures can be minimized by the following techniques:
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using a new condom for each act of intercourse. using latex condoms. using only fresh condoms. using a lubricant or pre-lubricated condoms. using condoms having a tip, bubble or nipple at the end to collect semen. condom not be unrolled until placed on the head of the penis, as instructed on the product. avoiding usage of condoms that are gritty or gummy, a clear indication of deterioration.

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condom to be held at the base of the penis immediately after ejaculation, in order to prevent the condom from slipping while withdrawing the penis.
For those involved in prostitution, same sex relationship, and those who want to risk their lives by indulging in sex outside marriage, condoms may be useful to some extent, as recommended by experts on the subject. HIV Prevention The best ways to prevent the spread of HIV:
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practicing abstinence before marriage. Be(ing) Faithful; limiting sex only to one partner. educating oneself and one own family members about HIV/AIDS, how it is spread, and how to avoid i. t avoiding in sexual activities with homosexuals, strangers, commercial sex workers, etc. educating oneself about moral values and the teachings of ones own religion. seeking guidance from parents, teachers and elders in your family. abstaining from sex with anyone outside the marriage even for once as it can infect one with HIV. not navely believing that the condom offers anyone full protection against HIV/AIDS. In fact it has not shown 100 per cent safety against birth control. Moreover, India offers poor quality condoms which are very unreliable. One needs to respect the opposite sex. Nobody stops you from mingling with the opposite sex or making friends.
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realising the worth of waiting till marriage to have sex. entertain an alternate thought that if one wishes to have an uninfected virgin as ones spouse, the same may be the desire by the would be spouse. Therefore it you want some one to wait for you, you should also wait for some one to share all you have. believing that life can be thrilling, meaningful and joyful, if you could take care of oneself for some more time.
HIV Transmission through Blood and Blood Products

In this sub-section we shall study transmission of HIV through blood and blood products. The magnitude of transmission through blood is much less when compared to transmission through sex. The important aspect about transmission through blood is that this can be completely reduced if certain precautions are followed. All these issues will be discussed in the present unit. HIV reproduces itself in the CD4 lymphocytes, which circulate in the blood and other body fluids. Blood collected for transfusion contains such lymphocytes. HIV is not only present with these cells, but in the serum (blood component unassociated with cells). Thus, introduction of blood from infected person to uninfected person will transfer the virus that is present both in the cells as well as the serum. Of all the forms of exposure to HIV, blood transfusion is the most effective means of transmitting the virus from person to person. No barrier of any kind exists between the infected person and the individual who receives contaminated blood directly into the blood stream.
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Instruments such as scalpels or suture needles, if contaminated with infected blood can transmit the infection. Similarly, needles having blood stains on them, can transmit the infection. Sometimes injuries that occur with broken glass vials containing infected blood or serum can also transmit the infection. The risk of infection through small cuts and abrasions that occur with contact sports e.g. wrestling, football etc. is very low. Transmission of Hiv Through Blood Products Blood that is collected from a donor can be separated into different components using a cell separator. Thus, blood will be separated into red blood cells (RBC), platelet concentrates, and plasma. These components can be used as and when required. Apart from these conventional uses, substances present in the blood i.e. antibodies are removed to produce immunoglobulin. These immunoglobulins are used in treatment of many medical conditions. HIV can be transmitted through these products also. Treating these products with caution can prevent transmission. HIV transmission through intravenous drug use (IVDU) Intravenous drug use acts as a source of transmission of HIV, because drug users frequently share syringes and needles to inject drugs. These instruments are not sterilised before use. Very small volumes of contaminated blood remains inside previously used needles and syringes, thereby providing opportunities to transmit the virus, via their blood contents. During the early years of the epidemic, studies found links between HIV drug users and male homosexuals who were already infected with HIV. The overlap of these
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two groups facilitated the introduction of HIV, into the drug using population, and then onto the sex partners of these drug users. Transmission through organ transplantation HIV can be transmitted through infected organs. HIV is found in the blood as well as the tissue of an infected organ. Before any organ is transplanted the donor has to be screened for HIV. In cadaver (removal of organs from brain of dead patients) transplantation, the donor has to be checked. This route of transmission is very rare in practice. Since an infected persons body fluids contain HIV it is essential to screening for HIV is carried in cases of organ transplantation of any kind such as kidney, bone marrow, eyes, skin, semen etc.
Prevention of Transmission through Blood and Blood Products

Needles and Surgical Instruments Transmission of HIV from one person to another is possible through the use of un-sterilized needles, syringes and other skin- piercing instruments such as surgical equipment. In procedures involving surgical instruments, the instrument should be properly sterilized. Wherever possible, disposable instruments such as disposable syringes and needles should be used. The disposable instruments should be properly discarded after use. For the very same reason, one needs to be careful in getting an injection from a hospital or health clinic. It is advisable to carry a fresh disposable needle as on of the best and safest means to avoid infection. Or you must ask the nurse or doctor, whether the needle being used is fresh and sterile one, before they use it to inject you. Similarly, one needs to ensure that a dentist
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takes adequate precaution when providing dental care and treatment to his/ her clients. While visiting a barber for a shave, one should carry a fresh blade, or insist with the barber to use a fresh blade. While getting your own or your relatives ears or nose pierced, one needs to ensure that a fresh and sterilized instrument is used. The same is applicable to tattooing as well. HIV through blood transfusions HIV/ AIDS is passed on to a person through blood transfusion with contaminated blood. A person can also contract HIV through tissue and organ transplant. Anaemic persons may need blood transfusions. All these provide ample routes for HIV to cross over to uninfected persons. Hence, it is important to ensure that every unit of blood is screened for HIV before transfused. Hemophiliacs and HIV In 1989, the Medical and Scientific Advisory Council of the National Hemophilia Foundation (USA) released revised guidelines for therapy of hemophilic patients, in order to reduce the transmission of HIV. The major recommendations were:
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Factor VIII products were to be heated for 10 hours at 60 degree C, or are detergent-solvent treated, or are monoclonal antibody purified, or are heated in suspension in organic media, or, are dry heated at high temperatures. Viral attenuated Factor IX concentrates to be treated with the methods described above for patient with Factor IX deficiency. Fresh frozen plasma, a blood product containing clotting proteins, need to be used in Factor IX deficiency, with mild to moderate factor deficiency.
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Decompression (DDAVP), a synthetic hormone that improves clotting should be used when possible, with mild to moderate Hemophilia Type-A. persons with Von Willebrands Disease (different from of Factor VIII clotting disorder), should be treated with DDAVP or Cryoprecipitate from carefully tested donors. Patient with severe disease should receive processed Factor VIII. Bleeding episodes should continue to be treated with appropriate clotting factor.
Therefore, one needs to double-check the HIV status of the person donating, before blood, tissue and any organ is transfused or transplanted. Blood supplied from any blood bank including that of the Red Cross Society should be tested for HIV. It is advisable not to accept blood from a professional blood donor. Professional blood donors in India are found to be infected with HIV. Sperm Donation and HIV Sperm donation and artificial insemination, which are activities not permitted by most religions. In India, hardly any community is known to approve of this practice. Such extremely high-risk activities can infect the recipient with HIV. There are also much wider implications for the child born through such artificial procedures. Therefore, it is always better to avoid such acts for healthy and peaceful living. Injecting Drug Users HIV/AIDS virus can be passed on to an uninfected person from injecting drug abusers. Needle sharing is a common practice among drug addicts. We already have thousands of HIV victims especially in the North- eastern states who, have been infected through sharing needles. Drug addicts also suffer a double jeopardy, as they indulge in
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a lot of sexual activities. Through these sexual activities, these addicts can easily pass on the virus to their partners either spouse or another person. It may also culminate in the birth of an HIV infected baby. All these are undesirable activities, not approved by our families, religion and society. Therefore, let us try to avoid such unhealthy practices for the well being of the entire humanity. For those, who cannot manage, use of anyway.
Hiv Transmision from Mother to Child

Women, because of their social, gender and sexual subordination are disproportionately affected by the epidemic. The inabilities of women to control the factors posing a risk, place them at risk of HIV infection. Thus, their problems are further, and are compounded by the fact that many societies define the social and cultural identity of women primarily through their role as childbearers. Hence, whenever, we attempt a discussion on mother-to-child-transmission, we need to look at the problem in a broader perspective, not just in a compartmentalised manner. Broader perspective includes role of husband, societal pressure, norms, and values and above all her own rights over the sexual act, as well as the right over her body. Another serious consideration, is the family pressures that moderate her rights. Extent of Infection among Children One in ten of all HIV infected in India is reported to be a child, and the vast majority of them acquired the virus form their infected mothers. Africa has the highest prevalence of HIV-positive children. Though Africa accounts for only 10 per cent of the worlds population, 90 per cent of the worlds HIV infected children are
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found in Africa. This is largely a consequence of high fertility rates combines with very high levels of HIV infection among women of reproductive age group. However, the number of cases in India and Southeast Asia appears to be rising rapidly. Consequence of High Level of Infection The effects of the epidemic among young children are serious and far-reaching. AIDS threatens to reverse years of steady progress in child survival achieved through such universal measures as the promotion of breast feeding, immunization, and oral dehydration (ORS). UNAIDS believes that by the year 2010, AIDS may have increased mortality of children under 5 years of age by more than 100 per cent in regions most affected by the virus. In a number of countries, AIDS is now the biggest single cause of child death. With 27 million pregnancies a year and an overall estimated 0.3% prevalence rate of HIV infection among pregnant women, it is estimated that about 1, 00,000 HIV infected women deliver every year. Projecting based on a conservative vertical transmission rate of 30%, about 30,000 infants acquire HIV infection annually. The life span of a child infected by HIV infection is lower than that found in adults. Thus, HIV infection may increase health care expenditure both-public and at family level. Increasing number of children infected by HIV has a propensity to alter the mortality rates in childhood. The effects of the epidemic among young children are serious and far reaching. Although currently, India has overall, a low prevalence of HIV among pregnant women, with the progression of the epidemic in general population, it is bound to rise in women in reproductive age group and thereby increasing chances of mother-to-child transmission
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(MTCT) of HIV infection. Therefore, the challenge for future is how to keep the prevalence of HIV infection among women low and reduce mother to child transmission. Various Stages of Mother-to-Child Transmission (MTCT) HIV can be transmitted from the mother to child in three ways. It can occur in the womb, at the time of delivery, and also, when the child is breast-fed. Womb Throughout the period of pregnancy, the mother is capable of infecting the foetus. The foetus receives nutrition from the mother through the placenta (before birth). When the mother has a high viral concentration in the blood, some of the virus can pass from the mother to the foetus, through the placenta. The probability is high throughout the period of pregnancy, and a small number of foetuses get infected through this route. At the Time of Birth The lining of the birth canal (vagina) contains a high concentration of HIV. The baby may sustain minor cuts to its skin, which may come into contact with the mucous membrane during the process of birth. Hence, the baby can get infected. It has been also shown that the maximum chance of infection of the foetus occurs during the time of delivery. About 30 to 40 per cent of children born to HIV infected mothers, become infected at the time of delivery. Breast Milk About 14 per cent of the children, who are breast-fed by the HIV infected mothers, contract the infection. Hence,
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change in breast-feeding practices, substantially reduce HIV transmission. Issues Related To Mother to Child Transmission There are various issues related to mother-to-child transmission, which still remain debatable. Some of the debatable issues are posed as questions given below: 1) Should HIV- positive women be encouraged to have children or not?
It is every womens fundamental right to decide for herself, without coercion, whether she should have children or not. This is enshrined in the International Human Rights Conventions. It is the responsibility of the Government and health services to provide HIVpositive women and their partners, comprehensive information and education about the risks associated with childbearing, as part of routine pubic information about HIV/AIDS. The health services should ensure that they have real choices of action and respect and support the decisions that they reach. NACO in its Policy 5.8.3 states that HIV positive women should have complete choice in making decisions regarding pregnancy and child birth. There should be no forcible abortion or even sterlisations on the grounds of HIV status of the women. Proper counselling should be given to the pregnant women for enabling them to take an appropriate decision either to take the baby to full-term or to terminate the pregnancy. Best practice as recommended by UNICEF, and supported by NACO, will need to be disseminated. Clear advice and support of feeding options should be given to HIV positive women. This will need appropriate training of the counsellors and health care workers. Training will include breast feeding counselling, complementary
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feeding, infant feeding in MTCT, and replacement feeding options. Messages need to be consistent with the related programme of Reproductive and Child Health (RCH) of the department of Family Welfare. The aim of such counselling should not be just giving of information, but to empower the mother to assess the appropriateness of the alternatives to her specific situation. Every effort should be made to promote exclusive breastfeeding up to four months in HIV positive mothers followed by weaning and eventually complete stoppage of breast feeding at 6 months, in order to restrict transmission through breastfeeding. However, such mothers will be informed about risk of transmission of HIV through breast milk. 2) Whether HIV- positive mother must be instructed to breastfeed her baby?
Breast feeding has been the corner stone of child health and survival strategies for the past two decades that has played a pivotal role in reducing infant mortality rate in many countries. Even in the era of AIDS, breastfeeding remains the best possible nutrition for the greatest majority of babies. As against this there is another view. You may recall that the transmission of HIV through breast milk is about 14 percent. If the mother has received prophylaxis to prevent mother to child transmission (MTCT), then it is illogical to recommend breastfeeding. There are many reasons why such advice may not necessarily be appropriate and might indeed be dangerous. The cost of infant formula supplements is often beyond the means of poor families in developing countries, even when it is widely available. Besides, many people lack easy access to the knowledge, safe and clean water, as well as the fuel necessary to prepare replacement feeds safely, or still further, simply have
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no time to prepare them. If it is mixed with dirty, unsafe water, a breast milk substitute may lead to infection, malnutrition, and eventually death. Breastfeeding suppresses ovulation and delays a womans return to fertility. A mother who dose not breastfeed her baby, loses the natural contraceptive effect and has the increased risk of getting pregnant again, too soon. In August 1997, WHO, UNICEF and UNAIDS issued a joint policy statement on HIV and infant feeding. They subsequently prepared guidelines to help national authorities, to implement the policy. These documents emphasize that it is the individual mothers right to decide how she will feed her child. Any attempt to influence her decision, no matter what the circumstances or motives, is an abuse of her human rights and freedom of choice. The responsibility of people who counsel HIV- positive women about infant feeding is to give them all the available information on the risks associated with breast feeding. They should be educated about substitutes to breast feeding. They also have to discuss the feasibility, pros and cons of alternative feeding methods, in the context of their personal circumstances. They also have to give them appropriate support for the course of action they choose. 3) Should every person undergo HIV Counselling and Testing?
Whether every person in the reproductive age should undergo confidential HIV counselling and testing, or not, is an ethical consideration. This is very much essential, as it becomes a global concern in terms of its magnitude and severity. It is very much needed for pregnant and married women, as well as their male counterparts.
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For pregnant, women to take advantage of measures to protect their off spring from HIV infection they need to know whether or not they are infected. Hence, voluntary counselling and testing services are an essential part of any programme for the prevention of mother-to-child transmission of HIV. Ideally, however, every one should have access to such services since there are clear advantages to know ones sero- status. People who know they are HIV infected, are likely to be motivated to look after their health, perhaps with behaviour modification and life-style changes, and to seek early medical attention. They can take wise decisions regarding sexual practices, child bearing, infant feeding as well as steps to protect partners, who may still be infected. And those whose test results are negative can be counselled about how to protect themselves, their partners and their children from infection. Furthermore, voluntary counselling and testing has an important role to play in unmasking the silent epidemic and reducing the hysteria of and fear surrounding AIDS. At present UNAIDS estimates that around 90 percent of people with HIV are unaware of their status. Efficient, widely accessible and user friendly testing services can help societies recognize and come to terms with the fact that there are many people living with HIV, who show no outward signs. This in turn encourages commitment to prevention. It is still common for women to be blamed for spreading sexually transmitted diseases, including HIV, despite the fact that very often they are infected by the husband or partner to whom they are entirely faithful. Voluntary counselling and testing, involving the partners of the pregnant women, where this is feasible and desired, can play a vital part in challenging this pervasive prejudice.
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4) Whether HIV-positive men and women can marry among themselves or not is another debatable question? As far as right of a human being is concerned, HIVpositive men and women may marry among themselves.
Universal Standard Precautions for Hiv Prevention

Until now we have studied the three direct methods through which there is a high possibility of getting infected by the virus. Universal precaution consist of a set of guidelines created to prevent the spread of diseases transmitted through body fluids, for the protection of caregivers and anyone with such diseases. These precautions were created primarily for medical professionals working in a hospital setting whenever they are likely to come into contact with blood or other body fluids. The Centers for Disease Control (CDC), Atlanta, USA, introduced universal precautions to emphasize that precaution must be taken when exposed to any blood or body fluids Because any patient could be infected, all blood must be treated as infected by any person handling or exposed to blood. These precautions also apply to other bodily fluids that are a potential source of HIV including semen, vaginal secretions, and tissue. These universal precautions are now known as standard precautions. The change in the nomenclature has been brought about, because these precautions have to be applied in all situations and have become the accepted standard of care. Universal precautions include the following practices: 1 . Treat every patient as potentially infected. By the time a patient is diagnosed as HIV positive almost 50% of blood investigations may be over.
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Hand washing with soap and water between each patient contact. Hands should always be washed before and after contact with patients. Hands should always be washed even when gloves are worn. If you accidentally touch blood or other bodily fluids, thoroughly wash hands. Use of disposable gloves if body fluids are contacted and double gloves during surgical procedures. Those with open skin lesions should not perform any procedures, if they are exposed to body fluids. Wearing of gowns when clothes may be exposed to body fluids. Wearing of masks and eye wear when performing procedures that may splash the worker with body fluids. Sharp instruments should be disposed off in puncture-resistant containers, immediately after use. Needles should be disposed of immediately after use without recapping. Disposal containers should be placed in all areas where sharp objects are used.
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4 . 5 .
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HIV Prevention and Health Care System No health care worker has been reported to have been infected with HIV infection through casual contact while taking care of infected patient. Till 2000 there have been 57 documented cases of HIV transmission to the health care workers from percutaneous exposure. The registry was stopped in 2000 because the infection rate was low. There have been no cases where a HIV infected health care worker has infected a patient. In 1990 a dentist in Denver, transmitted HIV infection to six of his patients. The method used by the dentist is not known. Although the risks form HIV infected health care patients are
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very low, the CDC issued recommendations in 1991, to reduce the risks even further. Its recommendations include: 1 . 2 . Health care workers who perform invasive procedures should know their HIV status. HIV-infected health care workers should: i ) Avoid performing invasive procedures that involve significant exposure to body fluids and that pose a clear risk of HIV transmission. These procedures include those that present a risk of a puncture wound to a health care worker and contact of the health care workers blood with the patients body cavity, tissues beneath the skin or mucous membranes. Seek opinion from an expert panel on which an invasive procedure will be conducted of his or her infection.
i) i
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HIV infected health care workers approved for conducting invasive medical procedures should inform the patient on whom an invasive procedure will be conducted of his/ her infection. Mandatory testing of health care workers is not warranted because of the low risk of transmission and the expense of conducting a screening programme. A pregnant health care worker limiting her interaction with HIV infected persons to casual contact, runs no increased risk of HIV infection for either herself or her child. Patient with AIDS are infected with other micro organisms such as cytomegalovirus that are more readily transmissible than HIV. The possible transmission of these other agents prompts recommendations by some that pregnant health care workers to limit their
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exposures to AIDS patients and avoid direct involvement in their care. Prevention of Infection after an Accident in Hospital If a health care worker gets accidentally injured, he/ she can be protected against the dangers of acquiring the infection. Most of the injuries that occur are due to needle pricks; these can be prevented if they are careful and follow the procedures diligently. If they get a needle prick, bleeding from the wound should be encouraged. The wound should be washed with water and an antiseptic (not Dettol or Quaternary ammonium compounds). The injury has to be assessed by medical personnel. If it is not known, then patient should be checked for the infection after obtaining his/her consent. If the patient refuses consent the test can be done without the consent of the patient. This is legally permitted as it posses a threat to an uninfected person. Consult your doctor for the drugs. These drugs have to be taken for a period of twenty eight days. If a healthcare worker gets an injury from an infected patient, he should get his blood tested immediately and it should be repeated after an interval of six weeks. If the first test is negative, and the second test is positive, then the injury can be attributed to cause the infection.
Conclusion
In this chapter we discussed with you various means of transmission of HIV that is through sex, blood and blood products and mother to child. Sex is one of the known sources of HIV transmission. We have also discussed the transmission of HIV through blood and blood products. HIV transmission occurs through blood when the blood is transfused, though intravenous drug abuse,
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dialysis and organ transplant. There are various issues involved in the transmission of HIV through blood. One of the important issues that are discussed is mother to child transmission. There are almost 14 million women of childbearing age throughout the world, who are HIV positive. There are various issues related to mother to child transmission which are still debatable.
References
Almond, Brenda (1996 Ed.), AIDS: Moral Issue. The Ethical, Legal and Social Aspects. Macmillan Press Ltd, London Overall, Christine and Zion, William P. (1991 Eds.), Perspectives on Aids: Ethical and Social Issues. Oxford University Press, Ontario. Illingworth, Patricia. (1990). AIDS and The Good Society, Routledge, London. Thomas,Gracious. (2001). HIV Education and Prevention: Looking Beyond the Present. Shipra Publications, New Delhi.
HIV/AIDs Among Women and Children

*Gracious Thomas
Introduction
There are certain groups, which are vulnerable to HIV/ AIDS. Women are one such group. AIDS was first detected in the U.S.A, in 1981, among male homosexuals. Initially there were more men being infected with AIDS virus than women, the ratio being 10:1; but over the years, the number of women infected with HIV, are increasing. In 2003, 50% of all HIV infections occurred among women. The burden of HIV disease among women in the developing world has been acquired heterosexually (i.e. from man to woman). This is due to the following facts: 1 . 2 . 3 . 4 . HIV infection is transmitted more effectively, sexually, from men to women lack of education and illiteracy among women cultural beliefs regarding the role of women in the family and society; and lack of economic power in the women
All the above factors influence the relative vulnerability of women, and decrease their access to means of prevention and support in the face of HIV/AIDS. Women who are infected with HIV infection can also transmit the HIV infection to others. For health care
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workers dealing with the care of HIV positive women, it is important to understand the psycho-social and cultural issues, as they hold important implications for women, especially when it comes to related issues such as childbearing and breastfeeding.
Socio-cultural Factors
The link between powerlessness and the risk of exposure to HIV provides the key to understanding the source of womens vulnerability to HIV infections. The HIV epidemic has taken advantage of the social, economic and cultural subordination of women, and has translated it into a death sentence. The following are some of the factors that make an Indian woman not only more prone to HIV infection, but also less likely to seek medical attention. Early Sexual Intercourse Culturally, initiation to sexual intercourse begins several years earlier for females than for males. Many women are still in their mid-teens when they marry. Often women get married to much older men, who are more sexually experienced. Therefore, there are more chances for women to get HIV infected, from a husband, who might be indulging in sexual activities outside marriage. Source of Infection In the developing countries nearly all HIV infection reported among women have been acquired heterosexually. Majority of the Indian women have been infected not through their own behaviour but through that of their husbands. An Indian womans greatest risk of HIV infection might be her husband.
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Lack of Choice In a marriage, women lack control over their lives, forget alone over their husbands life outside the marriage. Extra-marital relationships, intravenous drug abuse, and bisexual behaviour on the part of the husband are possible routes for entry of the virus into the marital union. For these women, sexual intercourse is not a question of choice, but rather a question of survival. The wife has hardly any say in when to have sexual intercourse, or how to protect herself from HIV infection, if the husband is infected. She also does not enjoy the freedom to choose whether to become a mother, or to protect the life of an unborn child from forced abortion. Poor Access to Health, Education and care Women are looked upon as child bearers and child rearers. In the sociological division of labours, they have much greater obligations and responsibilities towards their children and home. There is limited access to education, mobility and information. There is lack of financial resources to pay for the use of health care facilities. Blame It is an unfortunate reality that when the first case of HIV/AIDS is identified within a family, the blame is most often attributed to the woman, even if the evidence contradicts this. There is fear that her family, because of her perceived past behaviour, will abandon her. She is forced to keep quiet and she is not in a position to argue her case. The stigma and discrimination associated with this disease, thus, often rests with woman.
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Isolation and Stigma HIV positive women feel extremely lonely and isolated. Fear of social stigma compels them to keep the condition secret. They are afraid of being abandoned by family, friends and the community. Delay in Diagnosis Indian women are often unaware of their HIV positive status, or, they may be the last in their family to know their diagnosis, due to the power hierarchy in the family structure. Some women discover that they are HIV positive by accident, usually after the husband or the child is found to be symptomatic with an HIV related disease. The women will then be dealing with two crises, that of illness of her husband or child, or both as well as her own illness. Emotional Response All of a sudden,, the woman has to deal emotionally with her husbands unfaithfulness. She may feel anger towards the husband, grief at the loss of health and status, and guilt relating to how she may have been the cause of illness in her own family, particularly her children. She may also be filled with worry. Dependency In India, most women are dependent on their husbands, or his family for food, clothing, shelter and money. It is usually the male partner, who usually controls the financial matters at home. As a result of this, abstinence, faithfulness on mans part, which has now become the mainstay of protection against HIV disease, is totally the mans prerogative.
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Burden and Bereavement From the time of her birth, the Indian psyche considers the female child, a burden, initially to her family, and later on, to her husbands family. The main aim of her biological family is to marry her off, as quickly as possible in order to ease this burden. She is usually given minimum education and care before marriage. After marriage, in case of the husbands death his property, provident fund (if any), remains with the husbands family and in many cases, the wife goes back to her own family, where she continues to be a financial and emotional burden. Many such women are also forced into prostitution for a living. In fact, most women living on prostitution have a painful past, such as the desertion by a husband, being a rape victim, forced migration to cities in search of job, forced flesh trade through kidnapping, or sale, etc. Pregnancy Women are considered to be the potential bearer of sons. It is a persistent Indian belief that the sons are the ones, who will grow up, and earn and look after the old parents while daughters are a burden, who will have to be given away in the marriage. Even if a woman is HIV positive, she may be under pressure to produce a son, at risk to her own life and future, as well as that of her unborn child.
HIV/AIDS In Women
Reasons for transmission The reasons for transmission of HIV disease to women are many: Intercourse: Worldwide the cause of HIV infection among women is the prevalence of promiscuity involving heterosexual intercourse. This is a primary risk factor.
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Data also suggests that male to female transmission of HIV-I is relatively more efficient than female to male transmission. Sexually transmitted diseases (STDs): Sexually transmitted diseases, particularly those associate with genital ulcers and strongly associated with a increased risk for HIV infection. Non-ulcerative STDs (gonorrhea, Chlamydia, Trichomonias, and bacterial Vaginosis) also have been associated with increased risk of HIV transmission. Drug Abuse: In western countries at the beginning of the AIDS epidemic, drug use was the major factor in women acquiring HIV. Drug use in women is associated with sharing of unsterilised needles used for injecting drugs, and high-risk sex behaviours with increased number of partners. Contraceptives: The inability of the woman to compel her male sexual partner about using barrier contraception such as condoms, etc., places her at risk of acquiring HIV infection and other sexually transmitted diseases. Several studies have not been able to conclusively prove or disprove the role of oral contraception or intra-uterine devices (IUDs such as Loops, Copper-T, etc.) as a risk factor of acquiring HIV infection. Oral contraception may thin the vaginal epithelium, making it easier for HIV transmission. IUCD may injure the mucosa and hastening the transmission of the virus. Host factor: If the infected partner is in the more advanced stage of HIV, the person might have a lower CD4 count, and a higher viral load in the semen; then there is an increased risk of HIV transmission to the uninfected partner. Studies have also revealed that some partners in spite of being repeatedly exposed to highrisk sexual behaviour do not sero-convert, and appear
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to be protected against infection due to immunologic responses, which has a protective effect. Viral Factors: Viral load and viral characteristics play role in the risk of sexual transmission. Higher the viral load in the semen and vaginal secretions, greater risk of transmission. Also certain sub-types of HIV-I virus may be associated with certain types of transmission, but again this has not been conclusively proved. Signs and Symptoms There are no differences in the manifestation of HIV infection among men or women. As in the male, the female also, once she has become infected with the AIDS virus, may not have any signs or symptoms at all. In a significant percentage of people, at the time of seroconversion (when the antibodies are formed) there may be flu like illness with fever, body pains, rash, headache, etc. This may last for few days to weeks, and then disappear. The HIV infected person may then not have any more signs and symptoms. She may continue to do her routine work of cooking and caring for children and submitting to her husbands needs. Her blood test may be done only when her husband or her child becomes sick. Later on, as her CD4 count begins to fall, she becomes prone to other, super-added infections known as opportunistic infections. Opportunistic Infections: Fungal infection of the throat and esophagus (the hollow tube that connects the mouth to the stomach) is a common opportunistic infection in women. Recurrent Bacterial Pneumonia and Pneumocystis Carini lung infections are common in women. Other co-infections commonly seen in HIV infected women include Cytomegalo virus, recurrent Muco-cutaneous, Herpes Simplex infections, Mucocutaneous Candidiasis, Toxoplasmosis, Tuberculosis and Crytococcol infections.
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Gynecological Infections: Infections of the reproductive tract are referred to as gynecological infections. Gynecological diseases in HIV infected and non-HIV infected women are the same. Certain diseases are more common in the HIV infected women. Extensive Herpes Simplex ulcerations resistant to standard treatment, may be seen in HIV infected women. Vaginal infections such as Candidiasis, Trichomomaisis, and Bacterial Vaginosis may be more common. Apart from the usual causes of genital ulcers such as Syphilis and Chancaroid, HIV infection too can cause genital ulcers. Pelvic Inflammatory Diseases (PID) are common and more aggressive in HIV infected women. Immunosuppression has been associated with consequences of Human Papillomma Virus (HPV) infection including cervical cancers. HIV associated cancers and pre-cancerous conditions in women: It is noted that HIV positive women have higher risk of acquiring cancer of the cervix. Due to the loss of cell-mediated immunity in HIV infected women, they tend to develop HPV or Human Papillomma Virus infections, which are associated with pre-cancerous lesions. The common occurrence of HPV infection, often of multiple types, the rapid progression of cervical intraepithelial Neoplasia, the high rate of reoccurrence in spite of therapy, and the multiple lesions, makes this an important area of concern. Treatment In HIV disease, one has to consider two regimes of treatment.
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Specific treatment for HIV disease. Drugs that are given for specific HIV disease are called anti-retroviral drugs and several drugs are available. These drugs may given in double or triple
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or even as four drug combination. These drugs are very expensive and beyond the reach of the common man. They also have many side effects.
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Treatment for opportunistic disease. For opportunistic diseases, there is a specific treatment depending on the disease, such as Tuberculosis, Candidiasis, Toxoplasmosis, Cryptococcus and Cytomegalovirus etc.
Disease progression and overall survival comparison with men Reports during the late 1980s, suggested a less favorable outcome for HIV infected women in comparison to men. However, more recent studies have not confirmed this finding. Majority of research data suggests no difference between women and men, in HIV disease progression or survival. HIV infection does not extinguish womens desire and hopes for sexual bonding, companionship, intimacy and child bearing. In India, a pregnant woman is considered to be the potential bearer of a son. Her social status improves after birth of a son. This culturally prevalent attitude should be kept in mind when counselling the HIV positive women of childbearing age. The pregnant HIV positive mothers chance of producing a HIV positive child is 25-30 per cent. This transmission from mother to child can occur during pregnancy itself, or at the time of childbirth, or even during breastfeeding. However, there is at least 70 per cent chance of having an infant, who is not infected with HIV. (For more detail, refer Block 3 of the Basic Course on HIV/ AIDS). The stage of HIV infection in the pregnant mother is also important. If it is in earlier stages of HIV infection, pregnancy has little (if any) effect on HIV infection. However in later stages of infection, especially if the
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mother has AIDS, the pregnancy can be more complicated. It is very important to help HIV positive women and their husbands, assess the risks of conceiving a child with a high chance of being HIV infected. They should consider the possibility of having an infected child, or if the child is uninfected, who will care for the child in the event of their own illness or death. Counselling should help the women develop a plan of how she will care for her child, how her family and community will help her, and how she expects to support and care for her child if she becomes sick and dies. Whenever decisions about avoiding or terminating a pregnancy, or about preparing for a possibly infected infant need to made, they should involve both the parents. Such couples should also discuss the matter with their religious leaders or spiritual guides. This is ever so important, considering the fact that the mother and her family will require compassionate support and psychological support during the pregnancy. She should be advised to undergo regular medical check up, use medication, and consider delivery in a hospital. Risk factors associated with transmission The risk factors associated with HIV transmission from mother to child may be sub-divided as follows:
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Virologic factors Maternal factors Placental factors Foetal factors Birth canal factors Obstetric factors Newborn factors
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Viral factors A high viral load in pregnant mother could lead to high risk of transmission to child. Maternal factors Frequent sexual intercourse with multiple partners during pregnancy, could lead to increased risk of transmission. A low CD4 counts in mother indicates high risk of transmission to child. Similarly, an advanced stage of HIV infection in the mother, as well as low maternal Vitamin A levels poses high risk of transmission to child. Prevention Strategies
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less frequent intercourse limiting the number of partners and still better, having a single partner use of barrier contraception decreased maternal viral load with anti-retroviral drugs Vitamin A supplementation to mother
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Placental Factors HIV-1 can be isolated from the placenta. Any placental disruption could lead to higher risk of transmission; this can also happen with Chorrioamionitis, cigarettesmoking, drug abuse, self-medication and sexually transmitted diseases in the mother. Prevention Strategies
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Antiretroviral therapy (ART) to prevent infection of the placenta. treatment of STDs, Chorioamnionitis.
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stopping cigarette smoking and drug abuse. avoiding self-medication.
Foetal factors There are differences in the susceptibility of the foetal cells to infection by virus, which may be related to genetic factors. Swallowing of infectious maternal fluids during the delivery and labour can ingest the virus. Factors during delivery Given the amount of virus in the genital tract, the infants thin skin and mucous surface can absorb the virus during the birth process. This may happened during the breaking of waters, or any bleeding happening during labour or prolonged labour after the rupture. Prevention Strategies
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adequate treatment of genital infections during pregnancy. elective Caesarian section can reduce the risk of infection. Veridical cleaning of birth canal before vaginal delivery may also reduce transmission.
As mentioned previously, the chance of the pregnant HIV positive mother producing an HIV infected baby is 25 to 30 per cent. By giving the mother an antiretroviral drug during the pregnancy the chance of transmission can be reduced by 70-80 percent. The drug most commonly used is Azidothymidine (AZT) or Zidoivudine. Sometimes, a combination of two or three drug combination may also be given. The baby should also receive AZT for six weeks after birth. Recently, Nevirapine, another drug was also found to be useful in
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reducing the transmission from mother to child. It can be given as a single dose to the mother at onset of labour, and to the newborn child as a single dose seventy-two hours after birth. Any treatment should be under the prescription of a qualified physician. One should never opt for any type of self-medication. HIV Among Chindren The mere mention of the word HIV in association with a child sounds repugnant. Most children suffer from HIV disease unconsciously, or due to unforeseen circumstances. Therefore, the parents, adult members, community and society are to be held responsible. Can any one imagine the anguish and remorse of a mother when she holds her doomed child in her arms? On the other hand there are no answers to many vital questions concerning HIV infection in children. In this section an attempt has made to analyze the various factors responsible for children contracting HIV.
Modes of HIV/AIDS Transmission in Children

Let us explore the possible routes of HIV transmission among children. Mother to Child-transmission (MTCT) Mother to child-transmission is by far the largest source of HIV infection in children below the age of fifteen years. In countries where blood for transfusion and blood products are regularly screened, and where clean syringes and needles are widely available in health centres and hospitals, mother to child transmission is virtually the only source of infection among young children. The extremely high rates of HIV infection among women of child bearing age in some parts of the
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world, and increasing risk of infection among women everywhere is therefore a profound cause for worry. A child whose mother is HIV positive can be infected in three ways: I . In the womb before birth: HIV has been detected much early in the foetus, and in the blood in the umbilical cord. A baby can also be infected during delivery by the mothers infected blood or vaginal secretions. This is because during the time of birth the childs skin is very soft and thin, which paves the way for the virus to get into its body.
I. I
II The third means of transmission from the mother I. to child is from breast-feeding. Researchers now believe that the handful of documented cases, where mothers did transmit HIV by breast-feeding was a typical. In each instance, the mother had received infected blood during blood transfusion immediately following delivery, and was therefore unusually infectious while she was breastfeeding because of high levels of virus in her blood. It is estimated that about 90 per cent of the pregnant rural women are anaemic, and require blood transfusions during pregnancy. Medical researchers estimate that the risk of transmission via breast milk is about 30 percent for mothers who are post-natally infected. The risk is even higher, as much as 41 percent of the women were infected. It may be noted that human milk supplied to infants from milk banks operational in some of the hospitals in the country could also be a source for HIV infection, if the milk is not tested for HIV. Similarly infants should not be fed with breast milk of women whose HIV status is unknown.
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Prevention There are various ways and means to prevent motherto-child transmission at various stages. Some of these methods of prevention are listed below: a. The protection of girls and women from HIV infection: HIV transmission can be minimized among women of childbearing age if they are provided adequate protection. This strategy is sometimes referred to as primary prevention. It involves promoting abstinence before marriage, responsible sexual behaviour among couples, providing them with knowledge about HIV/AIDS, and about how to prevent infection, and ensuring that they have the necessary personal skills and access to marital and sexual health counselling services, so that they can act on their knowledge. It also means providing good quality, user-friendly prevention and treatment programmes for other sexually transmitted diseases (STDs), the presence of which increase risk of HIV transmission to as much as from 6 to 10 fold. And, crucially, it means taking steps to deal with the cultural, legal and economic factors that make girls and women vulnerable to HIV infection by protecting them from such exposures. b. The provision of safe/healthy and accessible family planning services: Safe, healthy and accessible family planning services will enable women to avoid unwanted pregnancies. The aim is to ensure informed reproductive choice. If woman is found to be HIV positive, counselling should enable her to give up the desire for conceiving, as conceiving will further cause her health to deteriorate. Besides, the chances of a child are being born HIV positive is 25-30 per cent. c. Provision of HIV counselling, testing and treatment: An integrated package of measures consisting of voluntary HIV counselling and testing
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(VCT), the provision of antiretroviral drugs for HIV Positive pregnant women, counselling on infant feeding, and support for the feeding method(s) chosen by the mother, can also minimize the chances of HIV transmission among children. This package is often referred to as the Prevention of Parent to Child Transmission Programme (PPTCT). d. Caesarean section: An HIV positive mother should opt for a Caesarean section, which will substantially reduce the chances of the child getting infected during delivery. e. Breast Feeding: The choice to breast feed or not, should be made by the mother. The benefits as well as disadvantages must be conveyed to the mother, and she should be allowed to make a choice. Her decision needs to be respected.
Children At Risk of HIV Infection

Street Children India has the dubious distinction of having the highest number of street children. Most of these children are found in almost all big cities of the country. They earn their living through rag picking, working in hotels, involvement in prostitution, etc. This group is the most vulnerable because they do not have an alternative option. The most vulnerable are the girl street children. We will dwell at some length on the risks that they are exposed to. Puberty brings new stresses into young street girls lives. These girls do not have mothers or female relatives to explain to them that menstrual periods are part of normal life, or help them cope with their anxieties. Most of them are sexually abused even before they are 10 years of age.
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The street girl may not also develop a positive attitude about menstruation or appreciate her new ability to have children. Their poor nutritional status can render their menstrual cycles irregular. They may not understand why months pass in between their periods, and may incorrectly conclude that they are pregnant or sick. Avoiding an unwanted pregnancy may be constant stress for an adolescent girl. This is especially true when viewed in the context of the high incidence of sexual abuse, rape and victimization of girls living on the streets. They hardly have the emotional, physical and financial resources needed for a pregnancy, or for a safe motherhood. An unsafe abortion, often the only option for street girl, and it can cause severe health problems as well as emotional distress, and in some cases death. Street girls needing abortion usually approach quacks (roadside doctors). This further increases the risk to their reproductive health, and also exposes them to other exploitative, unscrupulous adults, who may lead them to the flesh market. Service providers from several towns and cities often report about street girls becoming pregnant. There are reports of some girls even delivering babies on the streets, with risks both to the undernourished young mother and her infant. Without having any basic means to support her, it must extremely difficult to keep both herself and her baby alive. Devadasies The devadasi system has been a practice in India since ancient times, when young girls of certain sections of society, were trained as skilled courtesans, and were initiated into the profession through a temple ritual. This was propagated by the Hindu Goddess Yellamma. This practice is still prevalent in India, especially in
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the states of Karnataka and Maharashtra, particularly among some of the economically weaker sections of the society. Young girls are offered to the temple priests, and were sexually exploited by others, much before they even had their first menstruation. Many of these girl children get infected with HIV and several of them also land up in brothels or the flesh market. Children of Commercial Sex workers While other communities in India dread the birth of a girl child and celebrate the birth of a son, her mother, the brothel keeper, and pimps welcome the girl child of a prostitute as a potential source of income. The estimated six million children of prostitutes in the country, have no other options than to follow the profession of their mothers pursued. Given the present situation of HIV/AIDS in the country, many of these children of prostitutes are likely to be HIV infected either from their infected mothers, or through customers who engage them for sex at very tender ages. Thalassemia Thalassemia is a hereditary disease, widespread in the Mediterranean countries, Asia and Africa. In this disease there is an abnormality in the protein part of the hemoglobin molecule. The affected red cells cannot function normally, resulting in anaemia. Other symptoms include enlargement of spleen and abnormalities of the bone marrow. The spleen is the scavenger of the body, which destroys the dead blood corpuscles. But in case where the spleen cannot get adequate blood, it also takes over the function of making it. This does great harm, because the body does not get good quality blood, and the spleen enlarges to be able to meet the demands of the new role. Hence it starts destroying more red blood cells.
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The exact number of thalassemic cases in the country is not known. Every year approximately 5000 thalassemic babies are born in India. Patients with this disease are treated with repeated blood transfusions. Several patients were believed to have contracted the dreaded disease from infected blood transfusion. Twenty-one cases of HIV infection were reported from one of the hospitals in New Delhi in 1994. There are similar reports from hospitals situated in cities across the country. Haemophilia Haemophilia is an inherited condition, which mainly affects men. The condition involves a reduced capacity for the blood to clot due to a deficiency of Factor VIII. Consequently, an otherwise minor accident can be dangerous because the person continues to bleed. Most bleeding may occurs internally. The patient suffering from Haemophilia is prone to HIV infection because they also require regular transfusions of blood or use of blood products and these may be infected with HIV. Meeting the special needs of HIV-infected children As with adults, most symptomatic HIV-infected children do not know that they are infected. They continue to lead normal daily lives. Simple infection control procedures can protect all family members or institutional workers from contracting the virus. Both mandatory and voluntary testing has been advocated to determine the HIV status of orphans. However, there are serious ethical issues involved in testing and disclosure to children. Issues, which need to be determined, include: Who wants to know and why? Will it benefit the child to tested, and how? Who should determine this and how? Can a child give informed consent to testing? Public policy needs to be drawn up in this area to ensure clarity and to protect this vulnerable group.
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Infants and children with HIV-related illness may have special care needs. Meeting these needs is all the more difficult where one or both of the parents is/are also infected, or has expired. Components of this programme element should ideally include: 1 . 2 . 3 . support to families with a sick child. promotion of non-discrimination policies and programmes. reaching the vulnerable, especially children and adolescents.
Among and within families affected by the HIV epidemic, there will be some children or families of children, at particular risk of destitution and of HIV infection. These include urban families without the support of their extended families, families who for whatever reasons are on the streets, children suffering from sexual abuse within their families (incest), etc. For many of these young people survival sex, sex in exchange for money or affection, food, shelter, clothing, etc., developing a basic coping strategy is necessary. Components of such a programme should include:
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Assistance to street children. Reducing the susceptibility of young women to infection.
Rights of the Child Suffering from HIV/AIDS

The United Nations Convention on the Rights of the Child (CRC) in the context of HIV/AIDS has spelt out principles for reducing the childrens vulnerability to infection, and for protecting children from discrimination, because of their real or perceived HIV/
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AIDS status. Governments need to ensure that the best interests of the children are promoted and addressed. They can use the proposed human rights framework: 1 . States should include HIV/AIDS, as a disability laws exist to strengthen the protection of people living with HIV/AIDS against discrimination. profile children prone to HIV. take special measures (by the governments) to prevent and minimize the impact of HIV/AIDS caused by trafficking, forced prostitution, sexual exploitation, inability to negotiate safe sex, sexual abuse, use of injecting drugs, and harmful traditional practices. Childrens right to life, survival and development should be guaranteed. Childrens right to confidentiality and privacy in regard to their HIV status should be recognized. This includes the recognition that HIV testing should be voluntary, and done with the informed consent of the person involved which should be obtained in the context of pre-test counselling. If the childrens legal guardians are involved, they should pay due regard to the childs view, if the child is of an age or maturity to have such views. Children should have access to social benefits, including social security and social insurance. Children should have access to HIV/AIDS prevention, education and information, and to the means of prevention. Measures should be taken to remove social, cultural political and religious barriers that block childrens access to these. Children should have access to HIV/AIDS prevention education and information both in school and out of school, irrespective of their HIV/AIDS status.
2 . 3 .
4 . 5 .
6 . 7 .
8 .
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9 .
Children should have access to health care services and programmes, and barriers to access encountered by especially vulnerable groups should be removed.
10. Children should enjoy adequate standards of living.

(Source: The Role of the Committee on the Rights of the Child and its Health and its Impact on HIV/AIDS: Problems and Prospectus Presentation by World Health Organization Global Programs on HIV/AIDS at AIDS and Child Rights: The Impact on the Asia-Pacific Region, Bangkok, Thailand, 21-26 November, 1995)
Conclusion
This chapter has described to you in detail about how women and children are more vulnerable to HIV/AIDS. We discussed the socio-cultural factors and how it influence the vulnerability of women and children to HIV/AIDS. We have also explained HIV/AIDS in women and also its transmission in children. Apart from this a very important aspect that we have discussed is Rights of the child suffering from HIV/AIDS. HIV affects children in numerous ways. Most children get infected through mother to child transmission, other children who are at the highest risk of infection include street children, child prostitutes, devadasies etc., and children with diseases such as Haemophilia and Thalassemia. With the rate of HIV as a whole escalating, it is found that many children are orphaned.
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References
Nemisharan, Mital. (1991). Drug Mafias Pustak Mahal, New Delhi. Thomas Gracious (1997) Prevention of AIDS: IN search of Answers, Shipra Publications, New Delhi. Sreedhar, Jaya & Colaco, Antony (1996). : Broadening the Front: NGO Responses of HIV and AIDS in India, ACTIONAID, UNDP & The British Council: New Delhi Society for Human Resource Management, 1800 Duke Street, Alexandria, Virginia 22314 USA-1994-1999. Global Report on HIV/AIDS, UNAIDS 2004. NACO (2000) Specialists training and Reference Module, NACO, New Delhi. UNDCP (1999) Drug Demand Reduction Report, UNDCP, New Delhi.
HIV/AIDS in the Working Population of the Organised and the Unorganised Sector
*Jyoti Kakkar,
Introduction
It is nearly three decades since the HIV or the Human Immuno-deficiency Virus was first reported in the United States of America, considerable research has been conducted to develop a better understanding of the virus. Reportedly, HIV belongs to a family of viruses classified as retrovirus. It has different sub-types. In terms of its infectivity, HIV is selective by nature. It does not infect all with equal probability. There are certain population groups, who by very nature of their occupation or other behavioural risk factors have a greater chance of becoming hosts to the HIV. Chief among these, are the commercial sex workers, truck drivers, injection drug users (IDUs), migrant workers, etc. Not only this, those undergoing regular blood transfusions, or suffering from sexually transmitted infections, are more vulnerable to HIV. So also is the case with the children born to sero-positive persons. HIV infection is not associated with specific population groups, but more specifically to the risk behaviours that makes people more vulnerable. These could be drug abuse, blood transfusions, sexual promiscuity and sexually transmitted infections (STIs). Let us take a brief look at each of these.
* Dr. Jyoti Kakkar,, Jamia Millia Islamia, New Delhi
HIV/AIDS in the Working Population of the Organised...
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HIV and Substance Abuse It is a known fact that the incidence of HIV infection is higher among the substance abusers. A substance, as it is used in the term substance abuse, is a chemical or a drug, used for the purpose of altering the mood of the user or for intoxication. A person who becomes a compulsive drug abuser, would do anything to procure drugs. He may steal, cheat, or do risky jobs, to get the money to procure the drug on which he is dependent. Some also start donating blood on a regular basis. In many instances, women who are drug dependent, get into the sex trade just to earn quick money. The linkage between drug abuse and HIV transmission starts with the use of injectable drugs but does not stop there. When drugs are injected using a syringe, the drug abuser need not always use disposable syringe, or sterilise his injection equipment. When these drug injecting equipments are shared with others, it becomes an easy channel of HIV transmission. Transfer of blood between the needle users usually occurs through the sharing of the equipment. Even a tiny drop in the syringe is good enough to transmit the virus. Further, one needs to understand that both injection and non-injection drug abuse increases HIV vulnerability. Most non-injection drugs induce high risk sexual behaviours among the users. Under the influence of tobacco, alcohol, cocaine and other such drugs these individual may engage in unprotected sexual intercourse with multiple sex partners, have sex for money or drugs, or visit the red light areas. In this way, consumption of non-injection drugs or alcohol can lessen inhibitions and reduce reluctance to engage in safe sex. Along with the disinhibiting effect of alcohol and other drugs, these men have low self-esteem, lack assertiveness, and feel powerless. These factors make safe sex difficult for them. Given the above, it is evident that any programme
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towards de-addiction or AIDS risk reduction demands an in-depth understanding of the behavioural and contextual risk factors. Multipartner Sex and HIV Promiscuous sexual behaviour contributes largely to the transmission of HIV. This factor is reportedly prominent among commercial sex workers. The clients of these sex workers may be the truck drivers, daily wage workers and migrants who carry the HIV, and contribute to its spread in the general population. In India, sexual transmission accounts for about 75 per cent of the HIV infections. It is in no way restricted to heterosexual population; homosexuals also add to this number. Detailed studies further show that the chances of the virus infecting a female partner are higher than the male for biological reasons. With this being a major mode of HIV transmission, prevention programmes mostly target the sexually active groups for their intervention strategies. HIV and STD linkage It is well understood that STDs and HIV have common epidemiological determinants, that is, high risk behaviour. Both are spread by sexual activities. A person afflicted with an STD could be presumed to be sexually promiscuous. Having an STD makes the person more susceptible to get infected with HIV. This happens in two ways: A number of STDs cause open lesions that facilitate the easy entry of HIV, into the bloodstream. Research shows that a person who has an STD, has two to five times higher chance than the general population, to acquire HIV. The converse situation of an HIV positive person catching STD has an even more fatal prognosis. An HIV
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positive person is one whose immune system is damaged and he cannot fight infections. If he suffers infection from another STD, this reels out of control. In India, the picture of STDs is ambiguous. Given the cultural taboos associated with the issue of sexuality, the very mention of STDs, brings forth a negative reaction. Many infected persons, especially women, hesitate to approach medical services. Often, they resort to home remedies, or seek treatment from other sources that are questionable, but where anonymity can be maintained. There are survey reports which indicate that only five to ten percent of those infected with STDs, seek treatment from public health services. Blood Transfusions and HIV When people move away from their villages in search of employment they often find themselves exposed to grave difficulties than they had initially foreseen. The plight of the workers in the unorganised sector can be well understood. They struggle to earn their livelihood, live in unhygienic conditions, and on top of this, struggles to save money and send it home. Any unexpected event in their lives makes things more difficult. Very often, they have no savings to fall back upon. Hence, to earn quick money, they resort to selling their blood. Professional blood donation is a major concern for the medical profession. Blood safety had to be a priority in the HIV prevention programmes. As is known, blood is the medium through which a number of organs can be transmitted. This source of transmission through blood is accountable for the spread of many diseases such as hepatitis, syphilis, malaria and HIV/AIDS. In most cases, it is the blood donors who have been responsible for this spread. Blood donors, who would mostly be from the lower socio-economic strata, would be the ones to sell their blood on regular basis. A number of them also
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use drugs, and are prone to promiscuous sexual relations. Apparently, they have receded into the background after the blanket ban placed on professional blood donation by the Supreme Court in 1998. The Government further tried to take control of this mode of HIV transmission by launching a blood safety programme under which, it became mandatory for all the blood banks to test for HIV.
HIV/AIDS Vulnerability of Workers in the Unorganised Sector

The unorganised sector comprises the majority of the work force. It consists mostly of people working in organizations, or in sectors, where there are no laws, unions and measures of social security. Men who work as vegetable sellers, rickshaw pullers, load carriers, transport workers, fishermen, farmers, construction workers as well as women, who work in these sectors and as domestic workers, all fall in this category. A majority of them are also people, who have moved out from their villages in search of better livelihoods. They have often left their families and homes, hence may be classified as migrants. These migrants are a group that because of their life circumstances, are vulnerable to HIV. Now we entertain two questions: Who are these migrants? And, why are they so vulnerable to HIV? Simply stated, migrants are people who are on the move. They are people who move from one place to another temporarily, seasonally, or permanently for a range of voluntary and/or involuntary reasons, including the search of livelihoods (UNDP, 2001). According to the International Organisation for Migration (2006), people move from one place to another due to a number of push and pull factors. Pull factors commonly are the search for economic and professional opportunities, or,
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the need to join the family living away from home. Push factors include poverty, food insecurity, civil war, and other forms of violence, human right abuses, ethnic tensions and persecution. It is well understood that there is a close association between mobility, and the spread of HIV. Many believe that migrants and the displaced, bring HIV with them when entering new territories. Evidence has established however, that the opposite is more likely: rather than bringing disease, migrants often become vulnerable to contracting HIV at the destination place. Being mobile in itself is not a risk factor for HIV infection. It is the situations encountered, and the behaviors possibly engaged in during mobility or migration, that increase vulnerability and risk to HIV/ AIDS. Their new place of residence, in an urban slum or a shanty in an industrial town, poses fresh problems for them. Coping with a different life, they face many social, economic and psychological problems. Being away from their families, their home communities, and the binding, familiar socio-cultural norms, can lead to isolation, loneliness, and high risk behaviour. In some cases the isolated migrant, to improve his mental state, takes to alcohol and drugs. These habits and vices become factors that increase their vulnerability to HIV. It is the loneliness that may sometimes prompt the migrant worker to engage in risk behaviours which he would never have attempted in his home environment. He may engage in multi - partner sex. Also, the peer group may exert upon him a stronger influence, and he may find himself giving in to such promiscuous acts, which exposure him/her to infections such as the HIV. Vulnerability also influences the social and economic conditions in which people live and work. These include
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the uncertainty about employment, and even their legal status. In India for example, 92% of workers, consisting primarily of migrants, exist in the informal sector, and remain outside the protection of laws or unions. A majority of these migrant workers are placed on unskilled jobs, and illiteracy is common. Migrant groups often have poor living and working conditions, with little or no recreational facilities. Being in unfamiliar territory, they are also ignorant of the services available, and are unfamiliar with the social norms prevailing in their host territory. Given their lack of awareness, these migrant workers have little access to HIV information, health services, testing and treatment centres for sexually transmitted infections and means for HIV prevention. Cultural and linguistic barriers further handicap their ability services that exist. They might not even know where or how to obtain a condom, even if available. The plight of the families of the migrants does not end with him becoming sero-positve. For this worker who had left his partner at their source community, a visit home, may be once in many months. This much looked awaited visit home, can end up as the means by which the HIV virus is tranmitted. There have been many instances where media has reported of such women, who mostly live alone, once tested HIV Positive. They are the spouse of the migrant workers, who are away seeking a better life. To summarize, there are certain common characteristics that render the migrants vulnerable to HIV and also helpless to do much about it. They are: ( ) The nature of work undertaken by migrant workers a places them largely in the informal or unorganised sector - the construction industry, transport sector, and informal home based production - that keeps most workers mobile;
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( ) in the unorganised sector, workers spend more time b at their place of work than they do at home, leaving them less space to unwind, socialize and emotionally bond with others; ( ) By its very nature the unorganised sector is c characterized by absolute lack of facilities or access to public services. The employers do not make provision for potable drinking water, toilets, restrooms, etc. and the workers work in unhygienic conditions, vulnerable to various infections. Many of the responsibilities proposed for and taken up by employers and trade union leaders in the organised sector, are as yet alien to workers in the unorganised sector (ILO, 2001); ( ) The migrant workers mostly survive on bare d minimum. A large number who work on daily wages, go without employment for days in between. Poverty further creates the vicious cycle, where they are unable to take care of their health or access proper health care services. Not only this, this kind of a life pattern makes them somewhat anxious and insecure; ( ) Migrants usually leave their families behind. Living e alone in cities, they have little support from the community. The loneliness that results from such a way of living oftentimes makes the worker resort to alcohol and drugs during the evenings. Such workers may then be involved in risk behaviours that they would not have normally resorted to at home or in circumstances, where he had the support of family and community members. He is away from the socio-cultural norms that guide behaviour in more stable communities; () f The workers are in some cases having a closed peer group and are strongly subjected to its influence.
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According to the Census 2001, there are as many as 307 million persons, who have migrated from their place of birth, in India. Out of them, about 259 million (84.2 per cent) migrated from one part of the state to another, from one village or town to another village or town. Migration from outside the country accounts for only 2.0 per cent of the total. Data on migration by last residence shows that total number of migrants is 314 million. A large majority of them (85 per cent) are of intra-state migrants. Migration can be from rural to rural areas, rural to urban, or even urban to rural. Given the large number of persons who finally migrate and take up work in the unorganised sector, it is important to reach out to them with programmes and interventions for HIV prevention. All these workers in the unorganised sector are also more likely to suffer the consequences of any illness including AIDS to an extent, higher than others. By and large they cannot access health facilities or social protection benefits available to the workers in the organised sector. Their plight is also much worse, because of their inability to save money, and still further, their inability to work would mostly mean a termination of their present employment. A lot of work is therefore needed to reach out to these workers, make them aware of HIV, and offer them care and support services.
Implications of HIV/AIDS in the Organised Sector

The impact of HIV and AIDS has been evident in the social, economic and political spheres of each country, whether developed or developing. As the prevalence of HIV Positive went high, Governments sprung into action. Some of them formulated policies towards control of HIV transmission. Many programmes have been
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initiated to reach out to special population groups. Further, blood safety has been ensured, and antiretroviral therapies (ARTs) have been made available to the AIDS afflicted. Many organizations have responded by showing concern for their employees and towards the affected in the community. They have also undertaken various sponsored programmes on HIV and AIDS prevention. The present section features the implications of HIV/AIDS, the related policies and programmes, to workplace. ILO estimates show that there are at least 26 million people infected with HIV worldwide, are workers aged between 15 to 49 years, in the prime of their working lives. In many countries, such as Africa, AIDS has become a major threat to employment and labour market efficiency. The loss of workers and man-day due to AIDS related illness or the demands of caring, can result in significant declines in productivity, loss of earning, wastage of skills and experience. HIV/AIDS have changed the age and sex distribution of the labour force, and has increased the number of women, children and the elderly who are facing economic uncertainty. The premature entry of orphans into the labour market, exacerbates the worst forms of child labour. Also, in many cases the elderly in a family are forced into employment to support the ever diminishing family resources. The epidemic hits harder those who are poor, and who could least afford treatment and care. The effects of AIDS on employment and on the labour market are therefore a major concern. Thus, AIDS is both a workplace issue and a major challenge to social development. Another concern in this regard is possibility of discrimination against workers, who are HIV infected. As an organization founded to promote social justice and equity and to protect workers rights, ILO is
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committed to fight against HIV/AIDS related stigma and discrimination. It has adopted the Code of Practice on HIV/AIDS and the World of Work, which will be discussed later. Impact on Population and Labour Force The most obvious impact of HIV/AIDS on labour force is on growth of the population. This has been most significant in sub-Saharan Africa. South Africa, which lies within this region, has the highest rate of infection. What requires to be highlighted is the significant impact of the wastage of the labour force, on the structure of populations. The majority of those who die of AIDS, are adults in their most productive phase, both sexually and economically. The concern is not only with the size, but also the composition of the labour force. Many of those who get infected with HIV are highly skilled and competent workers. It goes without saying that the pandemic would impact the supply of human capital. There comes a pressure on the children who are orphaned, to drop out of school and join the labour market. Estimates have shown that some African countries will lose between a fourth to a third of their skilled and educated population, to the pandemic. Impact on the household The impact on the household is immediate and inevitable. Illness of a household member means loss of income due to absence from work by the person affected, an increase in medical expenses, as well as diversion of other family members from their work and education to take care of the sick person. There is loss of income, drop out of children from schooling, elders forced to take on the new responsibilities, and ultimately death which further complicates the problem.
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Impact on Agriculture In agrarian families, as in most areas of Africa, the loss of adults may cause a switch from cash crops to subsistence farming, a reduction in soil improvement, irrigation and other capital investments, and within subsistence farming changes to less labour intensive crops. Families are forced to sell food grains, livestock, equipment and land to cover AIDS related expenses. Women carry multiple responsibilities not only for household duties and child care, but also for tasks related to farming. Impact on Enterprises In enterprises, AIDS related illness and deaths substantially reduce productivity and increase labour costs. Organisations in the more seriously effected countries report of an ever increasing absenteeism, inreased labour turnover, as well as escalating costs of recruitment, training and staff welfare. In organizations where there are infected workers, workload of the colleagues goes up. Special groups with higher vulnerability If we take into account both the organised and the unorganised sectors, the most vulnerable group are the commercial sex workers. In general, workers hold jobs that require them to be away separated from their family. This group, highly vulnerable to HIV, includes transport workers (long distance truck drivers, sailors, etc.), traders, miners, construction and plantation workers, seasonal workers in agriculture and tourism, and migrant workers of all categories. Another category facing higher risk are the health workers and the security personnel.
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Social Issues in the Context of HIV and the Workplace

Denial A common misconception held by people is the belief that HIV is somebody elses problem. HIV is perceived to be a disease that infects only the so-called high risk groups. What is ignored is the fact that the primary mode of infection is sexual transmission. The virus does not put only some people at risk. Such misconceptions can result in many groups disassociating themselves from the epidemic. This would further hinder the efforts of developing policies and programmes for its prevention. Fear Misconceptions, misinformation and the fear of the unknown leaves many people in a state of heightened anxiety. They are afraid of getting themselves tested for HIV. Considering the fact that sex related issues are a taboo, many people fail to or cannot obtain the right information on HIV. Most programs and intervention strategies do not have the desired impact because they are not able to reach out to people. All such misconceptions can be removed and people encouraged to undergo testing, only when they can talk openly. Fear is only handled when people can openly and freely talk about their fears. Experts should also be available to handle their queries. Discrimination Fear often leads to discrimination of the AIDS afflicted. Loss of jobs and friends is not an uncommon occurrence for the AIDS afflicted. Misconceptions about modes of transmission of the virus, such as by casual contact, can lead to isolation and segregation of the HIV infected.
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It is important therefore, to educate people with the right information in order to reduce discrimination. Confidentiality A HIV+ persons medical problem usually involves an issue of a confidentiality. Revelation of a persons HIV status may result in his being discriminated against. There have been reports of people losing their jobs, and even breaking family associations, once they divulge their HIV status. Confidentiality with regard to a persons medical problem, including HIV, has to be maintained. Employment Issues and HIV The National AIDS Control Policy in India does not allow for HIV testing as a precondition for employment. Numerous Supreme Court rulings have upheld the right to employment of a person suffering from HIV. It asserts that an HIV+ person, cannot be denied a job if he is capable of working. There is no scientific basis for doing a pre-employment HIV test. Also, it is known that HIV will not spread through casual contacts at the place of work. It is unethical to test the blood of a person without his consent. So denial of job through ascertaining the persons HIV status prior to employment has no basis.
Addressing Issues of Hiv/AIDS at the Workplace

In June 2001, the International Labour Organisation adopted a Code of Practice on HIV/AIDS and the World of Work. The fundamental aim of this code is to ensure and safeguard conditions for decent work, as well as the protection of the rights and dignity of workers and all people living with HIV/AIDS.
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The Code is intended to help prevent the spread of the epidemic, mitigate its impact on the workers and their families, and provide social protection necessary to help them cope with the disease. The code provides practical guidelines to Governments, employers, and workers organizations for developing national and workplace policies and programmes relating to HIV/AID. The Code addresses several important issues, including prevention through information, education and gender awareness programmes, and by promoting behaviour change. It covers the protection of the workers rights, and it deals with the challenges of care and support (including confidential voluntary counselling and testing, as well as treatment in settings, where local health settings are found to be inadequate).
Key Principles on Workplace Code on HIV

The Code of Practice for HIV/AIDS and the World of Work (ILO, Geneva, 2001) includes various aspects related to the HIV intervention. It covers the following: a ) Recognition of HIV/AIDS as a workplace issue: It is for two main reasons: for one, it affects the workforce, and secondly, the workplace has a role to play in the wider struggle to limit the spread and effects of the epidemic. Non-discrimination: There should be no discrimination on the basis of HIV status of a person at his workplace. Gender equality: Given the higher vulnerability of women to HIV, more equal gender relations and the empowerment of women are important to successfully prevent the spread of the virus. Healthy work environment: This is to facilitate optimal physical and mental health.
b )
c )
d )
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e )
Social dialogue: There is a need to have cooperation and trust between the employers, the workmen, their representatives and the Government. Screening for purposes of exclusion from employment or work processes: This should not be a requirement. Confidentiality: Information regarding the HIV status does not have to be shared with employer or coworkers. Continuation of employment relation: HIV status is not a cause of termination of employment. Prevention: The social partners should promote all prevention efforts. Care and support: All workers are entitled to affordable health services with no discrimination in terms of access.
f ) g )
h) i ) j )
The importance of comprehensive educational programmes for AIDS awareness cannot be understated. However, it is important that these have the support of the employers. Successful HIV programmes have always requires the support of the top management. This helps to develop an atmosphere conducive to promoting the health of all workers. It is important that a workplace education programme, meeting the needs of all workers must be developed. Each programme must be tailored made to the particular audience and organization. Union representatives should be involved in the design of the educational programmes. Planning the HIV/AIDS Education programme: The first step in addressing the issue is acknowledging the need for an HIV/AIDS education programme. This need is followed up by building contacts with professional groups that can help build up and support the implementation of the programme. In some communities, the States AIDS Control Organisations, local health departments, can
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support with appropriate material. The ILO, UNAIDS, and the WHO, have several publications for this purpose. In many communities, local non-governmental agencies too have a contribution to make. Steps for planning an HIV/AIDS Education Programme:
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Compiling information regarding HIV and AIDS. Generating data regarding what organizations are present and identifying the services offered by them. Approaching the management for support and ensuring their willingness to take up the programme. Identify leader/s who can take up the challenge of generating AIDS awareness. Developing Teams can be wherever possible. Encourage team work. Compiling data on composition of the work force, the occupational hazards, etc. (can be of immense use in designing intervention programmes). Collecting information on the cultural aspects, and special issues pertaining to this organization. Identifying and gathering information about resources - material resources and manpower and how you can use them. Plan the budget by identifying all the expenses that have to be incurred. The costs of programmes and materials - brochures, posters, flyers, in house magazines - all need to be included. Plan for training of the managers and supervisors in the area of HIV/AIDS. Plan to hold meetings to define the organisations policy on HIV/AIDS and how the programme would be implemented.
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Workplace Policy on HIV/AIDS

All organizations need to deliberate and come up with their respective policies on HIV/AIDS and other communicable diseases in relation to their workplace. The policy is an important first step. It sets the tone for the programmes to be initiated, and shows the willingness of the management and the employees to take up the cause and lend support to the community efforts. Both the managers and the workers should be involved in designing the policy. The policy should be as comprehensive and cover all aspects of HIV prevention. The policy would include education regarding the modes of HIV transmission; educational measures to enhance understanding of personal risk and promote enabling strategies; practical prevention measures which encourage and support behavioural change; measures for the care and support of affected workers; and the principle of zero tolerance of stigma and discrimination. The policy should spell out how it will treat and protect the confidentiality of the employees regarding HIV. Finally, it is important that the policy be communicated to the employees and posted at suitable places. The formulation of the policy is only a first step. It needs to be strategically implemented. After its communication to all concerned, it should be continually monitored for successful implementation. Regular reviews of the policy in light of the scientific information or empirical evidence available, as well as the field experiences, are all important. At the end it should be evaluated for its effectiveness.
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Partnership of NGOs and Corporate Sector in HIV/AIDS Prevention

With the growth of the epidemic there has been a concerted response from various sectors regarding the problem of HIV. NGOS and Corporates have realized the importance of developing programmes for tackling the epidemic, and many have supported the preparation of related training modules, videos, as well as peer training programmes. It has been realized that business and NGO collaboration is important for successful launch of AIDS prevention programmes. In India, The Confederation of Indian Industries (CII) has developed programmes and modules to support HIV prevention. Many Corporates have joined hands in this endeavour. NGOs can play a significant role by offering support in the form of providing pre-test and post-test counselling, training of trainers (ToTs), legal literacy and guidance, condom distribution, family counselling, etc. Such collaborative partnerships are imminent in order to reach out with the right messages to large populations.
Conclusion
The issue of dealing effectively with the problems of HIV/AIDS in relation to workplace is very crucial, at local, national as well as international level. Since most of the HIV/AIDS cases fall in the age group of 15-49 years which is the economically productive and biologically reproductive population, it results in several direct and indirect economic and social costs along with several problems to be confronted by professional social workers. It is, therefore, important that we address the workplace with regard of HIV/AIDS.
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The present chapter has described to you in detail about HIV/AIDS vulnerability of workers in the unorganized sector. We discussed the implications of HIV/AIDS and the related policies and programmes in relation to workplace. We have also explained social issues in the context of HIV and the workplace and also workplace policy on HIV/AIDS. Apart from this a very important aspect that we have discussed in this unit is the partnership of NGOs and corporate sector in addressing various aspects pertaining to HIV/AIDS prevention.
References
International Labour Office (2001): An ILO Code of Practice for HIV/AIDS and the World of Work. Varma, U.K and Sasikumar, S.K (2005): Migration and Vulnerability to HIV/AIDS: Towards Evolving Viable Intervention Strategies, V.V. Giri National Labour Institute. IGNOU (2006): HIV / AIDS and Vulnerable Population. Course Material. Kakkar, J (2005): AIDS Risk and Awareness. InterIndia Pub. New Delhi.
HIV/AIDS Prevention and Control: Governmental and United Nations Initiatives

* Gracious Thomas
Introduction
The Human Immunodeficiency Virus (HIV) is continuously spreading its tentacles throughout the world. According to various estimates, by the year 2010 throughout the world, several millions are likely to lose their lives due to this disease. The HIV has more than doubled the adult-death rate in some countries and is the single largest cause of adult death in some countries. HIV / AIDS have been identified as one of the top ten killers throughout the world. In the Indian sub-continent, the epidemic of HIV / AIDS is prevalent in all parts of the region. The number of AIDS cases has been consistently rising over the years. About half of the Indian population is in sexually active ages i.e. 15-49 years and therefore needs special attention. Looking into the alarming situation of HIV / AIDS in the country, the Government of India has initiated several measures. Here an attempt is made to talk about the measures and initiatives take up by the
HIV/AIDS Prevention and Control...
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Government, for the prevention and control of HIV / AIDS.
Intiatives by the Government of India

The Government of India recognized quite early the seriousness of the problem caused by HIV/AIDS and reacted soon after the first cases were reported. The Ministry of Health and Family Welfare constituted the National AIDS Committee in 1986, with the intention of bringing together various ministries, NGOs, and private institutions for effective coordination in implementing the National AIDS Control Programme (NACP). The committee oversees the performance of the programme, deliberates on policy, and encourages multi-sectoral collaborations. The committee is the highest decision making authority on policy matters. In the initial years, the focus of the programme was on screening of blood meant for the purpose of transfusion, as well as on conducting surveillance activities in the epicenters of the epidemic. The NACP launched in 1987, aimed at establishing a comprehensive, multi-sectional programme for the prevention and control of HIV / AIDS in India. The main objectives enlisted were:
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prevention of HIV transmission, moderation of the morbidity and mortality associated with HIV infection, and minimising the socio-economic impact of the HIV epidemic
National AIDS Control Organisation (NACO) The NACO was established in India in 1992 as an executive body in the Ministry of Health and Family
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Welfare. The main functions of NACO are as follows: 1 ) 2 ) 3 ) 4 ) To expedite sanction, approve procurement and to undertake and award contracts to private agencies. The board allocates funds between programme components. Forms the programme managerial teams and appointment of senior programme staff. The board exercises all administrative and financial powers.
Initiatives at the State Level To strengthen HIV/AIDS control programme, various steps have been initiated at the State level. Each State has a State AIDS Control Society, which is responsible for the implementation, supervision, inter-sectoral coordination, as well as for the monitoring and evaluation (M & E) of the programme in the State. Now each State has a State AIDS Control Society, registered under the Societies Registration Act, 1860. This is in place of the State AIDS Cell. At the State level, an empowered committee has been constituted, which takes the policy decisions regarding the implementation of the HIV/AIDS control programme in the respective States, as well as the approval on administrative and financial actions, which otherwise would have required the approval by the State Department of Finance.
The Components of National AIDS Control Programme

Let us now briefly describe the programmes which are being run under the NACP.
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STD Control Programme The predominant mode of transmission of both HIV infection and other STDs is through the sexual route, the other routes of transmission being both blood and blood products, donated organs and tissues, and mother (infected women) to child during delivery. Many of the measures of preventing the sexual transmission of HIV are the same as for prevention of STDs. Before Independence, a National STD Control Programme was started in 1946. This programme was brought under the purview of NACO in the year 1992. The importance of treatment and control of Sexually Transmitted Diseases (STDs) in relation to HIV infection was recognized by NACO. Increasing evidence suggests that STD significantly enhances the acquisition and transmission of HIV. Some of the reports show that in Mumbai alone, over 50 per cent of sex workers were found to be HIV+, while the rate of HIV infection among patients attending STD clinics was about 36 per cent. Evidence also suggests that concomitant infection with other STDs, particularly those characterized by genital ulcers, increase the chance of HIV infection. Therefore, it may be concluded that a person already having STD, has the greater risk of acquiring HIV from sexual relationship, if he/she comes in contact with an infected partner. The earlier programme emphasized more on health seeking behaviour of the individuals having STD, and on the removal of the social stigma attached to the problem of STD. Studies had shown that less than 5% of patients suffering from STD accessed the public health care system. The majority sought clinical assistance from various other formal as well as informal sources; sometimes, they even resorted to self- medication.
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STD clinical services are an important access point for persons at high risk for both HIV and STD, not only for diagnosis and treatment, but also for health education, counselling and prevention. Trends in STD incidence and prevalence can be useful indicators for change in sexual behaviour and make it easy to monitor the trends in HIV sero-prevalence. This is valuable for determining the impact of various HIV/AIDS intervention programmes. The STD control programme has two major objectives: i ) i) i Reduction STD cases and thereby control HIV transmission by minimizing the risk factors; and Prevention of the short term as well as long term morbidity and mortality due to STD.
Policy on Control of HIV/STD The Ministry of Health and Family Welfare has adopted a policy to integrate STD control into the existing health care system, both in the public and private sector. Special emphasis is being placed on the integration of comprehensive STD management at the primary health care level, to provide non-stigmatized services with greater accessibility and acceptability to the patients, while maintaining the confidentiality and privacy of the patients. The policy strategy also emphasizes on the cooperation and collaboration with the private sector as well as non-government organisations for the control of STD. A number of manuals and guidelines have been prepared base on a widely circulated STD policy document, and also has been distributed in all States and UTs. Objectives of the STD Control Programme The following are in a nutshell, the objectives of the STD Control Program:

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Reduce STD cases, and there by control HIV transmission by minimizing the risk factors. Prevent the short term as well as long term morbidity and mortality due to STD.
The strategies for control of STD in India are: 1 . 2 . undertake adequate and effective programme management. promote Information, Education, Communication (IEC) and social mobilization initiatives for the prevention and transmission of STDs and HIV infection. adequate arrangement for comprehensive case management includes diagnosis, treatment, individual counselling, partner notification and screening for other diseases. creating facilities for diagnosis and treatment of asymptomatic infections through the method of case finding and screening. increasing access to health care for STD, by strengthening existing facilities and structures, and creating new facilities wherever necessary. Promotion of safer sexual behaviour by the use of condoms.
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6 .
The following major actions have been taken along the lines suggested in the strategies:
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training of health care workers in both public and private sector in comprehensive STD case management. developing appropriate laboratory services for the diagnosis of STD. conducting Microbiological, Socio-behavioural and Operational research.
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surveillance on epidemiological situation. monitoring and evaluation (M & E) of the on-going STD control programme.
Use of Condoms to prevent HIV/AIDS In India, almost 85 percent HIV infections occur due to unprotected and multi-partner sexual contacts. This type of transmission can be prevented to some extent by consistent use of good quality condoms. It is keeping these views in mind, that the condom programme was initiated all over the country. Objectives The objective of the condom programme is to ensure easy access to good quality, affordable and acceptable condoms to promote the safe sex encounters. Strategies The strategies for the Condom Program are as follows:
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Making provision for technical assistance to companies to manufacture condoms in conformity with the international specifications laid down by the WHO, and to improve the quality assurance system. Strengthening of the existing social marketing structure in the Department of Family Welfare, with a view to fulfilling the needs and requirements of the AIDS control programme. Introducing an exclusive social marketing scheme of condom promotion for NACO. Strengthening the management ability of NGOs that promote and distribute condoms for STD/HIV prevention and to more effectively plan, coordinate, monitor and evaluate their activities.

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Collaborating with the existing IEC programme of the Department of Family Welfare for promoting the use of condoms for achieving the dual purpose of averting conception as well as protecting from STD/ HIV. Supporting and strengthening the Indian Council of Medical Research (ICMR) and Population Research Centres (PRCs) for undertaking research studies on all matters related to the use of condoms and increasing their use particular among high risk groups.
The major areas in which NACO has significantly made progress in relation to condom programming are: (I) Quality Control of Condoms NACO follows specifications set by WHO for quality standards for condoms. Nirodh (the non lubricated condoms) has been phased out, and manufacturers have been directed to adhere to the new specifications. The states have been asked to conduct regular quality tests to check the quality of condoms. (II) Social Marketing of Condoms Social marketing has been accepted as the most-effective strategy for condom promotion in the country. This strategy not only helps to increase the acceptability, but also provides easy access to the users, while improving the sustainability of condom provision. The emphasis has shifted to increase the social marketing of condoms as a priced item, but at a subsidized rate. NACO has developed social marketing scheme for NACP in collaboration with the Department of Family Welfare. The salient features of the scheme are as followsThe subsidized condoms will be provided to SACS by Department of Family Welfare. Condoms are being made available to the clients through three schemes namely-
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() i
distribution scheme
(i social marketing i) (i) commercial brand scheme ii Blood Safety Programme There is no other fluid, which can substitute for blood in the human body. In the case of transfusion of infected blood, it is almost sure that such blood can cause transmittable diseases such as Hepatitis, Syphilis, Malaria, and, can spread HIV/AIDS. Blood safety is an integral part of the National AIDS Control Programme. Research shows that the blood banking services in the country has several shortcomings: () i the high level of decentralization of blood banking services, and the resultant lack of proper control.
(i unavailability of trained personnel. i) (i) limited availability of blood, causing the proliferation ii of commercial blood banks. Objectives The objective of the Blood Safety Programme is to ensure easily accessible, adequate supply of safe and quality blood and blood components for all, irrespective of economic or social status. Strategies The NACO laid down the following strategies:
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strategise the National Blood Transfusion Services. ensuring an adequate supply of blood to all blood centers. ensuring safe blood products. developing facilities for the production of components.
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strengthening quality control of blood and blood products. undertaking research on blood transfusion services, operations to improve safety, efficacy and supply. developing and strengthening of effective management, as well as, monitoring and evaluation (M&E) of blood transfusion services.
Blood safety is an integral part of the National AIDS Control Programme. At the State level, in State AIDS Societies, Blood Safety Officers have been assigned the responsibility to co-ordinate programmes. Government of India provides assistance for staff salary, contingency and transportation vehicles. The staff provided under this component is, Joint/ Deputy Director, Technical Assistant and Drug Inspectors. Safety of blood and blood products To minimise the risk of transmission of HIV infection through blood and blood products, Government has taken a series of measures: () i The Drugs and Cosmetics Rules provide mandatory testing of blood for HIV in addition to other bloodtransmissible diseases such as Hepatitis B Surface Antigen, Hepatitis C, Malaria and Syphilis.
(i Under Supreme Court directives, licensing of blood i) banks is mandatory and operation of unlicensed blood banks has been banned. (i) The system of collection of blood from paid donors ii has been phased out completely. To ensure availability of blood, the Government has undertaken large scale mobilisation efforts to increase voluntary blood donation through involvement of governmental and non-governmental
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agencies. ( v Government would ensure establishment of i) adequate blood banking services at the State/ District levels including provision of trained manpower. ( ) To ensure proper clinical use of blood, more blood v component separation facilities would be established in the country, which would improve availability of adequate blood components and their use instead of whole blood. ( i The Government has set up National and State Blood v) Transfusion Councils to oversee blood transfusion services as autonomous bodies. The facility of 100% tax exemption for contributions to these Councils has also been given. These Councils will play a very important role in augmenting blood transfusion services in the country and to ensure safe blood to the people. To ensure generation of adequate medical and para medical personnel specialised in blood banks, States are required to upgrade blood banks located in Medical Colleges, and to be named as the Department of Transfusion Medicine. Thrust Areas (i) Establishment of HIV Testing Facilities To screen blood, zonal blood-testing centres have been established in order to provide linkages with other blood banks affiliated to public, private and voluntary sectors. These zonal centres receive the blood sample and after testing, report the results to the blood banks the same day. (ii) Support for Testing for other Blood Transmittable Diseases NACO provides assistance to the centres for the purchase of necessary equipments and kits for screening
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of the blood. Testing of every unit of blood is mandatory for detecting infections for various diseases. (iii) Modernization of Blood Banks Several steps have been initiated to ensure safe blood by modernization and strengthening of all licensed blood banks. NACO provides financial support for blood bank equipment, contingency and purchase of consumables, chemicals and reagents. (iv) Appropriate Clinical Use of Blood For the purpose of reducing the wasteful use of blood, NACO has set up component separation units all over the country. The doctors and technicians working in these labs have been duly trained to separate the blood components, and preserve these in best manner possible. A national guideline for appropriate use of blood has been widely circulated too. (V) Training and Personnel Development Lack of trained personnel and non-availability of training programmes are the major problems in the blood safety related issue. Realizing the problem, Government identified 10 regional training courses for in-service training of the personnel. The Medical Council of India has already recognized Transfusion Medicine as a specialty, and is planning a MD course on this subject. Since Blood Transfusion has become a distinct specialised discipline, it is hoped that many more such centres would come up and a large number of trained manpower would be available in the near future. Another step in this direction that may be taken is to upgrade existing blood banks in the Medical Colleges, to function as Department of Transfusion Medicine. Promotion of Voluntary Blood Donation Acquisition of blood is mainly done through voluntary
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donations. From the blood safety point of view, the Government of India has taken the following steps:
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For raising motivation of the people to donate blood, specially developed TV spots have been created for telecast by Doordarshan regularly at suitable intervals during the prime time. Messages are being broadcast through AIR FM music channel. IEC material for one to one communication on blood donation programme, in the form of folders, posters, and stickers have been developed by NACO with the help of Central Health Education Bureau, New Delhi, and in all the States and Union Territories, with the suggestion to be reproduced in vernacular languages. Every year, 1st of October is celebrated as the National Voluntary Blood Donation Day. Special campaigns to educate people as well as special camps for blood donation are organised on this day. On the occasion, the President, the Prime Minister, and the Minister of Health and Family Welfare, appeal through broadcast and televised address, for voluntary blood donation. These messages are also printed in the dailies.
Information, Education, Communication and Social Mobilisation (IEC) Information, Education and Communication (IEC) can be used to motivate people to adopt and maintain healthy practices and life styles. IEC is useful in educating the public regarding the various misconceptions, in order to deal with their ignorance. NACO has given top priority to the IEC campaign. These programmes have been integrated in various components of the AIDS control such as STD services, condom programming and blood safety, etc.
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IEC Strategy In 1994, a comprehensive IEC strategy was prepared and operationalized both at the State/UT and National levels. The IEC Department of NACO provides basic information pertaining to HIV/AIDS, prepares policy decisions and board guidelines on IEC strategies. It also develops publicity materials and distributes it to the States, NGOs, media, all concerned agencies, as well as individuals. The IEC strategy in NACO is operationalized at two levels. At the national level, political and media advocacy, creation of a supportive environment that reduces social stigma and discrimination, and provides for better access to services, has been taken up. NACO has set up a team at headquarters comprising of a Joint Director, Deputy Director, Under Secretary and National Consultants in the IEC division. This division is responsible for developing the IEC strategy, policy and guidelines both at the national and state level. It is also responsible for monitoring and supervising the IEC activities undertaken by the State AIDS Control Societies. The objectives of the IEC Strategy in NACP are to: () i Raise awareness, improve knowledge and understanding among the general population about AIDS infection and STD, routes of transmission and method of prevention.
(i Promote desirable practices such as avoiding i) multipartner sex, condom use, sterilization of needles / syringes and voluntary donation of blood. (i) Mobilize sectors of society to integrate messages ii and programmes on AIDS into their existing activities.
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( v Train health workers in AIDS communication and i) coping strategies. ( ) Create supportive environment for the care and v rehabilitation of persons with HIV/AIDS. Components of IEC Strategy The IEC strategic plan for AIDS prevention and control programme in India includes a variety of communication strategies for raising awareness, behavioural change and social mobilization. The IEC strategic plan has the following components:
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appropriate use of Mass Media advocacy at various levels Inter-Sectoral collaboration Training involving NGOs Research
Inter-ministerial support HIV/AIDS cannot be fought independently. If left unchecked, AIDS can achieve an epidemic proportion within a short span of time. The NACO cannot counter this disease alone. Close collaboration and effective coordination among the Central and State Governments, various government departments, educational institutions, local bodies and partnerships with NGOs are therefore needed for preventing and controlling HIV / AIDS in India. A multi-sectoral committee has been constituted. It has representation from various ministries and departments that may have any links with NACO and its programmes (refer diagram).
HIV/AIDS Prevention and Control... Ministry of Social Justice and Empowerment
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Ministry of Tourism
Indian Council of Medical Research
Ministry of Human Resource Development
NACO
National Councial of Educational Research and Training
Ministry of Coal and Mines
Ministry of Labour
Ministry of Information and Broadcasting
Non Governmental Organization Collaboration The NGOs are playing a very important role in the social development of the country. They occupy a unique place as they have a direct involvement with the community. Some of the NGOs have developed expertise, and have the necessary infrastructure to carry out such activities including health education and outreach programmes. The collaboration and participation of the NGOs and Private Voluntary Organizations (PVOs) are welcomed by the NACO. Targeted Interventions All over the world, it has been commonly found that there are some particular groups of people, who can be easily identified as practicing certain behaviours, which can be termed as risky in the context of HIV/AIDS epidemic. These groups, because of their behavioural attributes, are more prone not only to contracting the infection more quickly, but also to transmitting and
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spreading the disease within a very short period of time. However, this is not to deny that others are less risky or cannot spread the disease. In fact the disease has been found to be spreading to the general population as well. The basic purpose of the Targeted Intervention (TI) program is to reduce the rate of transmission among the most vulnerable and marginalised populations. One of the ways of controlling the disease from further spread is to carry out direct intervention program among these groups through multi-pronged strategies, beginning from behaviour change communications, counselling, providing health care support, treatment for STDs and creating an enabling environment that will facilitate behavior change. Targeted intervention is, therefore, one of the most important components of the NACP-II. It envisages a comprehensive and integrated approach to marginalized and vulnerable populations such as sex workers, intravenous drug users, men having sex with men (MSM), truckers, migrant labour, and street children. Since most of these groups are extremely marginalized both socially and economically, it is not possible to access them through conventional Government services. NGOs, Community Based Organizations and other appropriate agencies are considered most suitable to reach out to these populations more effectively. These groups need information and services in a focussed and non-judgemental manner. It is, therefore, important to develop a peer-based approach, which enables and sustains behaviour change. Such interventions must be supported by an environment that is conducive to empowering them for behaviour change. The Targeted Intervention (TI) approach, as defined by NACO, incorporates all the above components to provide
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comprehensive interventions to the marginalised groups. The basic purpose of the Targeted Intervention programme is to reduce the rate of transmission among the high risk behaviour prone population. In order to plan for implementation of this programme NACO evolved the following strategy:
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decentralization-assigning implementation to the State AIDS Control Society. developing transparent and streamlined procedures for selection of NGOs. capacity building of SACS and NGOs for implementing and monitoring of TI Projects.
Objectives The objective of targeted intervention is to reduce HIV transmission among population groups at higher risk of HIV infection; by bringing change in behaviour through health promotion and education, and the provision of appropriate facilities and services. Overall Impact The project is succeeding in meeting its objectives. In fact, it has already achieved quite comfortably, most of the benchmarks identified in the tripartite agreement. Two stages of data were examined to assess the projects overall impact. The review included data taken from three waves (1996-97-98) of the HIV-Risk Behavioural Surveillance Survey (BSS) in Tamilnadu, as well as data selected from the monthly reports submitted by participating NGOs. The data was found consistent and showed that not only is meaningful behaviour change under way in the state, but that change can be attributed directly to the project. Various projects like the APAC project in Tamilnadu, the Partnership for
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Sexual Health Project in Gujarat, Orissa, Kerala and Andhra Pradesh respectively. The West Bengal Sexual Health Project the Healthy Highway Project, interventions for rickshaw pullers, Bosco targeted intervention among street children, are some of the projects that have used targeted interventions. Implementation The State AIDS Control Societies are fully empowered to provide funding support to the NGOs for Targeted Interventions. Every State AIDS Society has appointed an NGO Advisor, who is a professional in the field of social work, to manage and guide the Targeted Intervention (TI) Programme. Detailed guidelines have been formulated by NACO for the short listing of NGOs and for their training and orientation in Targeted Interventions. Care and Support HIV/AIDS is not merely a condition of ill-health, but a situation of great economic, social and psychological upheaval for individuals, families and communities. The National AIDS Control Organization (NACO) recognized clearly that there is a moral and humanitarian obligation to provide appropriate care and support to persons infected with HIV/AIDS. These patients are mostly the young, between the age group 15-45 years. If some kind of normalcy is maintained or the quality of the life is improved even for a short period, it would be rewarding. The purpose of investing on care is manifold suffering is reduced, and also, improvement is seen in the quality of life. NACO has spelt out a clear policy for care and support for people living with HIV/AIDS. Policies for the Care and Support of the HIV+
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The general policy on care and support of person living with HIV/AIDS (PLHAs), is to build up a continuum of comprehensive care comprising of clinical management, nursing care, counselling and psycho-social support through home-based care, without any discrimination. From the health care point of view, the existing services are not only inadequate, but also very often inappropriate to provide care and support to those who are already affected. The health care services therefore need to be completely reoriented. Health care workers must develop special skills for taking care of those living with HIV/ AIDS. Not only the health care workers, but the families and the communities too, have to be mobilized and trained to help the affected and their families, as well as to support those orphaned by AIDS associated deaths. Components of HIV/AIDS Care (I) Clinical Management of HIV/AIDS 1 . For the clinical management of HIV/AIDS, various guidelines have been prepared. With the help of these manuals and modules, NACO has organised workshop for specialists and medial officers for training of the trainers in the medical colleges and major hospitals and 31 States and Union Territories of the country. It was a structure training so that those trained in these workshops would train other specialist and medical officers down the line in medical colleges and hospital so that a saturation training is achieved. The trainers in the medical colleges will further train the district hospital staff (medical and para-medical staff). All the government hospital and institutions have been started to be non-discriminative in managing HIV/AIDS cases. Funds are being released to State
2 .
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AIDS Control Societies for purchasing of medicines for management of different opportunistic infections in AIDS patients. 3 . For control of hospital acquired infections, States are being told to provide incinerators and other protective materials. Proper supervision is done in government hospitals and institutes for control of hospital acquired infections.
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(II) HIV/AIDS Nursing Care () i completion of training for HIV/AIDS nursing care, palliative care, use of universal precautions for all the nurses and for all the government hospital and institutions. (i ensuring supply of appropriate drugs and nursing i) supplies including protective materials. (i) monitoring and supervision of organisational ii nursing care from time to time. (III) Continuum of Care HIV/AIDS is a disease with long incubation period. People suffering from this condition require a long, continuous treatment, and palliative care in the terminal phase. Hospital care in such condition is not feasible. So, home based care of care is absolutely necessary for care of such cases. Home-based care has to be monitored and the monitoring has to be done by community-based NGOs. A patient with AIDS, needs psychological support that pre-requires assistance by trained family members. The care providers will be members of the family and NGO volunteers. Ordinary symptoms like cough, diarrhoea will be treated by the family members. Together with NGO volunteers, they will be looking after the patient at home. They will be
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trained as to when to refer the patients to the dispensary for medical care. The dispensary staff doctor and primary health care doctors are competent enough to know when to refer the patient to the referral hospitals about counselling, diagnosis, medical treatment and nursing care. At home, family members will be trained how to deal with excreta, the swelling and the blood spit, and if there is, how to clean them. Moderate universal care will be taught to them during training, in order to make home care is possible. (IV) Community Care Community care is an age-old concept practiced since thousands of years under the Indian System of Medicine, Ayurveda. Under this system, patients are provided care and support in hermitage life settings, therefore, giving an ideal situation for the patients for living a life free from discrimination and hatred. For providing community care to the AIDS patients, a centre has already been opened by the Sisters of the Missionaries of Charity, and has been functioning since 1995. Community care centers can be useful in the following ways:
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it serves as a place to counter the negative response. it is managed as a part of an integrated cost-effective care system. it serves as an intermediary between hospitals, home- and community-based care system. it promotes a community response to the constituents of HIV infection.
Anti retroviral therapy. Since 2004, the Government of India is providing antiretroviral therapy in selected centres through out the country. The program provides medication to mothers, children, and men, who are being treated only in the Government hospitals. This does not cure the patient but reduces the mortality and morbidity
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rates, but it is costly and strict adherence is necessary for it to be effective.
Initiatives by the United Nations

Different agencies of the United Nations have been actively collaborating with the Government of India on different aspects of HIV/AIDS prevention and control in India. Let us begin our discussion on UNAIDS, one of the most important agencies responsible for coordinating the work of various U.N. bodies for the prevention and control of HIV/AIDS in the world. UNAIDS In order to address the challenges posed by the HIV epidemic, the United Nations took the first step by drawing six allied organizations together in a joint cosponsored programme the Joined United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS is the leading advocate for worldwide action against HIV/AIDS. The global mission of UNAIDS is to: ( ) prevent the spread of HIV. 1 ( ) provide care and support for those infected and 2 affected by the disease. ( ) reduce the vulnerability of individuals and 3 communities to HIV/AIDS. ( ) alleviate the socio-economic and human impact of 4 the epidemic. The goal of UNAIDS is to catalyze, strengthen and orchestrate the unique expertise, resources and networks of influence that each of these organizations offer. These co-sponsors work together with UNAIDS, to reach out through strategic alliances with other United Nation agencies, national governments, corporation,
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media, religious organizations, community based groups, regional and country networks of people living with HIV/ AIDS and other non-governmental organizations (NGOs). The UNAIDS Co-sponsors Working singly, jointly and with the UNAIDS Secretariat, the seven co-sponsoring organizations of UNAIDS offer countries a broad range of experience, effort and resources of relevance to fight against the epidemic. The seven co-sponsoring resources organizations are UNICEF, UNDP, UNFPA, UNDCP, UNESCO, WHO and World Bank. A brief discussion about the work performed by each UN agency in the area of HIV / AIDS is given below. The United Nations Childrens Fund (UNICEF) UNICEF mobilizes the moral and material of governments, organizations and individuals worldwide, in a partnership committed to giving children a first call on societys resources in both good times and bad. A decentralized operational agency, the UNICEF works with governments and NGOs to improve the lives of children, youth and women. Adolescence being a period of increased risk and a window of opportunity to adulthood, the epidemic has critical significance for adolescents. UNICEFs priority programme areas in HIV / AIDS include youth health, school AIDS education, communications, assistance to children and families affected by AIDS, and the prevention of mother-to-child HIV transmission. The United Nations Development Programme (UNDP) UNDP supports countries in strengthening and expanding their capacity to respond to the development implications of the HIV / AIDS epidemic. UNDP emphasizes support to initiatives that catalyse
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community and national mobilization; create a supportive ethical, legal and human rights framework; improve gender sensitivity; empower people to take charge of their own well being, drawing on local resource and building on local knowledge and values; and fostering an enabling political, economic and social environment. UNDP is responsible for assisting the Secretary General in strengthening the Resident Coordinator system through which the UN Theme Groups on HIV/ AIDS operate. United Nations Population Fund (UNFPA) The mandate of UNFPA is to build the knowledge and capacity to respond to needs in population and family planning. Reproductive health is major focus of UNFPA, support and includes family planning and sexual health, of which HIV prevention is an integral component. In its reproductive health activities, UNFPA gives special attention to adolescent, to Information, Education and Communication (IEC), and to the training of service providers. Among other things, UNFPA brings to UNAIDS, a vast network of country-level offices, which support national reproductive health programmes, its expertise in reproductive health promotion and service delivery, specially focussed on the needs of women, and its experience in logistics management of contraceptives, including condoms. United Nations Drug Control Programme (UNDCP) UNDCP which became an UNAIDS co-sponsor in April 1999, is responsible for coordinating and providing effective leadership for all United Nations Drug Control Activities. Because HIV spreads through drug use, both via shared injection equipment and as a result of the
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disinheriting effects of drugs on sexual behavior, international durg control is a vital tool for HIV prevention. In this context UNDCP is active in supporting HIV / AIDS prevention programmes and including prevention through its own programmes to reduce the demand for illicit drugs. Youth and high-risk groups are of particular concern. United Nations Educational, Scientific and Cultural Organization (UNESCO) UNESCO is to foster international cooperation in intellectual activities designed to promote human rights, to help establish a just and lasting peace, and to further the general welfare of mankind. Thus, the ethical imperative is central to UNESCOs mandate. In its own domains of competence education, science, culture and communication UNESCO can bring the vast network of institutions with which it collaborates in the fight against AIDS. World Health Organization (WHO) WHO is the directing and coordinating authority on health at the international level. In 1986, WHO established the Special Programme on AIDS, later renamed the Global Programmes on AIDS. This was however, dismantled in 1996, with the creation of UNAIDS. Through WHOs new initiative on HIV / AIDS and Sexually Transmitted Infections (STIs), the Organization contributes by providing countries with expertise in areas relevant to the health sector. These areas include: strengthening HIV and STD prevention (particularly those vulnerable and/or at increased risk); ensuring safe blood supplies; surveillance of HIV, AIDS and STDs; developing health policies and standards; planning of integrated services; caring for people with STIs and/or HIV/AIDS; and evaluating STI/HIV policies
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and programmes. World Bank The mandate of the World Bank is to alleviate poverty and improve the quality of life. HIV / AIDS entails enormous loss of human and economic resources, and poses a substantial threat to the economic and social growth of many nations in the developing world. Between 1986 and early 1999, the Bank disbursed over US$ 750 million for more than 75 HIV / AIDS projects worldwide. Most of these resources were provided on highly subsidized terms through the International Development Association. In its policy dialogue with borrowing countries, the Bank stresses that the epidemic is a development priority and highlights the need for toplevel political commitment, systematic health sector reforms, human rights protection, and a range of multisectoral reforms to help reduce the factors contributing to HIV spread. Whenever possible, other co-sponsors or members of the UNAIDS Secretariat provide technical assistance to Bank-assisted activities.
Collaboration with Bilateral Donor Agencies

Let us now explore and discuss some of the major contributions made by the other bilateral agencies in India, for the prevention and control of HIV/AIDS. US Agency for International Development (USAID) USAID has provided US$ 10 million for implementing NGO based HIV / AIDS prevention and control activities in Tamil Nadu. This project commenced in February, 1995. The initial support was for a period of seven years. The activities funded by this project-mainly focus on development of IEC systems and condom promotion.
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Norwegian Agency for Development (NORAD) In addition to extensive support to NGO activities throughout the country, NORAD has contributed financial support for HIV / AIDS intervention programme in the red light-areas of Kolkatta. This is being coordinated by All India Institute of Hygiene and Public Health, Kolkatta. A contribution of US$ 500,000 was also provided for inducting the National Physicians Training Programme, conducted by Christian Medical Association of India, in collaboration with NACO and WHO. Department for International Development (DFID) The DFID is providing financial support of 1.5 million for the Sexual Health Project in West-Bengal for a period of three years. The focal objective of this programme is to implement STD/HIV prevention and control programmes and develop IEC techniques. DFID is also supporting activities by NGOs in a number of states; the European Union, has earmarked Euros 500,000, which will be channeled through a nodal agency, viz. Voluntary Health Association of India.
Conclusion
In this lesson you have learnt about the growing concern towards HIV / AIDS in the Indian subcontinent. The Government of India launched the National AIDS Control Programme in 1992 and the objectives of the program were to establish a comprehensive multi-sectoral programme for the prevention and control of HIV/AIDS mortality associated with HV infection and to minimize the socio-economic impact resulting from HIV infection. The main components of the National AIDS Control programme were also discussed. Various initiatives taken by the UN and allied bodies
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such as UNESCO, UNAIDS, UNDP, UNFPA, UNDCP and WHO, had been described. Other than these agencies collaboration with the various bilateral donor agencies such as USAID, NORAD, DFID and EU have also been discussed in this chapter.
References
NACO (1999). Country Scenario 1997-98, NACO, New Delhi. Thomas, Gracious (2001). HIV Education and Prevention: Looking Beyond the present, Shipra Publications, New Delhi. Thomas, Gracious (1997). Prevention of AIDS: In Search of Answers, Rawat Publications, New Delhi. Thomas, Gracious (1995). AIDS and Family Education, Rawat Publications, New Delhi.
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Social Work Intervention in Prevention and Control of HIV/AIDS

*Rose Nimbiakkim
Introduction
In India, HIV which causes AIDS appeared much later than any parts of the world. However, the disease is spreading with unprecedented rapidity and has now emerged as a serious socio-economic and public health problem. HIV and AIDS is a term in todays world that has become synonymous with epidemic. The truth is that the HIV/ AIDS pandemic have affected not only the adults but even the youth and the children. Hence, it becomes all the more important to know the various interventions in the prevention and control of HIV and AIDS so that we all are able to live a safe and long life. Stigma and discrimination towards the victim and the family are the major obstacles to effective HIV/AIDS prevention and control. Social work has developed into a full-fledged profession and its methods and fields are quite diverse. The fields in which social services are rendered are gradually expanding and there is an increasing demand for such services as the non-availability of trained social workers affects the quality of services delivered to especially the HIV infected patients. Social workers play a major role in putting into practice the different kinds of intervention
* Rose Nimbiakkim, IGNOU, New Delhi
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meant for people living with HIV and AIDS or to bring about the prevention and control of this deadly disease.
Need and Importance of Prevention and Control

According to the UNAIDS 2008 report, there has been a decline in the number of new HIV infection from 3 million in 2005 to 2.7 million in 2007. More so, the number of infected individual dying has fallen from 2.2 million in 2005 to 2 million in 2007. The number of people taking treatment for HIV has increased to 1 million in 2007. All these have been possible because of the awareness that has been disseminated to individuals time and again by different agencies all over the world and that the infected person has realized the importance of preventing the virus and seeks treatment to contain its further spread. Treatment programmes have continued to expand and meet new challenges over time. Many clinics are now seeing patients responding well to antiretroviral treatment. Still, in 2007, 55 countries reported that fewer than 25 percent of adults and children in need of those therapies received them. And 88 out of 113 developing countries reported that fewer than half of mothers received services to prevent the transmission of HIV to their children during birth (UNAIDS 2008). It is important for every country to know their epidemic and have knowledge about the prevention and control of the epidemic. Most have acted on it, but they needed to know more than just the numbers or the districts where infections were happening. Prevention and control of HIV and AIDS is much needed so as to enable the health worker or the social worker to work towards prevention and undertake educational programmes informing all sections of the community in
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order to confront fears, attitudes and prejudices that may arise. It is also needed to encourage examination of biases towards people living with HIV and AIDS (PLHA) and biases towards practices obtaining accurate information about HIV/AIDS. Apart from obtaining information it becomes important to provide care and support to PLHA. Distancing oneself from the responsibility of care and providing support to PLHA will not help in combating the virus. Instead, at all levels one should be freed of all kinds of discrimination and not alienate PLHA from the society but enable them to live within the society with no differences. Let us now read the kinds of care and support that are provided to the PLHA by the social workers.
Social Work Intervention Through Care and Support

HIV and AIDS is a deadly disease. The PLHA need constant care and support but in most cases family members also shy away from such responsibilities. This leaves the PLHA nowhere and all the more dejected and depressed. Nonetheless, things are now changing with the advent of social workers in the area of HIV and AIDS. They are more informed, trained, have the required skills to work with PLHA and also have the ability to bring a smile on the faces of PLHA. In providing care and support to the PLHA, the social workers are the front-runners in this battle against HIV and AIDS. There is abundant evidence that science-based HIV prevention is effective, especially when backed by highlevel political leadership, a national AIDS Prevention and Control programme, adequate funding, and strong community involvement. Components of successful prevention efforts include clear and accurate communication about HIV/AIDS and methods to prevent
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infection, HIV counseling and testing, and treatment of sexually transmitted infections. The vast majority of people living with HIV/AIDS in the developing world do not have access to treatment, as a result of limited health care infrastructures and the high cost of many medications. When we talk of care and support of people living with HIV and AIDS, there is a whole lot of intervention that comes under the umbrella of care and support. Social workers are the mainstay in all the intervention. They are the ones who are providing care and support to the PLHA without any discrimination. The primary aim of providing care and support is to prevent the spread of HIV including risk behavior change for HIV+ve persons. Provision of Support i.e.: emotional, social and economic consequences of infection and to provide practical assistance and advocacy including palliative care and hospice care. Lobbying for and mobilisation of minorities and stigmatized groups and ensure equitable delivery of services, and development of resources where they do not exist.
Counselling
Let us first talk about counselling as a medium of providing care and support. Counselling is a professional area of work and only a trained and skilled person can give counselling. All social workers are trained in the area of counselling and are qualified to give counselling even to PLHA. In fact trained social workers are the best choice to provide counselling to PLHA as they have developed the required skill and have the right knowledge about the disease. Counselling refers to leading the client to understand and face up to real life situations and from there to
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make choices based on such understandings (Baruth, G and Robinson, H, 1978). Counselling as a process is concerned with influencing behaviour change on the part of the client which is solely voluntary. Social workers who are experienced counselors significantly help the people living with HIV and AIDS to learn how to confront certain interpersonal, emotional and decisional problems. They ensure passing on correct information, provide support at times of crises, and encourage change when change is needed for the prevention or control of infection. The techniques used by social work counselors may vary and perhaps also within countries depending on the background of the people being counseled and the type of health or social services locally available. Effective counselling need not follow any set pattern or approach. It should certainly not be restricted to a clinic or a structured doctor patient situation. The most successful counseling often takes place outside the context of formal relationships. Social work Counsellors feel that counselling people with HIV infection is important because infection with HIV is lifelong as of now. Besides a diagnosis of HIV infection can create enormous psychological pressures and anxieties that can delay constructive change or worsen illness, especially as HIV epidemic has given rise to fear, lack of understanding and discrimination. Further, most importantly counseling also promotes behaviour change which can prevent a person from acquiring HIV infection or transmitting it to others. International Non-Government Organisation International Non-Government Organisations (INGOs) also play an important role in providing care and support for PLHA and the social workers working with the INGOs are well equipped and informed with regard to the
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disease. One such example of the INGO working for the prevention and control of HIV and AIDS is: The Global Fund. The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution, invests the worlds money to save lives. To date, it has committed US$ 15.6 billion in 140 countries to support large-scale prevention, treatment and care programs against the three diseases. In the field of HIV and AIDS in particular, the Global Fund has brought about a change, only for the better. As of 1 December 2008, with Global Fund resources, 2 million people are receiving antiretroviral treatment; 62 million HIV counseling and testing sessions were conducted; and 3.2 million orphans were provided with medical services, education and community care. The Global Fund for HIV and AIDS is one such example of International agencys or the International Non-Government Organizations effort towards prevention and control of HIV/AIDS. Hospice and Palliative Care Hospice and Palliative care is one of the most recent interventions by social workers all over for taking care of the infected. Social workers have always felt the need to incorporate the principles and practices of social work into the management of patients with advanced HIV infection and AIDS through the hospice and palliative care and have been successful till date. However, HIV/ AIDS and hospice and palliative care have had a chequered history. In the early days, accepting hospice and palliative care was equated with giving up. Then as the death rates increased in the early 1990s, hospice and palliative care became a little more acceptable. But what actually is hospice care? In laymans term Hospice care treats the person rather than the disease. Hospice, in the earliest days, was a concept rooted in the centuries-old idea of offering a place of shelter and rest,
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or hospitality to weary and sick travelers on a long journey. In 1967 Dame Cicely Saunders at St. Christophers Hospice in London first applied the term hospice to specialized care for dying patients. Today, hospice care provides humane and compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible. In laymans term Palliative Care may be defined as care intended to keep the person with HIV/AIDS healthy for as long as possible. WHO has defined Palliative Care as an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care according to WHO includes the following among others:
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Provides relief from pain and other distressing symptoms; Affirms life and regards dying as a normal process; Intends neither to hasten or postpone death; Integrates the psychological and spiritual aspects of patient care; Offers a support system to help patients live as actively as possible until death; Offers a support system to help the family cope during the patients illness and in their own bereavement; Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; Will enhance quality of life, and may also positively influence the course of illness;
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Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
For preventing the extension of the virus to vulnerable groups, including children of HIV-positive parents, the aim should be centered on generating a positive and an enabling environment whereby positive persons and their families have proper access to the proper social and medical services available. Palliative and Hospice care for HIV-infected individuals becomes increasingly important as the disease progresses. The use of trained community social/health care workers such as volunteers, medical assistants, counselors, and family members could provide opportunities to expand the delivery of palliative and hospice care in the community setting. Trained community health workers can provide basic nursing care, support for treatment devotion and HIV prevention, monitoring and assessment of medication impact, referrals, pain and symptom assessment and management, psychosocial and nutrition counseling, and determination of need for, and provision of, social support (such as referrals to community-based support groups and income-generating activities). The success of palliative and hospice care programs depends on the involvement and leadership of PLHA. As a result of their personal experiences, PLHA can contribute to better the understanding of the true needs of other PLHA and best practices for HIV care and support. PLHA are often the best counselors and educators for others who are HIV-positive and their families, particularly in regards to treatment and pain management. All care and treatment programs must
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make a concerted effort to recruit PLHA and support leadership roles for them. At the same time appropriate awareness should be brought to the knowledge of the general public which is correct information. For this, the role of media is well defined. The Information technology has seen progress over the years and as of now, the media is being used, even if in a small way, to deliver message on HIV and AIDS.
Social Work Intervention Through Awareness

Mass media is an important communication strategy to generate awareness and disseminate information on HIV/AIDS. Despite ardent efforts to bring about awareness/information related to HIV/AIDS being made by governmental and non-governmental agencies, the misconceptions relating to HIV/AIDS continue to outpace the efforts to educate people regarding the disease. Thus, now in the 21st century with our technological advancements the role of mass-media has become increasingly significant. The tasks before visual and non-visual mediums of media are not only to create awareness and provide knowledge about HIV/AIDS but also to remove the misconceptions about the transmission of the virus and the social ostracism suffered by the infected and the affected persons. The lack of information leads to denial and rejection of PLHA at personal and societal levels. On the other hand, the technological advancement has been put to the maximum utility by the social workers. They have become well-versed with the different medium of spreading information, be it the TV, Radio or the internet. Many social workers have opened websites discussing the problems related to HIV and AIDS for PLHA who are unable to talk to anyone but can voice
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their opinion and fears without anyone knowing their identity. Further a data base of hospitals and clinics as well as good doctors have been created by some social workers as a reference sites for those affected and infected with HIV and AIDS; who wants to undergo treatment but unsure where to go. The World Wide Web provides an instant connectivity for people all over the world and one can have a discussion on the issues of HIV and AIDS whereby unknowingly creating further awareness among people who had little or no information about HIV and AIDS. The social workers play an active role and try and break down the myths that may arise providing the audience with valid and relevant information. While addressing the Media Leaders Summit on HIV/ AIDS in 2006, the Prime Minister of India, Dr. Manmohan Singh stressed on strengthening the national AIDS control efforts as commitment of the National Common Minimum Programme. He emphasized the need for supplementing all such efforts with an active and avid participation from all sections of the society culminating in a mass movement for creating awareness of AIDS. He further added that while focusing attention on research for finding a vaccine for this pandemic, no stone unturned should be left in preventing its occurrence by using media in an intelligent and creative manner. In the absence of a vaccine, the social vaccine of education and awareness is the only preventive tool we have. It is appropriately said that prevention begins with information. Media, which conveys information and moulds public opinion, must remain at the heart of our campaign to help people make informed choices. In most developing countries radio is an effective medium to reach general population. Unlike TV and print, Radio phone-in shows can be popular platforms for direct audience participation to exchange views and voice
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concerns on public health awareness. As we talk about communication strategies designed to generate awareness and disseminate information on a socially relevant issue like HIV/AIDS, it goes without saying that mass media serves a very important function. With an aim to increase accurate knowledge on HIV/AIDS, encourage open discussion on sexual health and promote sustained behavioral change towards prevention social workers are now donning the hat of being a radio jockeys and providing information on HIV/AIDS. The All India Radio (AIR) also airs programme related to HIV/AIDS every week, which discusses the various concerns of PLHA and the disease itself. PLHA also don the hat of being a radio jockey and share their experiences. For instance, the Members of five zones of the Maharastra Network for Positive People (MNP+) were selected to participate in the first radio training workshop as part of a proposal by Mumbai-based, The Communication Hub (TCH). The proposal, which is one of the 25 programmes supported by the World Bank for South Asia Regional Development Marketplace 2008, is called Tackling HIV/AIDS Stigma and Discrimination: From Insights to Action. This is one such example where an NGO trains HIV patients with radio journalism to fight discrimination. Some television programmes have been known to bring about a change in peoples attitude towards PLHA. More so, there information about the HIV is doubled after watching such programmes or short commercials. For instance, take the message on TV where you see a famous bollywood actress, Shabana Azmi walking in a hospital with a group of journalists. She then turns her steps towards a ward where HIV+ people are kept. The journalists hesitate to enter the ward but she tells them HIV/AIDS is not spread by touching or hugging, we spread love by touching and hugging. Hearing this, the
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journalists then enters the ward. The purpose of citing this TV clip is to help you understand that such messages have brought about a drastic change in the way people behave with PLHA. Earlier they were treated as untouchables but when such messages are shown on the television sets viewers receive information and become more aware thus, enabling them to be more sensitive to PLHA. According to a survey conducted in India, about 70 per cent of Indians identified television as a primary source of information about HIV/AIDS. The television programmes should therefore, focus on dissemination of related information and realities pertaining to the epidemic so that the ignorance is replaced by awareness and then creating multiplier effects of awareness engulfing the wider cross sections of the society. Indira Gandhi National Open University also organizes an annual National Seminar with HIV and AIDS as its main focus. These seminars have helped bring about awareness among the practitioners, academicians as well as students of social work. The participants of the seminar till date have taken initiatives in their states, at their own local areas to address the issues of HIV/ AIDS. Some of them included methods such as the formation of a human chain on World AIDS Day from the district headquarter of Kottayam to Cochin in Kerala which is about 80 Km. Also in Andhra Pradesh, one of the Social Work Educators after being motivated by the seminar started an activity of sensitizing the schools/ college students and the activity had such an impact on the students that they took a pledge voluntarily to provide HIV/AIDS test certificate to their would be spouse and demand the same from them so that they are able to live HIV/AIDS free and enable the others to do the same.
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In fighting the menace of HIV/AIDS, mass media is doing an impressive work but much more is required to be done. The task at hand requires vision, dedication and above all the creative programming that truly engages audiences with riveted attention. The most important tool at hand to engage people and disseminate information on HIV and AIDS is education. The first thing a man does after he is born is learn. So, the education sector can and does contribute significantly to national and international responses to the HIV epidemic. Let us now look into the social workers role as the torch bearers of educating the people about HIV and AIDS.
Social Work Intervention Through Educating on HIV/AIDS

Education has been defined as the activities of educating or instructing; activities that impart knowledge or skill. This hold true when we talk about education with regard to HIV and AIDS as disseminating information and knowledge related to HIV and AIDS is an activity that has been undertaken to impart knowledge and awareness. Through formal education settings, the sector can reach children and young people and educate them about HIV and AIDS. Through learning in nonformal education settings, HIV and AIDS education can reach out-of-school children and young people, parents and communities. Furthermore, education on HIV and AIDS can be an important force for addressing deeper socioeconomic, cultural and development issues. To educate people about HIV and AIDS, it is necessary first to overcome denial. Every country in the world, which has been faced with the problem of HIV and AIDS first reacted by denying the existence of the problem and this is where the social workers and their roles
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become magnified. Social workers campaign tirelessly going from schools to school and colleges to colleges talking about and breaking the myths related to HIV and AIDS. They are able to retain the enthusiasm of the students and also derive an active participation from them by holding poster competitions, essay writing and debates around issues related to HIV and AIDS in schools and colleges in different states of the country. The social workers also conduct capacity building programme among the adolescent groups in the schools and colleges and also provide them with life skills training so they are able to live a free and safe life. However, one cannot escape the fact that the AIDS education programme in India is still in its infancy. There are many areas in which the concerns about the AIDS pandemic interact with the fabric of the society. Such interaction becomes particularly intense and conflicting around the issue of AIDS education, a subject that appears erratically in the curriculum of medical colleges. Earlier there was no enrichment or a certificate, diploma programme on AIDS, anywhere in the country but Indira Gandhi National Open University (IGNOU) School of Social Work started the Certificate in HIV/AIDS and Family Education (CAF) as well as the Diploma in HIV/AIDS and Family Education (DAFE). IGNOU has also tied up with the Florida State University for the Master in Social Work programme. It has also jointly collaborated with AIDS Healthcare Foundation (AHF) and has launched a 3 months HIV Medic programme in 2008. It is the first collaboration in the country to offer such awareness programme. In the course under HIV Medic, paraprofessional healthcare workers are trained to assist clinicians in the provision of antiretroviral therapy (ART) for people living with HIV. The HIV Medic training is designed for students with no prior medical
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training or experience. Such a programme will again increase the involvement of social workers in the intervention for the prevention and control of HIV and AIDS. Several schools of Social Work taking a cue from the success of IGNOU have initiated an awareness programme and counselling services on HIV/AIDS. An example of such a school is the Sacred Heart College, Tirupatur as well as Loyola College, Trivandrum. Tata Institute of Social sciences has also introduced a certificate course in social work apart from their graduate; postgraduate courses and M.Phil and Ph.D in social work. The main objective of the Certificate in Social Work programme is to throw open the doors of professional social work education to those who cannot engage in full-time study. This course was developed in response to the need for more front-line workers to work at direct service delivery levels in social welfare organizations. The University Grant Commission (UGC), which is the apex body for higher education in the country has proposed the introduction of a compulsory course on AIDS at the undergraduate level. Heeding to this, as many as six schools of social work in the country have introduced AIDS as a unit in their social work curricula. In 1991, Universities Talk AIDS was started by the National Service Scheme, Department of Youth Affairs and Sports in collaboration with the WHO and Ministry of Health in 59 universities across India. The programme included seminars, workshops, debates apart from role-plays to sensitize the youth. National AIDS Control Organisation provides leadership to HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. State AIDS Prevention and Control Societies (SACS) implement NACO programme at state level, but have functional independence to upscale and innovate. SACS are
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autonomous and decentralized. Each State AIDS Prevention and Control Society has a governing body, its highest policy-making structure, headed either by the minister in charge of health or the chief secretary. It has on board representatives from key government departments, the civil society, trade and industry, private health sector and PLHA networks, who meet twice a year. It approves new policy initiatives, annual plan and budget, appoints statutory auditors and accepts the annual audit report. For better financial and operational efficiency, administrative and financial powers are vested in the Executive Committee and the Programme Director. The functions of SACS are:
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Medical and public health services; Communication and social sector services; and Administration, planning, coordination, monitoring and evaluation, finance and procurement.
For example, in Delhi, there is the Delhi State AIDS Control Society (DSACS), like that also, there are Nagaland State AIDS Control Society (NSACS), Maharastra State AIDS Control Society (MSACS), etc. Till date education is the best and the only AIDS medium available in the world. Until some vaccine is developed, the only way to prevent and control the spread of AIDS transmission is to educate people from every walk of lf. ie Multilateral efforts are also being made at global level such as United Nations, Individual countries, USAID (U.S), DFID (U.K.), European Commission etc. There are other various prominent NGOs like Bill Gates Foundation, Aga Khan Foundation, etc.
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Social Work Intervention Through Advocacy and Policy Planning

HIV/AIDS is development issue with devastating social and economic consequences. Its control is complex, difficult and costly, and needs strong determination and practical interventions. Experience has shown that strong political and a good Government is necessary in spearheading the fight against the epidemic. The prevailing political and Government commitment is expected to be sustained at all levels and that the Government accountability in the fight against the epidemic is strengthened at all levels. The Right to Life is the most important Fundamental Right. If a persons very existence is not protected, all other rights will have no meaning. The right to life does not mean only a physical existence. It includes all those things which enable a person to live with dignity like the right to food, shelter, clean environment, health and education. The Fear of stigmatization may prevent people living with HIV/AIDS from seeking early treatment. For this reason advocacy becomes necessary to protect the rights of PLHA so that they are able to live a life of dignity. But, what do we actually mean by Advocacy? According to Cohen, Advocacy is the pursuit of influencing outcomes including public-policy and resource allocation decisions within political, economic, and social systems and institutions that directly affect peoples current lives (Cohen, 2001). Advocacy for HIV/AIDS prevention is the combined effort of a group of individuals or organizations to persuade individuals; groups and organizations through various activities to adopt an effective approach to HIV/AIDS as quickly as possible. Advocacy also aims at starting, maintaining or increasing specific activities to a scale where they will effectively prevent HIV transmission
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and assist in the treatment, care and support of PLHA. The social workers at the national and international level of HIV and AIDS prevention and control are solely responsible for bringing about a change in the lives of PLHA with their determined pursuit to influence behavioral change among the people living in fear of HIV and AIDS. The advocacy activities undertaken by the social workers should aim to protect the rights of PLHA and it should be able to bring a balance between the long term and short term goals of intervention for HIV and AIDS. It should also concentrate on the prevention, control; care and support of PLHA. The objectives of advocacy worked upon by the social workers must relate to approaches and activities shown by research to be effective in addressing HIV and AIDS but it should be kept in mind that the specific and targeted advocacy activities should fit the social, cultural, political and legal context of the society and bring about the involvement, to the extent possible, of PLHA in the planning, implementation and evaluation of programmes. The social workers are furthermore, responsible for positioning various national, international as well as organizational policies to the advantages of PLHA. The word policy is not a tightly defined concept but a highly flexible one, used in different ways on different occasions. Websters dictionary has a number of closely related definitions. They are:
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A definite course or method of action selected (by government, institution, group or individual) from among alternatives and in the light of given conditions to guide and, usually, to determine present and future decisions. A specific decision or set of decisions designed to carry out such a course of action.

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Such a specific decision or set of decisions together with the related actions designed to implement them.
Policies may be written which may become a law or unwritten policies for e.g. etiquette or social mannerism. Policy may be formal such as the national AIDS programme or informal such as certain office rules which do not want to provide employment opportunities to PLHA. In regards to HIV and AIDS the policy planners have to be very careful so as not to hurt the sentiments of PLHA as put forward by the social workers and at the same time the policies should also be accepted by PLHA and those affected by it. While planning a policy for HIV and AIDS, the policy planers should aim the following:
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To minimize the possibility of HIV infection for the country; To ensure a supportive work environment for people infected and affected by HIV/AIDS; To manage and mitigate the impact of HIV/AIDS on the population; To eliminate stigma and discrimination in the social sphere on the basis of real or perceived HIV status, or vulnerability to HIV infection; To ensure educational opportunities for children orphaned due to HIV and AIDS; To protect the rights of vulnerable survivors, such as widows and orphans; and To raise awareness in communities in order to combat discrimination and stigma associated with HIV/AIDS.
Conclusion
This chapter dealt with various areas of intervention by the social workers for the prevention and control HIV
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and AIDS. You may have been able to explore the role of social worker in providing care and support to the PLHA; and their role as agent of disseminating information and awareness in educational institutions; Social worker have to play a major role in the advocacy and policy planning of PLHA. Though, it is a known fact that there are still many unresolved questions about how intervention at best can contribute to HIV prevention; the social workers are in the meanwhile, at best using the different prevention and controlling strategies to overcome situations faced by PLHA and those affected by the virus. However, what is beyond doubt is that effective AIDS responses still require the active involvement of people living with HIV and the positive attitude of the people towards PLHA.
References
AIDSCAP Project (1998). Policy and advocacy in HIV/ AIDS prevention. Arlington, VA, Family Health International. Baruth. G & Robinson H. (1978). An Introduction to the Counselling Profession, Sullivan Publishers: London. BSWE-005 (2006) Introduction to HIV/AIDS, Supplementary Reading Materials-1, School of Continuing Education, IGNOU, New Delhi. Chapman S. (2001) Advocacy in public health: roles and challenges. International Journal of Epidemiology, 30:12261232. Cohen, D., R. de la Vega, G. Watson. (2001). Advocacy for social justice. Bloomfield, CT: Kumarian Press Inc. Commission on AIDS in Asia (2008). Redefining AIDS in Asia- crafting an effective response Oxford University Press, New Delhi.
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Express India, Express News Service Posted: Sep 08, 2008 at 0223 hrs IST. Global Network of People Living with HIV/AIDS. Networks of people living with HIV/AIDS and resources related to involvement of people living with HIV/AIDS in advocacy and programmes. Web site: http://www.gnpplus.net International AIDS Economics Network. Focuses on the economics of HIV/AIDS. prevention and treatment, providing data, tools, and analysis for researchers. and policy-makers. Web site: http://www.iaen.org International Council of AIDS Service Organizations. An advocates guide to the. International Guidelines on HIV/AIDS and Human Rights. Toronto, ICASO, 1999. Joseph F. ONeill, Peter A. Selwyn, and Helen Schietinger (Eds) (2003) A Clinical Guide. To Supportive And Palliative Care For HIV/AIDS, HIV/ AIDS Bureau, Health Resources and Services Administration, US Department of Health and Human Services. National AIDS Control Organisation (2000) HIV AJDS Counselling Training Module, New Delhi. Thai Working Group on HIV/AIDS Projection and the Analysis and Advocacy (A2) Project in Thailand. The Asian Epidemic Model (AEM) Projections for HIV/AIDS in Thailand: 2005-2025, 2008. T. Gracious et al (1997). AIDS, Social Work and Law, Rawat Publication, Delhi. UNAIDS (2006). Scaling up towards universal access. Considerations for countries to set their own national targets for HIV prevention, treatment, and care. Geneva. http://data.unaids.org/pub/Report/2006/ Considerations_for_target_setting_April2006.pdf
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UNAIDS (2007) Practical guidelines for intensifying HIV prevention: towards universal access. UNAIDS (2007) United Nations and Global Fund framework to support civil society engagement in universal access from 2007-2010. Draft. Geneva. UNAIDS (2008). Report on the Global AIDS epidemic, Geneva. WHO (2007). Guidelines on Essential Prevention Interventions for Adults and Adolescents Living with HIV in Resource limited settings. Draft. Geneva. WHO (2008). Towards universal access. Scaling up priority HIV/AIDS interventions in the health sector, Geneva. Website References: www.unaids.org/en/KnowledgeCentre/HIVData/ GlobalReport/2008/2008_Global_report.asp (accessed 4th May, 2009). www.expressindia.com/latest-news/Now-NGO-trainsHIV-patients-with-radio-journalism-to-fight.../358638/ - 51k (accessed 7th May, 2009). www.theglobalfund.org (accessed 7th May, 2009). www.who.int/cancer/palliative/definition/en/ (accessed 4th May, 2009). www.aidsalliance.org/sw10473.asp - 23k (accessed 5th May, 2009).
11
Communication in HIV/ AIDS Prevention

*Jyoti Kakkar
Introduction
Communication is an integral part of every social exchange. Simply from interpersonal dialogue to global mass media (music, theatre or local radio) all of them have a specific role. Communication is a dynamic process that has shaped the development and growth of human civilization over centuries. Newer forms of communication keep on developing with advancement of technology. However, the traditional forms of communication keep on continuing in many traditional societies and can be well used to communicate and send messages to populations on even the most sensitive issues. This has been the case with communication for HIV/AIDS prevention in many countries. HIV/AIDS is a health problem with multiple dimensions. As is well known AIDS affects people, usually in their most productive years. It takes its toll on every family when those who are the bread earners are incapacitated and the burden falls on either the children or the elderly. The HIV virus has definitely been reported to have taken its toll on many communities and societies. With the burden of the disease falling on many societies it has been recognized as a developmental problem. Towards combating the pandemic of AIDS, many nations have taken a pro-active approach and evolved policies
* Dr. Jyoti Kakkar, Jamia Millia Islamia
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for AIDS prevention. Effective HIV/AIDS communication strategies are thus at the core of such policies and programmes.
Definition
The word Communication comes from the Latin word communis, meaning common. When we communicate, we are trying to establish commonness with someone. That is we are trying to share information, an idea or attitude. The standard definition of communication reflects the everyday usage of the term to communicate. It is defined as to impart, bestow, or convey, to make known, give by way of information. The New Websters dictionary defines communication as the act of communicating, transmission, the imparting or interchange of thoughts, opinions, or information by speech, writing or signs, which is communicated or imparted; a document or message imparting views of information There are numerous definitions of communications but the common strand running through them all is that communication is a social process of interaction through messages. According to Dennis Mc Quail, communication is a process which increases commonality. He describes human communication as the sending from one person to another, meaningful messages. An expanded definition considers communication as the processes of dialogue, exchange of information and resources, and the capacities that enable understanding, negotiation and decision making around an issue. Such an understanding of communication includes the technical focus on audiences and media channels for information in development communication programmes. It also brings into view the existing relationships and
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processes of dialogue in any setting, the resources and capabilities that different groups draw on for communication, and how these support individual and social change. Communication in development has often been understood in a technical sense to refer to the variety of ways of providing information and messages to people, and the different approaches and media channels for this purpose. Participatory communication suggests a need to go beyond delivering messages to particular groups of people to change their attitudes and behaviour, focusing instead on a two-way process of dialogue and participation. A wide array of communication interventions have proven effective from media and social marketing campaigns that raise awareness of HIV/ AIDS, to peer education that supports HIV prevention efforts in particular high-risk groups. Communication interventions that promote engagement and dialogue particularly among peers have been key for changes in behaviour. Any attempt to define communication has to take into consideration the idea of mutuality and commonness, an exchange, a shared environment, a social relationship among the participants, and the existence of a common need, urge, aim or goal.
Information, Education and Communication

The major approach of HIV/ AIDS prevention has been developing awareness, especially among the vulnerable populations. IEC (Information, Education and Communication) techniques have been used extensively and as a major strategy of prevention programmes in India. A look at the components of IEC is important. (a) Information (Mass Media): The media of mass communication have a significant role to play in creating
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and sustaining public opinion and the political will to deal with the HIV/AIDS epidemic. The media can facilitate certain trends and phenomenon in the community or society that facilitate the spread of HIV/ AIDS and inform the public about them. They help in educating the masses about the risk factors and about the importance of prevention. In doing so, they help create public awareness and mobilize public opinion against cultural practices that favour the spread of the epidemic. Radio programmes and television programmes are widely accessible to populations, including those in the rural areas. However, radio telecast lacks interaction with the people. The television provides a certain amount of flexibility in developing interactive programmes, making it a more people friendly medium, however there are huge variations in the number of television receivers across the world. A number of factors determine the usage of mass media in reaching out with the message of AIDS. Important groups are not reached out by the media prevention messages due to multiple factors. These can be political will and a possible repressive attitude of the authorities. Communities in remote areas and those that also communicate in minority languages are not reachable through use of media of mass communication. Also, in some cases the message may not be contextualized to the specific cultural context. In the context of AIDS, it is well understood that the content of the messages and an understanding of the behaviour it intends to change is important. For example, in some South African countries, media messages to rural, uneducated and poor populations have reinforced irrational fears, provoked rejection of sick people, resulting infact in a fatalistic attitude concerning prevention and selfprotection. Reportedly, in South East Asia there are
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tribal populations that were so scared by images broadcast on the television that they refused to hear more about the disease (see UNESCO, 2001). (b) Prevention Education: Education in the context of HIV prevention has mainly been targeting the youth. Specific information courses that are an integral part of the school curriculum were developed in many countries. It was aimed at reaching out to students and educators. All these efforts have highlighted the differences between the education levels, social/cultural background and local situations. Also it does not cover the out of school youngsters and illiterate populations. (c ) Communication (non-media): Communication here refers to the exchange of information between both professional information advisers and counsellors. In this context emphasis has been placed upon counseling. It is recommended that counseling should always accompany testing. This is to give them the right information and also to help them make future plans. Advocacy is also needed in areas of safe attitudes and practices, including the use of condoms. In all these areas there is a serious deficiency in the design of communication strategies, that aim at building a political will and a supportive societal and cultural environment. In India, IEC efforts operate at two levels. At the national level, National AIDS Control Organisation (NACO) is responsible for policy and strategy formulation, framing of guidelines for IEC activities and for implementing national level campaigns. On the other hand, at the state level, the State AIDS Control Societies (SACS) conduct communication need assessment studies and evolve their IEC strategies according to local priorities, within the overall national strategy and framework. Most of the field action takes place at this level. At both
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national and state level, political and media advocacy are being strengthened in order to create greater ownership of the programme which will result in impact awareness generation and behaviour change.
Traditional and Modern Means of Communication

Both traditional and modern means of communication have been used extensively in the HIV/AIDS prevention programmes. An understanding of the different types of media, their functions and the reasons behind choosing them is important. The term traditional means of communication refers to methods used in a specific culture for communication of ideas and dissemination of information. It is important to understand the relationship between communication and culture. When we discuss the components of culture such as art, mythology, religious practices, family, social systems, we can well understand the role communication plays in the perpetuation of culture. A number of people who live together and are bound by a culture cannot function as a group if they do not have common means of communication. Folk Media Folk media means media of the people. The word folklore and folk media come from the German root word volks (pronounced folks) which means people. Folklore refers to the myths, legends, folk tales, riddles, costumes, dances, dramas, songs, etc prevalent in a particular community. Folk medicine refers to the various means of communication available to the rural and tribal people. It does not require any special training or money for its implementation. Inexpensive material available locally is what is needed. The folk media is totally
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operationalised by the people of the community and is characterized by a face to face contact. It can well be understood that because of such an origin and its ownership by the people it has a tremendous influence on the community. Even where the modern media of communication have reached, folk media have their own role to play. India is a country with immense cultural wealth. There are as many as 6000 folk media and traditional art forms in India. They help in imparting the social values, preserving religious bonds, mobilizing people to take action around a common cause and preserve social bond and cohesiveness. Folk media are immediately recognisable vehicle for education; they are easily accepted by most Indian masses, it is therefore imperative for projects whose goals aim at behaviour change and sustainability in rural Indian settings to recognise and use the potential of folk media for the benefit of the rural folk as well as project implementers and funding agencies. Some of the most widely used traditional forms of communications are: Storytelling: It is probably the most universal among the various kinds of folk media. Many rural societies in India have a rich tradition of storytelling. The story teller uses histrionic gestures and rhythmic language to tell the story. The audience responds with laughter and body movements. The narration of the story sometimes goes late into the night. People normally gather in the village squares or courtyard. Themes of the stories can well bring forth the values that are held in a particular community or the traditions that are part of that culture. Tamasha: It is a lively form of folk theatre in Maharashtra. Its origin could be traced back to some 400 years old to the time of the Peshawas. A jester
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named Songadya acts as a master of ceremonies. He makes witty remarks. Tamasha uses both male and female artists. Tamasha has been traditionally used as a medium of entertainment and to communicate religious stories. Its contemporary use includes creating social and political change by generating public opinion. The government uses it today to popularise issues like family planning. Nautanki: It is a north Indian folk drama performed in an open theatre. This folk form gets its name from Rani Nautanki whose young lover disguised himself to get entry into her chamber. This form too has a narrator called sutradhar. Musical instrument like the kettle drum (makkara) and dholak are used. The dialogues are sung in popular folk melodies. Jatra: Jatra literally means journey. It is a popular folk theatre of Bengal and Orissa. The name of this form is derived probably from the habit of the performers who wander from place to place to perform. Most of the stories are related to Krishna and Radha. Jatra helped to popularise the Bhakti cult among the masses. Later it was used to popularise the Shakti cult. During the freedom struggle Jatra was used for popularising the movement. The form consists of choral singing (juri), acting and rhetorical flourishes. Bhavai: It is a leading folk theatre form in Gujarat. A jester or clown called Ranglo enters into dialogue with the Naik or Sutradahar. The bantering, satire and gesture of Ranglo provide laughter to the audience. He connects the past with the present and pokes fun at the political and social evils of the day. Bhavai uses a mixture of dialogue, mime, fantasy, acrobatics, magic tricks, dance and song. Various classical and popular music forms make this folk art a lively medium.
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Keertana: This folk art form is called Harikatha or harikeertan. It is a kind of concentrated drama, a monodrama in which a gifted actor portrays a series of characters and moods. It is believed to have spread from Maharashtra to Karnataka and Tamil Nadu about 150 years ago. Associated with the Bhakti movement, it was used by Kabir and Tukaram to preach religious faith and to bring about social and political reform. A different form of Keertana is used in Gujarat. Sumang Leela: It is a very popular folk drama in Manipur. In this folk form all the actors are women, dressed and disguised themselves into men and women. This folk form attracts lots of people and is usually held in the courtyard or public places around the colonies. Ballad forms: There are several distinct ballad forms in vogue in India to narrate stories. To name a few: Alha (Uttar Pradesh), Burra Katha (Andhra Pradesh), Jugani and Vaar (Punjab), Powada (Maharashtra), Villupattu (Tamilnadu). Folk Music: Folk music is another powerful traditional media in India. According to scholars, there are some 300 folk musical styles in India. The more popular among them are: Baul and Bhatiali (West Bengal), Doha and Garba (Gujarat), Chaiti and KAjari (Uttar Pradesh), Kolkali Pattu (Kerala, Bihu Assam, Mand and Panihari (Rajsathan), Rouf and Chakri (Kashmir), Susa and Dadaria (Madhya Pradesh), Mando and Dhalo (Goa), Boli (Eastern Punjab) And Layani (Maharashtra) Folk Sayings and Riddles: The rural folk of India appreciate these forms of communication regardless of their economic condition or educational status. These forms are rooted in the culture and tradition of the community that uses it. These media entertain as well as educate, and preserve social cohesion and harmony. They transmit religious and social values
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and cement a strong bond among the members of the community. Puppetry: Puppetry is essentially a folk art used since several centuries to relate myth and legend. The medium has undergone change and is being used in many present day situations to impart education, entertainment and even therapy. Puppetry is the art of animating figures representing human or animal motifs. Puppetry did not originate as a source of entertainment, but as a cult observance. It has continued as an enduring art though it has undergone changes in preparation and presentation. Modern Means of Communication The modern means of communication have been made use of extensively in health interventions. Mass media are used to sensitise populations on the threats and the measures they can adopt to for disease prevention. Polio campaigns, the DOTS programme for tuberculosis, early detection of cancer are some campaigns that have made an impact on the masses. Let us take a look at these: Radio: Radio is a cheap and useful communication tool. Almost every household in the Indian society, both urban and rural, owns one. Considering the affordability and accessibility, radio is the most popular medium in India. Radio has the capacity of being heard by a large, diverse audience. Folk media such as story-telling, drama, poetry recitals, proverbs and music on the radio will appeal to rural audiences. Radio also offers opportunities for interactive participation by local residents. All India Radio, Vivid Bharati, Primary channel and FM Stations regularly air programmes that help carry the message to far flung areas through programmes like Jeevan Hai Anmol and Lets Talk
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Print: Print Media plays a significant role in creating and increasing awareness on different issues of public concern, including HIV / AIDS among the people. Press campaigns featuring modes of transmission and prevention are a regular feature. Pamphlets, handouts, stickers, flash cards, wall hangings and posters are developed for greater reach. Television: Television could be an effective means of communication for HIV/AIDS prevention. Television is both audio-visual, so it is a powerful means of communication. Initiatives have been taken up by Government of India, under Ministry of Health and Family Welfare through NACO, a nodal agency for HIV/AIDS in India through television programmes. Prasar Bharati and BBC have collaborated to make advertisements which are aired across the country. Television serials called haath mila and jasoos vijay have been aired on primetime television, providing information and generating awareness especially amongst the youth. NACO sponsored the Kalyani Health magazine in eight of its regional doordarshan kendras where sports and film celebrities endorse messages on HIV/AIDS prevention. Internet/ Websites/Fax/Telephone: Internet is a good option for people who do not have much time to commute from one place to another place to collect data and compare it. With the advancement in technology the world has become a smaller place where one person can access information about the other country sitting on the computer. This advancement in technology has made the work of researchers easier and less time consuming. Internet system plays a vital role in disseminating information, research findings and results. Fax and telephone can also be used where there is no internet facility and according to the urgency of the message. Toll free numbers also play a significant
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role when people want to communicate directly with officials and experts. In India, a toll free number 1097 is operational in more than 80 cities which people can make use of to seek clarifications and more information on HIV / AIDS.
Choice of Medium
While choosing the medium of communication one should keep in mind the following factors: 1 . Type of audience: If the target audience we want to reach is educated, then the print form of communication may be used, but in case of uneducated audience, pictures, symbols or voice may be more suitable. Since levels of literacy tend to be lower in the rural than in the urban areas, radio serves as an excellent medium for reaching such audiences in many countries. Also, traditional forms of communication, such as folk songs, puppetry, street plays could be used considering the type of audience setting. Sensitivity of the issue: Many aspects in relation to HIV and AIDS are not suitable for communication through media of mass communication. When risk behaviours, stigma and discrimination are being discussed it needs a highly personalized setting. These topics then become part of the curriculum for outreach activities and are best handled by people who have undergone training for the same. Complexity of the issue: Many of the issues of the pre-test and posttest counselling are of a highly personal nature. They demand a very professional approach and a completely confidential setting. Given this, the Integrated Counselling and Testing Centers (ICTC) provide a suitable setting for such an interpersonal communication.
2 .
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4 .
Cost of the medium: Cost of the different channels of communication vary by type and also by country. Whereas TV productions and airtime may cost a lot of time, radio is much less expensive and can reach specific audiences (e.g. youth in the rural areas). Thus, cost plays a determining role in the choice of media. Prevailing social norms: As is well known, cultural differences determine the openness with which people discuss issues that are related to sexuality or HIV transmission. For example, in many countries there may not be enough support to communicate on public media messages related to condom promotion. Alternatives, such as traditional media in the form of kirtans may be more acceptable to people. Proposed outreach: Some messages are meant for coverage to a large segment of the population whereas others are for only a small population. Needless to state, interpersonal modes of communication are needed when messages need to be tailored to individual needs.
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Challenges of Communication in Context of HIV /AIDS

Since HIV was first reported in 1981, professionals from various fields have made considerable progress in understanding the pandemic better. Research is tirelessly going on to find a cure for AIDS and meanwhile to develop a vaccine towards its prevention. Commitment from Governments across the globe has created special bodies to look into the problem, develop policies and implement programmes towards the mitigation of the pandemic. No doubt, there has been some success. At present, with much advanced drug therapies, the AIDS
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afflicted can lead a better life than before. The high cost of the drugs is also being supported by many governments. This being the situation prevention is the best option among all strategies to combat AIDS. If one takes a look at prevention strategies, they by and large comprise of screening blood supplies, creating awareness of HIV / AIDS through the mass media, and promoting safer sexual practices. As is well known the HIV is a silent and invisible virus and it does not debilitate for a number of years. A large proportion of those who are infected with HIV do not even know that they are carrying it. So, communication strategies have an immense responsibility of educating people about the virus, its means of transmission and how to prevent infection. To understand the immense challenge that communication strategies face in the event of HIV and AIDS, one needs to understand the behaviours it is addressing. They are largely sexual behaviours which are private and personal; behaviours that are habitual and repetitive (such as drug abuse); behaviours that satisfy physiological and psychological needs; behaviours whose discussion is taboo in most societies; behaviours that are moralized upon and stigmatized by society. If these behaviours are contextualized they are behaviours that are shaped by deep rooted cultural traditions, and in a number of cases they involve interaction between parties that are unequal ( as we see between a CSW and her client). To bring about change in these is by no way an easy task. It requires a lot of understanding of the social context in which they occur and also an approach that would be targeted group specific. Those who are involved in HIV prevention are well aware that success of any HIV prevention strategy can be
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ascertained only when there is a response efficacy. Targeted populations have no immediate benefit to observe upon changing their behaviour, and most changes that have to be made are not individual. Either they need the cooperation of another partner and / or they need the availability of services and products (for example, a supply of condoms). Another task at hand for communication specialists is reaching out to population groups that are difficult to reach by the conventional media channels. Commercial sex workers, truck drivers, and migrant populations are some such groups who are in need of special interventions. In many such cases, peer educators have been able to make the desired impact (Singhal and Rogers, 2003). Experiences of countries across the globe show that in a few countries early prevention interventions have effectively reduced HIV prevalence rates. Reportedly, Uganda was the first country to reduce its HIV prevalence rates (Green et al, 2003). This success is largely attributed to open and effective communication and to the political will to fight HIV/AIDS. Whereas on one hand these successes have been learning experiences, on the other the failure of the programme in many countries has provided much learning. As already discussed sexual behaviour is something that is too personal and irrational. Even where alcohol and drug intake are concerned, people have their own reasons for taking to them and for giving them up. Individual may or may not perceive themselves to be at risk for HIV infection because of their drug or alcohol consumption, what to say of their sexual behaviour. Not only this even after success in reverting their risk behaviours they may revert or backslide to their risky behaviours (Kakkar, 2005). Experiences have
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shown that cultural norms play a key role, such that programmes have to address the risk behaviours and the cultural norms. Also, advocacy and social mobilization are integral components of communication programmes. Hence, communication strategies need to be tailored to special population groups. To conclude, it is well understood that there is a need to combine mass media with interpersonal channels, together with both social and community mobilization (McKee, 2004). Many authors now advocate a combination of mass media communication with activities that allow for face to face interaction, such as community based events and interpersonal communication/counseling. According to McKee (2004), strategic communication combines elements such as extensive use of data, careful planning, stakeholder participation, creativity, and high quality programming. Researchers have highlighted the need for a systematic approach in communication strategies for HIV/AIDS prevention. Since time and cost are high in the programme development, it is imperative to have a scientific base to all intervention strategies and do away with adhoc approaches. In this regard, strategic communication would combine a series of elements, extensive use of data, careful planning, stakeholder participation, creativity, high quality programming, and linkage to other programme elements. When programmes are designed on the basis of data they would certainly have a better chance of being successful. Hence, specific expected outcomes must be set before each programme is designed. Whereas, the targets could be raising awareness and increasing condom use, now these need to be more specific. For example, in a particular community the objective could be to have 25 per cent of the youth to access HIV testing centers and get themselves tested in a period of two months. It goes
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without saying there has to be services of an Integrated Counselling and Testing Centers (ICTCs) available right there. Success of a communication strategy would thus be assessed on the basis of outcomes, i.e. how many youth accessed the services of an ICTC in the specified period. Segmentation of the targeted audience has been shown to be of importance in communication for HIV prevention (Kakkar, 2005). Usually when messages are created for some vulnerable groups, they tend to bring forth an adverse response from the general population. They tend to disregard the messages as they link the risk not to certain behaviours but to certain groups. Interventions have to be designed so as to use the channels that reach the vulnerable groups, without drawing the attention of the general population, making the message audience specific and also highlighting the risk behaviours and not the risk groups. Evidently, development of communication strategies for HIV and AIDS mitigation is no small task. It has to have a sound data base and also fall back on theoretical concepts. Also, research is needed at all stages of programme planning, designing and monitoring and evaluation. This would help in taking mid-way corrective actions and make the interventions more cost effective. Research generated knowledge on media usage and access is also of tremendous use. For example, it is important to have data on television viewer-ship and the best time slots to make space for AIDS prevention messages. Not only this, use of multiple channels is of great benefit. Here the radio, television and print media reinforce the messages for their maximum impact. Furthermore it is important that the services promoted by the media are actually available in that community for the audience to make use of.
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Behaviour Change Communication -An Approach

Behaviour Change Communication (BCC) is an interactive process with communities (as integrated with an overall program) to develop tailored messages and approaches using a variety of communication channels to develop positive behaviours; promote and sustain individual; community and societal behaviour change; and maintain appropriate behaviours. In the context of the AIDS epidemic, BCC is an essential part of a comprehensive program that includes both services (medical, social, psychological and spiritual) and commodities (e.g., condoms, needles and syringes). It is important for individuals and communities to understand basic facts about HIV and AIDS, adopt key attitudes, learn a set of skills and be given access to appropriate products and services when they start to identify their risk behaviours and move towards making changes. All behaviour change is not unidirectional. People can adopt safe sex practices and may well revert to their old patterns of risk behaviours. It is important therefore that they are supported in these efforts and helped in sustaining positive changes. They must also perceive their environment as supporting behaviour change. Also, they need easy accessibility to appropriate treatment for prevention, care and support. In most parts of the world, HIV is primarily a sexually transmitted infection (STI). Development of a supportive environment requires national and community-wide discussion of relationships, sex and sexuality, risk, risk settings, risk behaviours and cultural practices that may increase the likelihood of HIV transmission. A supportive environment is also one that deals, at the national and community levels, with stigma, fear and discrimination,
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as well as with policy and law. The AIDS epidemic forces societies to confront cultural ideals and practices that can contribute to HIV transmission. It needs people to go deep into the social fabric and be able to pick on the cultural practices and traditions that make up for increased vulnerability of some sub-populations to the HIV infection. BCC as a strategy then sets the tone for compassionate and responsible interventions. BCC is an integral component of a comprehensive HIV/ AIDS prevention, care and support program and has several roles to play. It has a number of different but interrelated roles. Effective BCC can first and foremost increase knowledge. BCC can ensure that people are given the basic facts about HIV and AIDS in a language or visual medium that they could be understood and related to. Next, it helps to stimulate community level dialogue. BCC can encourage community and national discussions on the basic facts of HIV/AIDS and the underlying factors that contribute to the epidemic, such as risk behaviors and risk settings, environments and cultural practices related to sex and sexuality, and marginalized practices (such as drug use) that create these conditions. Further, it can also stimulate discussion of healthcare-seeking behaviors for prevention, care and support. BCC can lead to appropriate attitudinal changes about perceived personal risk of HIV infection, belief in the right to compassionate and non-judgmental provision of services, greater open-mindedness concerning gender roles and increasing the basic rights of those vulnerable to and affected by HIV and AIDS. Communication about HIV prevention and AIDS mitigation should address stigma and discrimination and attempt to influence social responses to them. No doubt it has a number of objectives to fulfill. (a) BCC can spur individuals and communities to demand
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information on HIV/AIDS and appropriate services. (b) BCC can lead policymakers and opinion leaders toward effective approaches to the epidemic. (c) BCC can promote services for STIs, intravenous drug users (IDUs), orphans and vulnerable children (OVCs); voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT); support groups for PLHA; clinical care for opportunistic infections; and social and economic support. (d) BCC programs can focus on teaching or reinforcing new skills and behaviors, such as condom use, negotiating safer sex and safe injecting practices. It can contribute to development of a sense of confidence in making and acting on decisions.
Combating Stigma and Discrimination

Stigma and discrimination are still an everyday experience for PLWHA (People Living with HIV and AIDS) and vulnerable populations, yet their complexity and diversity in practice, coupled with the failure to develop a greater understanding of their social roots, means they are often not addressed effectively. Stigma and discrimination are an example of where communication can be both part of the cause and the cure of social barriers. Stigma reflects existing social inequalities, since HIV is often associated with groups that are already marginalised in a way that compounds their marginalisation. Communicating that HIV/AIDS need not be a death sentence, and that households do not have to face them alone can be a vital source of hope. It can also make inroads into the stigma surrounding the epidemic. Reactions of denial and avoidance can often be a desperate coping mechanism for those faced with the prospect of caring for family or friends when their own households are near collapse. In this context, providing resources to strengthen community responses including the possibility of treatment can give people hope.
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Addressing the Barriers to Universal Access Although few campaigns against stigma have been successful, breaking the silence around HIV/AIDS and moving discussions from the personal sphere to interpersonal and public arenas can help overcome it. Mass media have stimulated discussion through highprofile human interest stories featuring prominent individuals who put a human face to the epidemic. The challenge for communication is how to move the issue of HIV and AIDS from a high taboo end towards a less taboo end. By having open discussions and being able to talk on the issue we can break the silence. This would be the first step in breaking the silence and reducing the stigma associated with AIDS. One way in which a sexually taboo subject can be brought out in the open is by the use of symbols. In the case of AIDS it has been the red ribbon. It is a symbol that is identified internationally with AIDS. The ribbon is distributed with pins, is placed on T-shirts, on caps, and posters and pamphlets. It is widely circulated by volunteers on the World AIDS Day that is observed on December 1st each year across the globe. In this way, without too many words, people can wear the ribbon and express their concern and support for those who are suffering from HIV and AIDS. A range of communication approaches have helped reduce stigma by promoting discussion and awareness of the realities of living with HIV/AIDS. Initiatives include: discussion forums and publications to raise awareness on the situation of older people as carers in Zimbabwe; youth care-givers who have promoted awareness about transmission risks, family reconciliation and community discussions in Zambia; radio listening clubs to promote discussions of stigma in Malawi; and awareness raising and training with
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healthcare worker and faith groups in Ethiopia and Rwanda. Another way to tackle stigma is through sustained dialogue within communities, using participatory approaches. Communication can help challenge stigma and discrimination at a range of levels, including advocacy, to ensure that policy and laws do not perpetuate discrimination enacting policies in institutional contexts like schools, workplaces and healthcare settings, promoting accurate information and frank dialogue with communities and households, as well as human interest stories in the media. Innovative techniques, such as humour, have been used to help overcome the taboo over discussions on HIV and AIDS. These techniques are in particular of great success when discussions are held with adolescents and youth in a community setting. Many successful condom promotion drives have been handled by individuals who have made use of culturally appropriate humour to reach across with their message. Sometimes barriers of communication can be broken when the audiences are captured in a place where they feel the much desired anonymity to have a discussion on an issue they are shy to talk about. In conservative societies such as India, men are too hesitant to go to buy a condom from a chemist shop and even find it more difficult to have an open dialogue on sexuality with a health-care provider or a counselor. Definitely other ways are used to have such a dialogue. Many organizations have made successful interventions by locating their programmes at the barber shops. Reportedly, in some localities of Tamil Nadu, men often have their beards and hair trimmed before visiting a commercial sex worker (Singhal and Rogers, 2003). The barbers now supply free condoms to their clients. The
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barbers are provided training and they take pride in their new role. Many groups of People With AIDS have taken up the issues of discrimination. They have organized anti discrimination campaigns using diverse communication techniques. These campaigns have been designed to reduce prejudice against groups such as the gays, injection drug users, and commercial sex workers. Campaigns have sometimes been led by political leaders and film personalities. The messages of these people of non discrimination have reached out and made a significant impact. In India, a network of People Living with HIV/AIDS (INP+) was formed in 1997 by twelve persons in Chennai. They also have their divisions in other cities. BCC and approaches towards stigma and discrimination: Stigma can manifest itself in a variety of ways, from ignoring the needs of a person or group to psychologically or physically harming those who are stigmatized. Stigma is often felt by PLHA, men who have sex with men (MSM), sex workers (SWs), IDUs, migrant populations and others. The importance of addressing stigma in the context of BCC campaigns has programmatic implications that transcend questions of compassion and humane treatment. Failure to address stigma jeopardizes BCC programs in multiple ways: Prevention BCC programs that fail to address stigma allow some people to ignore the messages of HIV prevention. Stigma can cause people to perceive individuals with or at risk for HIV as them, reinforcing their feeling that HIV is not their illness. Failure to address stigma can also deter individuals from seeking out VCT and proper medical care, including MTCT prevention services. Stigma is also sometimes attached to carrying condoms. Stigma can work against prevention programs; for example, an outreach or peer education program for
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MSM, IDUs, or CSWs can be damaged by round-ups and detention of beneficiaries. Quality of care Stigma can perpetuate harmful practices, such as discrimination against or poor treatment of PLHA, IDUs, MSM, or CSWs. Policy Programs that fail to address stigma help perpetuate discriminatory laws and practices and, in some cases, result in failure to enforce laws against them. Such programs also miss an opportunity to influence policy direction. BCC programs that address stigma can work with and employ people from traditionally stigmatized groups, such as PLHA, SWs and MSM, as advocates for policy change. Such individuals can also serve as dedicated caregivers, social workers, peer educators and role models for change.
Communication Strategies for Special Populations

We have already discussed the significance of targeted interventions in the context of HIV/AIDS. Targeting is the process of customizing the design and delivery of a communication programme according to the characteristics of the intended audience. In this sense not only is the message to be conveyed but it has to be done in a manner which is culturally sensitive and appropriate. This can well be achieved when the targeted audience is involved in the programme in different ways that could be from the stage of research, designing to delivery or implementation. When such tailored messages are prepared and sent out to these special groups, they have an immense impact. For example, the Healthy Highways Project with truck drivers or the Sonagachi Project in Kolkata which will be discussed later. If we take a look at commercial sex workers, they are undoubtedly a special group to whom messages have to
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be tailored. They have multiple sex partners, their clients. These clients can further pass on the virus to their spouse, who in turn can give birth to HIV infected children. Thus it is very important to develop specific interventions for the CSWs. The approach of having peer educators, that is, having persons from within the group to give the message to others, is an effective technique. The credibility of the researcher is high as he is perceived by the audience as one of us. Most peer educators are themselves sex workers. When they begin education work, they are given training. They may continue with their sex work and being in the same work, have a relationship of trust with their audience. Also, their credibility is higher because they are from the same socio-economic background. They are trained to first establish a relationship, understand the problem, then reach out with the relevant messages and to do followups if they want to change the individuals behaviour. This one to one approach works well with special groups. One successful intervention that needs to be studied is the Sonagachi Project in Kolkata. The CSWs of this area are well organized. They have organized themselves and take up the cause of their members in relation to police harassment, education of their children, and small savings. Interventions were started in this area by training and mobilizing 180 CSWs and 100 other outreach workers. They led the programme and motivated their peers to use condoms. As a result of this condom use escalated and this area has a very low HIV prevalence rate. The Healthy Highways Project is another project in which the communication strategy needs to be highlighted. In this programme messages of safe sex had to be communicated to a very diverse group that is of truckers. The truck drivers and their assistants are usually on the move for as much as 25 days in a month. Being
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away from their spouse, they engage in sex with CSWs on the highway dhabhas and also with other men. This project was started in 1997 with funding from DFID. The project reached out successfully to truckers in Andhra Pradesh, Karnataka and Tamil Nadu, bringing down STD prevalence and taking up condom use. Behind this was a lot of effort of preparing the communication material, mainly in the form of flip charts which were produced after a lot of formative research. Two characters were created, namely Ustaad and his companion Vijay. The communication material was generated in many different languages. Well trained outreached workers were then given this task of accessing the truckers at the waiting points on the highways.
Conclusion
In this chapter you have learnt about the importance of communication in the context of HIV and AIDS. Both traditional and modern means of communication are important and can be made use of in transmission of messages. Since there is a need to tailor messages and reach out to the targeted audiences, communication strategies should be based on research. Communication strategies have to address the special issues of the vulnerable groups. Also, communication has a major role to play in combating stigma and discrimination.
References
UNESCO ( 2001): A Cultural Approach to HIV/AIDS Prevention and Care. IGNOU (2006) : Communication & Counselling in HIV.
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PANOS, October 2006: Breaking barriers, Effective communication for universal Access to HIV Prevention, Treatment, Care and Support by 2010. Green, E. Nantulya, V. Oppong, Y. and Harrison, T. (2003); Literature Review and Preliminary Analysis of ABC Factors in Six Developing Countries. Cambridge: Harvard Center for Population and Development Studies. Behaviour Change Communication for HIV/AIDS: A Strategic Framework; September 2002 Family Health International Institute for HIV/AIDS 2101 Wilson Boulevard, Suite 700 Arlington, VA 22201 U.S.A. Singhal, A. and Rogers, E.M. (2003): Combating AIDS, Communication Strategies in Action. Sage, New Delhi. McKee, N.; Bertrand, J.T.; and Becker-Benton, A.(2004): Strategic Communication in the HIV/AIDS Epidemic, Sage, New Delhi.
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Models of Behaviour Change

*Jyoti Kakkar
Introduction
As it is well known, a number of health problems have linkages with human behaviour. Many are easily linked to illness and disease. For example, consumption of tobacco is linked to many serious problems such as cancer. The behaviour health link becomes clearer when examining the ten leading risk factors identified by the WHO for preventable death and disease the world over: maternal and child underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water; poor sanitation and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficiency; high body mass index; or overweight. According to WHO, 40 percent deaths are due to these ten risk factors. It is well said that global life expectancy would go up by atleast 5 to 10 years if health promoting decisions would be taken by individuals, families, communities, and governments. Risk factors translate into disease, disability and death. These then get classified into what is referred to as the burden of disease. One can well understand that addressing risky behaviours rather than specific diseases is more cost effective. One risky behaviour can result in a host of diseases. Under-nutrition is itself a cause of as many as 60 percent of child deaths. In the same way unsafe sex can lead to a multitude of problems such as cervical cancer, unwanted pregnancies, sexually
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transmitted diseases and HIV. So we can well understand that behaviour has a significant role to play, both in the causation and management of illness. The prime question that emerges is that can behaviour be influenced sufficiently to bring about this change and achieve health related goals? Behavioural science suggests that we can and offers evidence based theories of behaviour change.
Understanding and Influencing Human Behaviour

Human behaviour is multi-dimensional and complex. Though some generalizations can be made, individuals are unique in their perception of situations and more so in their response. Further individuals vary within groups and each group varies from others. However, considerable amount of research has been undertaken to understand and shed some light on the behaviour of individuals. The theories that have thus been propounded help in having a better insight into human behaviour and hence develop interventions that would guide behaviour in a positive direction. Why is theory important? Theory is important because it goes beyond trying to explain actions or inactions of specific individuals to provide a unified basis for understanding, predicting to the extent possible, and influencing human behaviour in general. Earlier thinking on behaviour change primarily gave importance to sending messages using appropriate media. The messages were targeted to certain population groups considered vulnerable. For example, sending messages such as Use condoms, practice safe sex always were common for AIDS awareness and safe sex. By and large this communication was unidirectional. Over the years the approach has changed. There is formative audience
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research on the relevant audience. Planning involves designing the intervention strategy, skill building, multichanelled education and advocacy using influential persons, community mobilization. It is now well understood that behaviour does not occur in isolation. The context has to be well understood for effectiveness of the intervention for HIV prevention. To illustrate this, if a young man has been motivated by media outreach programmes and perceives his behaviour as risky and determines to use condoms, he may not be able to put his determination into action. There are many things that may come in his way such as, peer influence, nonavailability of condoms at affordable price or even nonavailability of condoms at local health clinics. To conclude, behaviour change needs to place in a wider context, where organizations and systems have to play a supportive role. HIV/AIDS has been extensively studied in the last three decades. Basic research, clinical research, epidemiological research across various countries of the world has contributed towards a better understanding of the virus. A large number of studies have been undertaken on AIDS awareness and prevention looking into the role of mass media and modalities of behaviour change among different population groups.

In these models of behaviour change the individual is the most basic unit of behaviour change. Individuals can be reached out at any level groups, organizations, communities and nations. Health professionals spend a large amount of their time in face to face interactions such as in giving instructions and in clients. In most cases of interventions for behaviour change, as also in the case of HIV/AIDS prevention, these efforts have been
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largely supported with generation of reading and visual materials such as pamphlets, booklets, videos and posters. These apart, mass media reaches out to the masses with the use of print and electronic media. These efforts are now supported by theories that highlight the need to have multi-dimensional HIV/AIDS prevention and all this based on certain basic research and also on established theories. In the past three decades AIDS has thrown up several challenges to professionals from diverse disciplines. A major concern for the professionals has been to provide treatment, care and support to the AIDS afflicted and to those who are close to them. The already prevalent health care systems have been burdened and strained. In doing so, the paucity of funds and of trained human resources has always been a major concern. Not only this, the factors that lead to the spread of HIV have entirely different dimensions; risky health related behaviours to name one. Human behaviour is contextual and unpredictable. Social and behavioural sciences have an urgent task to develop effective methods of conveying information that will effect attitudes and belief systems that influence risk behaviours. Towards this considerable research has been conducted. It focuses mainly upon self directed behaviour change that is a function of perception of risk, psychological assessment of costs and benefits, efficacy of change, etc. All these theories are useful when interventions are planned and designed, In light of the fact that in the case of HIV/ AIDS, prevention is the best course of action, these theories must guide our interventions. In AIDS prevention, we are primarily concerned with behaviours and not with populations. It is true that some segments of the population are more prone to be engaged in risk behaviours than others, but it is behaviour that puts a person at risk, and not their
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affiliation with any group. For this reason, prevention and care would depend upon their ability to influence specific behaviours. Theory of Reasoned Action This theory was propounded by Ajzen and Fishbein in the year 1980. The assumption of this theory is that humans are reasonable persons who, in deciding what action to take, systematically process and use whatever information they have. In this theory it has been stated that although substantive specifics are expected to differ from one behaviour to another, and from one population to another, the theory argues that most behaviours can be understood in terms of the same small set of theoretical constructs and psychological processes. The theory links behaviour to intentions, intentions to a combination of norms and attitudes, and attitudes and norms to behavioral and normative beliefs. Research using the Theory of Reasoned Action (TRA) has explained and predicted a variety of human behaviors since 1967. Based on the premise that humans are rational and that the behaviors being explored are under volitional control, the theory provides a construct that links individual beliefs, attitudes, intentions, and behavior (Fishbein, Middlestadt and Hitchcock, 1994). The theory variables and their definitions, as described by Fishbein et al. (1994), are: l . Behaviour: A specific behaviour is defined by a combination of four components: action, target, context, and time, e.g., implementing a sexual HIV risk reduction strategy (action) by using condoms with commercial sex workers (target) in brothels (context) every time (time). Intention: The intent to perform a behavior is the best predictor that a desired behavior will actually
2 .
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occur. In order to measure it accurately and effectively, intent should be defined using the same components used to define behavior: action, target, context, and time. Both attitude and norms, described below, influence ones intention to perform a behavior. 3 . Attitude: A persons positive or negative feelings toward performing the defined behavior.
When any behaviour is studied, its performance or nonperformance depends upon the individuals intention to perform that behaviour. To change behaviour one must change the intentions of the person to perform and sustain that behaviour, and this change in intention has to be in the context of target, action, context and the time. In order to change the behaviour, attitudes and normative beliefs cannot be ignored. Behavioural Beliefs: Behavioural beliefs are a combination of a persons beliefs regarding the outcomes of a defined behavior and the persons evaluation of potential outcomes. These beliefs will differ from population to population. For instance, married heterosexuals may consider introducing condoms into their relationship an admission of infidelity, while for homosexual males in high prevalence areas it may be viewed as a sign of trust and caring. Norms: A persons perception of other peoples opinions regarding the defined behavior. Normative Beliefs: Normative beliefs are a combination of a persons beliefs regarding other peoples views of a behaviour and the persons willingness to conform to those views. As with behavioural beliefs, normative beliefs regarding other peoples opinions and the evaluation of those opinions will vary from population to population. The TRA provides a framework for linking
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each of the above variables together. Essentially, the behavioural and normative beliefs referred to as cognitive structures influence individual attitudes and subjective norms, respectively. In turn, attitudes and norms shape a persons intention to perform a behaviour. Finally, as the authors of the TRA argue, a persons intention remains the best indicator that the desired behavior will occur. Overall, the TRA model supports a linear process in which changes in an individuals behavioural and normative beliefs will ultimately affect the individuals actual behaviour. The attitude and norm variables, and their underlying cognitive structures, often exert different degrees of influence over a persons intention. For example, results from a study of northern Thai males revealed that mens perceptions of peer norms were the best predictor of condom use (VanLandingham, Suprasert, Grandjean and Sittitrai, 1995). To date, behaviours explored using the TRA include smoking, drinking, signing up for treatment programs, using contraceptives, dieting, wearing seatbelts or safety helmets, exercising regularly, voting, and breastfeeding. Limitations: Some limitations of the TRA include the inability of the theory, due to its individualistic approach, to consider the role of environmental and structural issues and the linearity of the theory components (Kippax and Crawford, 1993). Individuals may first change their behavior and then their beliefs/ attitudes about it. For example, studies on the impact of seatbelt laws in the United States revealed that people often changed their negative attitudes about the use of seatbelts as they grew accustomed to the new behaviour. Stages of Change Theory Mounting evidence suggests that behaviour change occurs in stages or steps and that movement through
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these stages is neither unitary or linear, but rather, cyclical, involving a pattern of adoption, maintenance, relapse, and readoption over time. The work of Prochaska and DiClemente (1986) and their colleagues have formally identified the dynamics and structure of staged behaviour change. In attempting to explain these patterns of behaviour, Prochaska and DiClemente developed a transtheoretical model of behavioural change, which proposes that behaviour change occurs in five distinct stages through which people move in a cyclical or spiral pattern. The first of these stages is termed precontemplation. In this stage, there is no intent on the part of the individual to change his or her behaviour in the foreseeable future. The second stage is called contemplation, where people are aware that a problem exists and are seriously considering taking some action to address the problem. However, at this stage, they have not made a commitment to undertake action. The third stage is described as preparation, and involves both intention to change and some behaviour change, usually minor, and often meeting with limited success. Action is the fourth stage where individuals actually modify their behaviour, experiences, or environment in order to overcome their problems or to meet their goals. The fifth and final stage, maintenance, is where people work to prevent relapse and make efforts so as to sustain these changes. The stabilization of behaviour change and the avoidance of relapse are characteristic of the maintenance stage. Prochaska and DiClemente further suggest that behavioural change occurs in a cyclical process that involves both progress and periodic relapse. That is, even with successful behaviour change, people likely will move back and forth between the five stages for some time, experiencing one or more periods of relapse to earlier stages, before moving once again through the
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stages of contemplation, preparation, action and eventually, maintenance. In successful behavioural change, while relapses to earlier stages inevitably occur, individuals never remain within the earlier stage to which they have regressed, but rather, spiral upwards, until eventually they reach a state where most of their time is spent in the maintenance stage. Further work undertaken and reported by Prochaska et el (1992) suggests that behaviour change can only take place in the context of an enabling or supportive environment. Prochaskas and DiClementes model has received considerable support in the research literature. An important aspect of both Prochaskas and DiClementes approach is that each of the five stages of behaviour change is said to involve different cognitive processes and require different treatments or intervention strategies for the overall change process to be successful. Other researchers also propose that different stages in the change process require different intervention strategies, and generally recommend a multifaceted, community-based approach to intervention in which all stages are addressed so that individuals at all stages of readiness for change can potentially be influenced. Social Cognitive-Behavioural Theories Social Cognitive Theory explains human behaviour in terms of a triadic, dynamic and reciprocal model in which behaviour, personal factors, and environmental influences interact. It addresses both the psychological dynamics underlying behaviour and their methods for promoting behaviour change. It is a very complex theory and includes many key constructs. Self-efficacy is one of the key concepts.
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Self-efficacy refers to ones confidence in the ability to take action and persist in action. It is seen by Bandura (1986) as perhaps the single most important factor in promoting changes in behaviour. Measures of selfefficacy and some of the other key concepts from Social Cognitive Theory have also been identified as key determinants of movement through the stages of change, (Oldenburg, 1999). Self-efficacy expectations have been found repeatedly to be important determinants of: a . b . c . the choice of activities in which people engage how much energy they will expend on such activities and the degree of persistence they demonstrate in the face of failure and/or adversity.
In general, higher levels of self-efficacy for a given activity are associated with higher participation in that activity. Learning and Behaviour Theories Learning theorists have demonstrated that behaviour can be changed by providing appropriate rewards, incentives, and/or disincentives. In learning or behaviourist approaches, such rewards and incentives are typically incorporated into structured reinforcement schedules, and the process of behaviour changes is often termed behaviour modification. While effective in bringing about behaviour change, such approaches require a high level of external control over both the physical and social environment, and the incentives (or disincentives) used to reinforce certain behaviours and discourage others. This kind of control is hard to maintain in real life settings, and thus, strict behaviourist approaches are subject to a number of limitations.
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Social Learning Theory Social learning theory is similar to learning and behaviour theories in that it focuses on specific, measurable aspects of behaviour. Learning theories, however, view behaviour as being shaped primarily by events within the environment, whereas social learning theory views the individual as an active participant in his or her behaviour, interpreting events and selecting courses of action based on past experience. The theory analyses psychosocial influences arising from the interaction of individual factors, the social environment, and experience. While the physical and social environment shapes behaviour, people are not passive in the process, since they in turn can act to change their environments. According to Murphy (2005) the theory emphasizes behavioural capability: A person needs to know what to do and how to do it. There may be a need for training. She further states that self efficacy is very important, that is a persons belief and confidence in ones ability to make the desired change. It is very important to bring about health related changes and recommends three ways of bringing about health related behaviours: ( ) Setting small, incremental goals when one sets a small goals and is able to achieve them, his or her self-efficacy increases. Changes targeted or desired then seem attainable. ( ) Behavioural contracting agreeing to a formal b process that specifies goals and rewards. It implies that individuals will receive feedback, guidance and praised for the progress made by them. ( ) Self-monitoring feedback from self-monitoring or c record keeping, such as keeping a journal, can reinforce determination to change and increase
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confidence in ones ability to achieve the desired action. One important theory deriving from Social Learning Theory which has had a major impact on many current models of behaviour change is that of self-efficacy. As stated earlier, self-efficacy has to do with a persons beliefs in his or her abilities to successfully execute the actions necessary to meet specific situational demands. Such expectations have been found to be consistently related to behaviour for change or modification across a wide range of situations and population sub-groups. Social Psychological Theories Social Psychological theories are concerned with understanding how events and experiences external to a person (i.e. aspects of the social situation and physical environment) influence his or her behaviour. Emphasis is placed on aspects of the social context in which behaviour occurs, including social norms and expectations, cultural mores, social stereotypes, group dynamics, cohesion, attitudes and beliefs. A number of useful concepts have emerged from social psychological theories, including attribution, locus of control, and cognitive dissonance, to name a few. Social Cognitive Approaches Social cognitive approaches combine aspects of social psychological theories with components of both social learning theory and cognitive behavioural approaches. Social-cognitive approaches emphasize the persons subjective perceptions and interpretations of a given situation or set of events, and argue that these need to be taken into account if we are to understand adequately both behaviour and the processes of behaviour change.
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A number of social psychological concepts have been found to be consistently related to behaviour change across a wide range of situations. For example, the social reality of the group (e.g. peer group, school group, family group etc.) will affect an individuals behaviour. All groups are characterized by certain group norms, beliefs and ways of behaving, and these can strongly affect the behaviour of the group members. Expectations of significant or respected others can also have a strong influence on a persons behaviour. This phenomenon has been most consistently demonstrated in the early research on self-fulfilling prophecies, which showed that teachers expectations of their students were consistently related to the students subsequent performance, even when these expectations were based on falsified information. Thus, support and encouragement, or conversely, low expectations from significant or respected others, can affect and bring about (or not), changes in individual behaviour. Health Belief Model The Health Belief Model attempts to explain healthbehaviour in terms of individual decision-making, and proposes that the likelihood of a person adopting a given health related behaviour is a function of that individuals perception of a threat to their personal health, and their belief that the recommended behaviour will reduce this threat. The model has been extensively used in studies of compliance in the context of health. In this model it is theorized that people are afraid of getting seriously ill and the health related behaviours (or health seeking behaviour) reflect the level of threat perceived and a persons expected fear reduction potential of taking action. Individuals calculate the net benefits of changing their behaviour. According to Kirscht and Joseph (1989) there are four components in this model: personal
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susceptibility to a negative heath condition; the perceived severity of the condition; the value of a behaviour; and barriers to action. The summation of all these create a situation where the individuals readiness to act comes forth. With circumstances being conducive, action is enacted and behaviour change may take place. Rosenstock (1974) suggested that a cue was necessary for action to occur. Some others added self-efficacy as an important element for change to occur. Thus, a person would be more likely to adopt a given behaviour (e.g. walk or cycle regularly) if non-adoption of that behaviour (e.g. unclean air or confused traffic situations) is perceived as a health threat and adoption is seen as reducing that threat. To date, the Health Belief Model has not received consistent or strong support in explaining behaviour change. When the concept of self-efficacy is added to the model, however, prediction of behaviour increases. AIDS Risk Reduction Model (ARRM) The Aids Risk Reduction Model has been developed by Catania, Kegeles and Coates (1989). It is a conceptual framework for organizing the factors that may influence the peoples abilities to change high risk sexual behaviours. It has built upon the earlier models such as the health belief model, self-efficacy theory, helpseeking behaviour. ARRM organizes the predictors of health behaviour in general and sexual behaviour in particular. As is well known behaviour change is not unidirectional. People may move back to their earlier behaviours. The process of behaviour change is broken into several stages: (a) recognizing and labeling ones behaviour as high risk for contracting HIV, (b) making a commitment to reduce high-risk sexual contacts and increase low risk activities, and (c) seeking and enacting strategies to obtain these goals. ARRM suggests that to
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avoid HIV infection people exhibiting highrisk activities must first perceive their sexual behaviours as those that place them at risk for HIV infection. They should be willing to make a strong commitment for changing their activities; this may require that they decide if the behaviours can be altered or whether the benefits of change outweigh the costs. Also, they should be willing to seek help by obtaining solutions. Help can be from informal social support or from professionals. Finally, enactment of solutions would require complex negotiations with sexual partners. These three processes are also termed as labelling, commitment and enactment. They are neither unidirectional nor irreversible. Further each state is influenced by a number of extraneous factors such as salience, perception of sexual enjoyment, condom attitudes, negotiation with spouse, peer influence, etc.
Perceived Self-Efficacy
It goes without saying that prevention from the AIDS virus requires people to take control over their own motivation and behaviour. All social efforts are by and large directed towards spreading awareness on HIV and its modes of transmission. People are educated and the assumption is that once they are aware they will take appropriate self-protective action. Heightened awareness and knowledge of health risks are important preconditions for self-directed change. However, information alone does not determine action. According to Bandura (1989) people need to be given reasons to alter risky habits but also the means and resources to do so. Success requires the skills necessary and also strong belief in ones ability to exercise control. Perceived self-efficacy therefore is the belief held by people that they can have a control over their motivation
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and behaviour and also their social environment. Self efficacy determines how much effort people will put in and how long will they withstand all adverse pressures in order to continue and sustain the changes made by them. A number of research studies have been conducted on the influence of self- efficacy on behaviour change. They go to show that every aspect of behaviour change whether people consider changing their health habits, how hard they try, how much they change, and how well they maintain the changes they have attained. If they perceive themselves as not competent to undertake such changes, it often leads to a feeling of dejection and consequent stress and depression. It then emerges that information alone is not enough. Some elements determine the translation of knowledge into effective action for harm reduction. These are social skills and a sense of personal power to exercise control over risk situations and these are incremental in nature. Each positive change builds on the perception of self efficacy. Further problems emerge when self protective behaviour comes into conflict with interpersonal relationships. The weaker is the self-efficacy, the more the chance of the person succumbing to outside pressure.
Perception of Personal Susceptibility to Harm

As researchers have studied human behaviour and the response of people, they have often reported of situations where with precautions certain ailments could have been avoided. Yet people refrain from doing so. According to Weinstein (1989) if the benefits of the preventive measure are uncertain and the burden of change substantial, it is not surprising that few people would respond. This failure to acknowledge personal vulnerability has long
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been considered to be a barrier to the adoption of prevention measures. A substantial amount of evidence has been put forth to show that people tend to be unrealistically optimistic about their susceptibility to harm. They may not claim they are invulnerable but they do claim that their chances of suffering negative events are smaller than the chances of their peers. To further explain risk reduction behaviour, Weinstein has explained that there are many motivations governing risk relevant behaviours. For example, use of condoms is an important way of reducing risk of HIV. But use of condoms, is also equated with reduction in sexual pleasure, and demonstrates lack of trust in the sex partner. Similarly, cigarette smoking is well known to result in harm to the body. However, the motivation to continue smoking is related to peer pressure and coping with a stressful situation. Apart from these motivations, there are some determinants of threat perception. People usually learn about threatful situations from their acquaintances or from mass media. Risk is not an individual judgement but also a social and cultural construct. Many times people have objected to an AIDS care home being set up in their vicinity without actually being aware of the threat to their own health. It is just something they have learnt without actually knowing about it. Salience is another component that may raise the perception of threat. Salient refers to vivid images and frequent reminders. Persons who have seen the suffering of an AIDS afflicted person and his familys struggle to cope may adopt all risk reduction behaviors in order to minimize his risk. It needs to be pointed out that salience influences many social processes so it may not impact hazard response in many cases. Most decisions about hazard response are influenced by the way in which problems are presented.
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Perceptions of Personal Vulnerability: Until and unless people believe that they are at risk they will not take precautions. There is a wide variation between objective and subjective risk. When people see data on road accidents, not many of them feel that it would have any meaning for them. The problem is similar in the case of AIDS. It cannot happen to me is the response that most people have when they come across messages in the context of HIV/AIDS. The error on personal susceptibility usually is directional. Mostly people have an optimistic bias; they think that their own vulnerability to harm is less than that of their peers. Why do people show this optimistic bias? Some researchers report that this bias is because of an attempt by the individual to completely deny that this problem could be related to him. This defense mechanism helps him to avoid the anxiety he would feel upon admitting his vulnerability. A second reason that is given for this optimistic bias, is denying ones risk to enhance or preserve their self esteem. Self esteem is most at risk if the hazards in question are such as are preventable by ones own actions.
Decision Making on Aids

What are decisions? Decisions are a set of choices among alternative courses of action (including inaction). In the context of HIV/AIDS a number of decisions have to be taken which are in no way easy. 1 ) One of the foremost decisions is related to whether to be tested or not. This outcome of this test would impact the physical and mental health and also the social and economic aspects. A person may respond to a positive result by beginning to take good care of his or her health, or may go into a state of complete self neglect, thinking that
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whatever he may do, in the end he cannot escape from AIDS. The mental health of the individual depends a lot on the ability of the individual to deal with the result. A person who has received counselling and is in a state where he can cope with the result is on one extreme. The other side is of a person who is unable to handle this situation and denies to be tested. The result would no doubt have an impact on the social relations. Whether the person is ready to share the result with the sex partner and close ones, the person is in a state to cope with the consequences, such as of stigma and discrimination. The economic impact are obviously on the increased health expenditure, the risk of loosing ones job and housing. 2 ) Another area of decision making in the context of AIDS is reading and developing an understanding of the pandemic. How keen is the person to learn about AIDS and have clarity? Is the information given in that reading material, a brochure may be, organized or scattered? A quick look over can help the person resolve whether he would like to proceed or not. An area of decision making that is highly contextual, involves a decision to be taken on whether to ask the partner to use a condom or not. Doubtless, it would affect the social relations and the physical health of both. The trust or lack of it between the partners would influence their mental health.
3 )
How can one help in the decision making process? As social workers we have to be very well aware of the social and psychological dimensions of HIV/AIDS. Every aspect of HIV involves decision making that is critical to the clients life. It is important to know how much information can be shared at what stage and also the
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preparedness of the client to take decisions on his own. Attention needs to be given to the most pressing concerns. Having decided what to communicate, the next concern is how to communicate? Some methods are available in the literature and others need to be developed. Many clients may need help in organizing their decision making process.
Other Considerations Relevant to Behaviour Change

Behavioural scientists have collaborated and identified eight key variables that account for most of the variance in any given behaviour. These eight key factors identified are potential determinants for intervention and behavioural change. They include an individuals behavioural intention; environmental constraints; skill or ability; attitude or anticipated outcomes of a given behaviour; norms; self standards; emotional reaction and self-efficacy. The theorists concluded that, generally speaking, for a given behaviour to occur, at least one of these eight factors must be true: 1 . 2 . 3 . 4 . The person should have a strong positive intention (or made a commitment) to perform the behaviour There are no environmental constraints that make it impossible for the behaviour to occur The person has the skills necessary to perform the behaviour The person believes that the advantage (benefits, anticipate positive outcomes) outweight the disadvantages (costs, anticipated negative outcomes) of performing a behaviour
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5 .
The person perceives more social (normative) pressure to perform the behaviour than not to perform The person perceives that performance of behaviour is more consistent with his/her self image than inconsistent, or that its performance does not violate personal standards that activate negative selfsanctions The persons emotional reaction to performing the behaviour is more positive than negative The person perceives that he or she has the capabilities to perform the behaviour under a number of different circumstances. That is, they have the perceived self-efficacy to execute the behaviour in question.
6 .
7 . 8 .
The first three factors are viewed as factors necessary and sufficient for generating behaviour. That is for a given behaviour to occur, an individual must (a) have strong intentions to perform the behaviour, (b) have the necessary skills to do so and (c) not be restricted by environmental constraints. The remaining factors are viewed as factors that can actively influence the strength and direction of behavioural intention. That is, these dimensions generate a degree of influence on changes in behaviour. In fact, the theorists argued that an individual will not form strong intentions to perform behaviour unless they perceive the positive outcome of performing the behaviour as greater than the negative or that they have the ability necessary to carry out the behaviour.
Conclusion
In this chapter you have learnt about the importance of understanding the dimensions of behaviour change in
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the context of HIV Prevention. Some of the concepts that are significant in the context of behaviour change, such as perceived susceptibility to harm, self efficiency and AIDS decision making have also been discussed under the unit.
Refrences
Ajzen, I., and Fishbein, M.(1980): Understanding Attitudes and Predicting Social Behavior. New Jersey: Prentice-Hall, Inc. Elaine, M. Murphy (2005): Promoting Healthy Behaviour, Health Bulletin 2, Population Reference Bureau, Washington, D.C. Fishbein, M., and Middlestadt, S.E. (1989): Using the Theory of Reasoned Action as a Framework for Understanding and Changing AIDS-related Behaviors. In V.M. Mays, G.W. Albee, and S.F. Schneider (Eds.), Primary prevention of AIDS: Psychological approaches. London: Sage Publications. Prochaska, J.O., DiClemente, C.C. and Norcross, J.C. (1992): Behavior ChangeA Summary of Four Major Theories In search of how people change applications to Addictive Behaviors. American Psychologist, 47(9)
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Counselling For HIV/AIDS: Nature and Process

*Jyoti Kakkar
Introduction
Counselling is a process of helping a person to learn how to solve certain interpersonal, emotional and decisional problems. It is a process through which guidance and support are provided to persons with problems. In counselling, people are helped to help themselves. Counselling can be done with individuals, with couples or with families. Counselling seeks to resolve personal and interpersonal problems through a variety of approaches, in a manner that is consistent with the values and goals of society in general, and the client in particular. Counselling is based on a special relationship. This unique helping relationship allows the client an opportunity to learn, feel, think, experience and change in ways that are socially desirable. Most people enter the counselling relationship voluntarily. Although clients typically expect the counsellor to resolve their difficulties, the counselling relationship is actually collaborative; i.e., the counsellor and client collaboratively work towards the goals of counselling, with the counsellor acting chiefly as a facilitator of behaviour change.
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Specifically stating, counselling has five important goals, namely: 1 ) 2 ) 3 ) 4 ) 5 ) to reduce the emotional distress in the client. to alter dysfunctional behaviors of the client. to facilitate better adaptation of the client to his environment, and to develop his innate potential, to assist the client to make wise, appropriate and realistic decisions, as well as to provide information.
While much of the work in counselling may involve one to one interaction with the client, interaction with significant other persons in the clients life can also contribute towards the attainment of the goals of counselling. To facilitate the achievement of the goals of counselling, the counsellor uses his/her understanding of behavior, learning and interpersonal relationship to establish conditions favourable for the client to change. The nature, course and techniques of counselling vary widely across client groupings, such as in the case of individual counselling, couple counselling, group counselling, etc. It also varies widely across categories of clients, such as children, adolescents, families, alcohol and drug addicts etc. Finally, the nature, course and techniques of counselling may vary widely across clients even if the client belongs to the same category because it is assumed that each client is a unique person, different from the rest. In the process, the client is respected and treated as an individual with worth and dignity. The process of counselling is client centered and special attention is given to each individuals unique issues and circumstances. The counsellor makes an attempt to develop autonomy and self-responsibility in the clients,
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which is similar to the social work principles respecting the clients right to self-determination. It needs to be highlighted that counselling is not telling or directing the client, nor is it advice giving. In the context of HIV and AIDS, counselling has specific objectives. It is a confidential process of communication between the client and a caregiver/counsellor, and is aimed at enabling the client to cope with stress and take personal decisions related to HIV/AIDS. The counselling process involves an assessment of risk to HIV infection and transmission, facilitation of preventive behaviour as well as the evaluation of coping mechanisms when the client is in situations of stress.
HIV/AIDS Counselling: Nature and Purpose

HIV/AIDS Counselling Counselling poses an essential part of HIV antibody testing. HIV/AIDS Cousnelling is universally performed in two distinct phases - before (pre-test) and after testing (post-test) - regardless of the clients HIV status. Counselling prior to the test, known as Pre-test Counselling, will help the client understand the test results and its implications. The counsellor may also undertake a risk assessment by reviewing along with the client possible sources of infection (Jose & Jyothiram, 2008). It would also teach the client how to protect her/ him from the virus, and gain the knowledge of how to prevent the spread of HIV. During pre-test counselling, the counsellor usually explains the following:
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the test and how is performed; AIDS, associated diseases and the ways HIV infection is spread; ways to prevent the spread of HIV;

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confidentiality or anonymity issues of the test results; meaning of the possible test results - positive and negative; importance of post-test counselling; information regarding who will be communicating test result; The importance of informing ones sexual and drugusing partner(s), in the event of a positive test result.
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After the above clarifications, She/he is required to give voluntary consent to carry on with the testing. The client is then referred to the nurse or the technician for HIV Antibody Testing. NACO policy rules out any mandatory testing in HIV. The client is issued a PID slip (person identification digit which contains a code number, age and sex) and appointment for post-test couselling, before s/he is sent to the lab for testing (Jose & Jyothiram, 2008). Following the testing, or on a later date when the result is available the client is subject to Post-test Counseling. Post-test Counselling is undertaken irrespective of the test results, whether positive or negative. During the post-test counseling the client is informed about the result and counselled to cope with the immediate reactions to the test result. The counsellor will help the client to integrate and understand the meaning of the test result at all levels - rationally, emotionally, behaviorally, and medically (Jose & Jyothiram, 2008). It is explained that a negative test result does not mean that the client is immune to HIV. The client is educated how high risk behaviours - including having unprotected sexual intercourse with an infected person, sharing needles or syringes with an infected person - may
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transmit HIV. Usually during post-test, the counsellor will discuss such behaviours and also the implications of the window period. If tested positive for HIV antibodies, the counsellor will first provide supportive counselling and later assist in referring the client to a doctor who specializes in treatment and monitoring of HIV. In the event of financial difficulty a counsellor can help the client locate necessary resources. A counsellor will also insist and assist in notifying the sexual/drug partners, and still further refer the client to a support group for people with HIV as a means of coping with the disease. Nature and Puprose of HIV/AIDS Counselling As is well known, the virus that causes AIDS, namely HIV is selective in nature. It infects people through specific modes only: sexual transmission, injectible drug abuse, and perinatal transmission. This being so, professionals from various disciplines, whether they be medicos, economists, psychologists, social scientists, teachers, or even voluntary workers, need to assign prevention the foremost priority. This being so, counselling for prevention and behaviour change assumes utmost significance. The second major area that is covered by HIV/AIDS counselling is the diagnosis and treatment of HIV. The diagnosis of AIDS has many dimensions including social, psychological, and spiritual. The process of supportive counselling aims to help the clients cope with this stress. Finally, the clients have to learn to live with the diagnosis of being HIV positive. They face multiple dilemmas such as sharing of their sero-positive status, their rights to employment, rights to marriage and in the case of infected women, the critical decision on whether to bear children or not. Each stage involves serious thinking and decision making. Counselling therefore has an important role to play.
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HIV/AIDS counselling has two general objectives 1 . 2 . to provide psychosocial support to those already affected; and to prevent HIV infection by change in lifestyle/ behavior.
In order to achieve these objectives, counselling seeks to enhance self-determination, boost self-confidence, and improve family and community relationships and quality of life. HIV/AIDS counselling therefore also means providing support to families and loved ones, so that they, in turn can help to encourage and care for people with HIV infection. HIV/AIDS counselling is strongly recommended for:
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persons identified as having AIDS or being infected with HIV, and their families; those being tested (pre- and post -testing) for HIV; those seeking help because of past or current risk behavior and planning their future; and those not seeking help yet involving in risk behaviour.
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With these priorities in mind, the types of situations in which counselling is of value, and people seek care, might include:
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persons with AIDS or other disease related to their HIV infection (opportunistic illnesses); persons experiencing difficulties with employment, housing, finances, family, etc. as a result of HIV infection; persons considering being tested for HIV; persons who have been tested for HIV (whether or not they are infected);
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family and friends of persons infected with HIV; health workers and other professionals in regular contact with persons infected with HIV; persons who choose not to be tested despite past or present risk behavior; and persons who are unaware of the risk of HIV infection involved in specific behaviors they have, or are, engaged in.
Being diagnosed as having, recognizing the possibility of, or suspecting the existence of HIV infection or AIDS all have profound emotional, social, behavioural, and medical consequences. The personal and social adjustment required in the context of HIV infection often has implications in diverse contexts - family life, sexual and social relations, work and education, spiritual needs, legal status, and civil rights. Adjustment to HIV infection involves constant stress management and adaptation. It is dynamic, evolutionary, and lifelong process that makes new and changing demands on individuals, their families and the communities in which they live. During the course of HIV infection, a broad range of physical needs and problems are likely to be experienced. These are not necessarily constant, and will progressively become more serious and difficult to handle. These call for increased and different resource, both for those who are HIV-infected as well as for the people looking after them.
Components of the Counselling Relationship

E m pa t h y Sympathy means having feelings of regret about another persons situation, but empathy is a feeling of emotional
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connection with the client and his problems, as if you have experienced them yourself. By reflecting on the clients experiences and trying to connect with what he must be feeling, the counsellor may be able to experience the clients pain. After greeting the client on his arrival, the counsellor may want to communicate something appropriate to show that s/he empathises with the client, based on what the counsellor knows about him. The counsellor will then assess whether the client is guarded (unwilling to open up), hostile (resentful or angry towards the counsellor) or tearful (on the verge of tears), and respond appropriately. For instance, the counsellor could say to a guarded client, Coming to counselling is a very difficult decision, and I really feel that you are very courageous to be here. To a hostile client, the counsellor could say, I can understand that you are upset to be here, and I appreciate your honest feelings about me and this situation. I hope that you will tell me all about your feelings. I think you will begin to trust me in time and understand that I am here to help, not to hurt you. Later on, the counsellor could say, Anger usually comes after hurt. I can see that youve been hurt very much. To the tearful client, the counsellor could say, I can see how much pain you are feeling. Please just let yourself cry and I will sit here with you. (Winiarski, 2004) Belief in the dignity of the client This is more than just accepting or tolerating a person. It communicates to the client that s/he is worthy of love and entitled to be treated a unique individual and that her HIV status makes no difference to the counsellor.
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Respect for the clients agenda Never attempt to transform the client into the person you think s/he ought to be. Such an attitude communicates: (1)I know what is best, (2) Im more important than you, and (3) You dont meet my standard This approach is devoid of any respect for the client, and is not a good way to enter into a relationship. A non-judgmental presence As we go about our lives, our heads are filled with judgments. For instance, we tend to opinion that my neighbour talks too much, or, my wife isnt fair to me. As we start learning how to counsel, such judgments often enter our thoughts and tend to be communicated through our words. A counsellor should never let them enter into the relationship. As a counsellor gains experience, it gets easier not to be judgmental. When a counsellor finds himself or herself being judgmental, he/she should ask herself, What is making me judge this client? She/he may have a deeply personal reason that is not too obvious. For example, an angry reaction to a client may be because the clients behaviour or comments provoke a memory for the counsellor. The role of the counsellor is not to judge. Critical judgments never help. Skilful listening Becoming a good listener takes some practice. You need to focus entirely on your clients speech, expressions and mannerisms. Taking note of the subjects that your client does not want to talk about will also tell you something about the person. Skillful listening leads to skillful responses that probe and challenge. These are important in helping a client to explore her feelings,
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understand problems and emotions, and come to terms with her situation. Safety The counsellor is responsible for the emotional as well as the physical safety of the client. This involves acting ethically and taking steps that involve the following:
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Ensuring confidentiality
Since there is so much of stigma and discrimination surrounding HIV and AIDS, you may not tell anyone else about your clients without a written consent from the latter. There are exceptions to this rule. For instance, you may have to discuss your client with your supervisor, or you may have to report the client to the authorities if she threatens to harm someone else.
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Never making promises that cannot be kept
It is human nature to say things like, Every thing will be all right. We may do this automatically in an attempt to assure and make the client feel better. It is important to avoid such assurances because it ignores the reality of the clients situation and is probably not true. Quite often the things we say as counsellors are really to make us feel better as counsellors, rather than to reassure the client.
Who is A Client?
A client is someone who agrees to counselling. The client brings along his/her problems, fears, suspicions and other emotions to the counselling sessions. The counsellor communicates only one request, one of openness, so that the client will try out the counselling process. The client need not be enthusiastic, and usually is not. There are scores of messages of acceptance and
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care that counsellors can communicate that can open up closed hearts. Sometimes the client is not just one person; there may be two or more people in a relationship, or even an entire family. In such cases, a skillful counsellor has a very clear idea of who the client is, and what his responsibilities are to each person. Obvious Needs Most of us who work in the area of HIV / AIDS understand the critical needs of people living with HIV (PLHAs). Often, HIV and AIDS are not the most pressing issues, and not even close to what needs immediate attention. Often, a clients more critical problems include:
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little or no money; hunger, with no access to food; illnesses - people with HIV/AIDS eventually contract opportunistic infections that occur when the bodys immune system is unable to fight off organisms that cause sickness. Also, people with HIV also have other illnesses, such as high blood pressure and malaria; difficulty in accessing health care - care if ever available, may be kilometres away and the client may not have transportation; emotional distress - because of the lack of mental health care, many people have psychological difficulties that are not recognisable and hence may not be treated; overwhelming family responsibilities - most of the cases are single women or widows with children. They have to sacrifice their own health and welfare for that of their children. Others may have taken in the children of their deceased relatives, or care for relatives who show up at their doors. There may
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still worse, be child-headed households in which children shoulder adult responsibilities;

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Shame, Discrimination, Stigmatisation; destitution, homelessness or inadequate shelter.
Stages of Counselling
The term process refers to a sequence of events. There is a process involved in counselling while dealing with various situations. The process in counselling comprises of the following stages: Stage One Establishing Rapport - gaining the clients trust Stage Two - Defining and understanding of needs, boundaries and roles Stage Three - Ongoing supportive counselling Stage Four - Closure or ending the counselling relationship STAGE 1 Establishing Rapport This stage is characterized by the initial interview. It comprises of the first contact with the client and creating an ambiance for the client to trust aimed at disclosure. It includes completion of the intake process, which recruits the client into the formalities of counselling. The initial interview is much important for the following reasons: 1 . It helps the counsellor get to know the client better, and plan appropriate intervention. These plans include taking up the client for counselling or referring the client to another, appropriate, treatment service; It helps the client to get to know the counsellor better, and obtain reassurance and even crisis support, as necessary;
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It allows the counsellor the opportunity to explain the nature and goals of counselling, and make the practical arrangements for counselling; It is a stage at which the client the counsellor assures confidentiality to the client and discusses the limits of confidentiality; All efforts are directed towards complete ventilation of feelings and statement of the problem in clear, unambiguous terms; The counsellor answers all the questions of the client so as to clarify clients expectations of the counselling process; By the end of this stage the counsellor describes the kind of help the counsellor can offer and also their commitment to work with the client;
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Clients who come into therapy are seldom clear and concise in their communication. More frequently, their thoughts are muddled, and heavily laden with emotional content. Clients do not say, I am anxious, or I am depressed. Instead, they frequently commence with an account of what happened, where and when. Such details are necessary, but it is all the more important for the counsellor to first understand what is bothering the client. This understanding provides the framework for an understanding of what the client subsequently describes. Therefore, the counsellor should gently but firmly encourage the client to clearly state the problem in a few words; to provide a birds eye view, so to speak. Or, the counselor may even paraphrase whatever is being transpiring between them. Once the counsellor has obtained a clear understanding of what the problem is, he needs to learn about its background. He needs as much information as is possible to make a systematic evaluation of the problem, its
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causes and its effects. The assessment so conducted provides the counsellor with a working model of the clients problem situation. This working model is necessary because it guides the counsellors thinking. This model, of course, needs to be continually updated with information obtained from subsequent sessions. It is important to ascertain the magnitude and extent of the clients problem situation, isolate his dysfunctional behavior, and to establish whether the client is amenable for counselling or whether further primary psychiatric intervention is necessary. In this context, it may be necessary to postpone completion of the intake process until a psychiatric evaluation rules out the existence of serious disturbances which require primary medical therapy. STAGE 2 - Defining and Understanding of Needs, Boundaries and Roles Problems seldom exist in a vacuum. They are generated by certain circumstances, and they, in turn, generate other problems. Thus, a clients problems cannot be satisfactorily addressed unless all the related issues are identified and tackled. Family dynamics frequently contribute to circularity of problems. Therefore, while assessing circularity the counsellor must remember to evaluate each family members role in symptom formation and symptom maintenance in order to identify the persons need for therapy. In this stage all efforts of the counsellor are directed at taking a detailed history with specific details. The counsellor clarifies clients needs, prioritizes them and then set the clients goals. While listening to the client, the counsellor makes a complete study of the clients beliefs, knowledge and concerns. Finally, he explains the roles and boundaries of the counselling relationship to the client.
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During this stage a lot of importance has to be placed upon the clarification of expectations. As already stated, the counsellor needs to find out what the clients expects from counselling. Some clients believe that once they tell the counsellor their problems; it is the counsellors responsibility (and not their own) to find the solution. Some clients believe that the counsellor will magically remedy problems that have existed for years. More specifically in the context of HIV/AIDS, the counsellor should take care to guard against unreasonable expectations, such as expectations of dramatic cures, total cures, one sided compromises, etc. Also in setting of goals for the counselling process, the counsellor has to be very realistic. General goals of counselling are to reduce emotional distress, to reduce dysfunctional behavior (here, high risk behaviour), to promote adaptation, to help realise their potential, and to assist in decision-making. After obtaining a general understanding of the clients problems and expectations, specific goals of therapy need to be set. The counsellor needs to guide the client in the setting of specific goals because the client is quite likely to be uncertain of what may be expected from counselling. Such goals are best explicitly stated as specific emotional and behavioral changes that are acceptable and desirable to the client and to society. Thus, an ethical element exists. It is important to break down the details of the goals into subcomponents which, by virtue of such identification, are more easily tackled. Such subcomponents helps translating the goals to be specific, measurable, achievable, realistic, and more specifically timebound (SMART) in order to be translated into definite action (Jose, 2008). There is no bar to the number of goals as long as the goals are specific, clearly defined, reasonable and attainable.
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There are many reasons why goals should be so specifically set. Setting specific goals gives a direction to therapy. Setting specific goals allows focusing of attention upon the relevant issues, and discourages irrelevant digressions. Setting specific goals also allows an objective evaluation of the progress of therapy. Counselling seldom concludes with perfect results; such an assumption leads both counsellor and clients to consider therapy a failure. By listing specific goals, both counsellor and clients can identify the goals that have been attained, derive satisfaction from them; alternately it may also occasion an introspection as for the reasons of failure in achieving goals if any, and work out strategies to achieve them.
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Establishing a Contract
In formal psychotherapy, the therapist and client establish a contract with each other. While a formal contract is unnecessary during counselling, an informal understanding between client and counsellor is essential and should be established. They should be clear between themselves that the client will strive to his best with the support of the counsellor to work towards the achievement of his goals.
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Discussing the Practical Details of Counselling, and Making the Practical Arrangements
The last step during the initial interview is to discuss practical details about counselling, and to make the practical arrangements for counselling. The counsellor needs to explain to the client what counselling does and does not. The client particularly requires understanding that counselling provides the guidance; working towards adaptation is the responsibility of the client. The counsellor also needs to explain to the client the need for motivation to change, the need for honesty
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during therapy, the importance of leaving nothing hidden, etc. Practical arrangements including details such as the frequency, duration and timing of therapy sessions, financial aspects etc. for counselling should be considered.
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Duration of the Initial Interview
With experience, the initial interview can usually be concluded over a single session of about one hour duration. Sometimes, the initial interview may spill over into a second session; a variety of reasons such as the non-availability of a key family member, an absence of clarity of problem situation, deep emotional trauma or even resistance from the client could be responsible for the same. STAGE 3 - Ongoing Supportive Counselling Assessment as an Ongoing Process: For a few sessions after the initial interview, the counsellor will need to continue to assess the clients psychological framework and his problem situation. The procedure will focus on collecting more detailed clarifications. During the assessment phase, the counsellor modifies and updates his working model of the clients psychological build and the problem situation. During assessment, the counsellor continues to provide support, guidance and other elements of counselling as the situation demands. Information in the assessment phase obtained primarily from the client, may also be cross checked with the significant others in the clients life, should the counsellor deem it necessary, and should the client consent. The information obtained should include not just present but also the past. Depending upon the circumstances, the counsellor may request for information about the clients early childhood, emotional development, education, track record at work, etc.
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Information is primarily obtained through verbal channels. But the counsellor can often glean much from the way the client dresses, speaks or communicates non-verbally. This face of ongoing supportive counselling occupies the bulk of the period of counselling. It is the phase during which the counsellor analyzes the clients feelings and behavior, provides a feedback to the client, provides support and guidance, and eventually effects behavior change. The following need to be considered towards effecting behavioural change: 1 . 2 . the emotional factors that need to be corrected to resolve the dysfunctional behaviour; to manifest faulty ways of thinking that need to be corrected for a resolution to the dysfunctional behaviour; the social and environmental factors that have to be addressed to resolve the dysfunctional behaviour.
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The counsellor throughout this phase encourages continued expression of thoughts and feelings, exploration and identification of options available to the client and their evaluation, identification of existing coping skills, development of further coping skills, and enabling behaviour change. This has to be completely guided and monitored. The approach has to be totally flexible and adaptive to the needs of the client at every stage. Wherever required, referrals should be made. STAGE 4 - Closure This stage marks the closure of the counseling process. Counselling should never be abruptly terminated; rather, it should follow a series of formal stages, letting the client branch out into life gradually, so to speak.
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Evaluation of Readiness for Termination
Counselling is always conducted with predetermined goals, set in consultation with the client, and modified as required during the course of therapy. The counsellor also approaches each case with a specific plan in mind. Accordingly, as the therapy progresses and the goals of therapy are progressively attained, the counsellor must evaluate readiness to terminate. He needs to answer the following questions: Is the plan of therapy running its course? Has the client grasped the principles of the therapy? Are the goals of therapy in the process of being attained? Will the clients morale stand up to termination?, and finally, Is the client able to maintain functional equilibrium?
The last question is particularly important because clients enter therapy with hope, and often show greater adaptation during active therapy than their degree of internal adjustment actually warrants. Therefore, if therapy is prematurely terminated under the assumption that the client has attained functional equilibrium, disequilibrium and decomposition may occur soon after the modified effect of the therapy is withdrawn. If the answer to all the above questions is yes, then the counsellor concludes that the therapy is approaching the termination phase. Sometimes, therapy termination may depend not upon intra-therapy factors (such as are addressed by the above questions) but upon external influences, such as time constraints or unforeseen contingencies. Wherever possible, the counsellor would be well advised to keep in mind and plan for termination accordingly. However, even if the termination of therapy is unplanned, the
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steps of termination are best religiously adhered to the extent permitted by the circumstances. The counsellor has to ensure the existence of a support system and supports being accessed by the client as per his needs. Therapy may also terminate because the client feels that he does not wish to continue; or because of a failure to make progress towards the set goals. Provided that the termination is not abrupt as when clients drop out of therapy, the counsellor must endeavour to adhere to the steps of termination again as may be applicable under the circumstances.
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Provision of Advance Notice of Termination
Many counsellors fail to realize that while they are following a specific plan during therapy, the client is merely following the counsellors lead. The client does not know what further assignments the counsellor wishes to undertake, or what further techniques in therapy the counsellor wishes to employ. Therefore, unless the counsellor provides sufficient advance notice of termination, the fact of termination is likely to catch the client unprepared. Adequate advance notice of termination is necessary so that the client can psychologically orient himself towards independence in functioning (i.e., unsupervised by the counsellor). This psychological orientation refers to not only an unconscious preparation for independence but also a conscious preparation as evidenced by seeking appropriate clarifications regarding handling of posttermination contingencies. Discussion of Readiness to Terminate Therapy The counsellor should always be aware that while he may consider therapy to be approaching completion, the client may yet have many internal problems to
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resolve. Therefore, the clients appraisal of the situation is essential before termination is formally announced. The discussion of readiness to terminate therapy should cover the clients understanding of what has transpired during therapy, his doubts and misconceptions, and his confidence to handle future situations on his own. The counsellor should usually bow to the clients judgment if he wishes to prolong therapy. However, the counsellor must guard against dependency (on the counsellor, and the counselling process) underlying the wish to prolong therapy.
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Review of the Course of Therapy
Assuming that the therapy has succeeded in establishing a functional equilibrium, it is necessary that the client understands the dynamics of the reequilibration. Such an understanding provides the client with the tools necessary to maintain the functional equilibrium after termination. The counsellor therefore draws to the clients attention the problems with which he had initially presented; the goals that were set up for therapy; techniques that were employed in therapy to attain these goals; assignments that were given; interpretations and insights that resulted; progresses and setbacks in therapy; and, other issues important to the course of the therapy. The client thus obtains a birds eye view of his therapy, or a somewhat objective perspective, much as though he was looking at himself from the outside. It hardly needs to be stressed that the counsellor should elicit the above from the client using appropriately worded questions rather than summarize the course of therapy himself.

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Emphasis of the Clients Role in Effective Change
Clients particularly in India, tend to glorify the counsellor in having made them functional again. Although this may be gratifying to the ego of the counselor, it is more important for the client to understand the initiative that he himself has taken in bringing about the change. Hence, the client need to be complimented for having taken the positive effort in effecting the change, change in itself of any nature being difficult. Such a compliment should positively reinforce the clients functional (as opposed to dysfunctional) behavior, and give him the confidence to handle a crisis in future. The counsellor should of course explain his role as that of a facilitator and guide to the client on his road to functional health, and assure assistance when needed in future.
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Warning Against Flight into Health
Flight into health refers to the phenomenon of dramatic recovery occasioned ostensibly by therapy but in fact by nonspecific factors such as hope; temporary benefits stimulated by the novelty of therapy; beliefs that a resolution of superficial issues has solved the entire problem; euphoria over minor or transient gains; etc. Such a reaction is quite common in therapy. There is a definite possibility that although the goals of therapy may have been attained, such may not be long-lasting; the client may relapse shortly after he has been returned to the original environment with all its former stressors. Warning the client against this flight into health keeps him aware of the realities of the situation and guards against unwarranted euphoria; it most importantly serves to protect against disappointment, should difficulties in adjustment resurface after therapy has been concluded. Such difficulties are far more common than realized.
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Giving Instructions for the Maintenance of Adaptive Functioning
Given the possible risk for setbacks - temporary or otherwise - after termination, the client should receive adequate counselling about how to handle potential troublesome situations. Such counselling should cover all levels of prevention - primary prevention, to preclude the development of crises; secondary prevention, to identify destabilization early and to defuse the crisis with the minimum of disturbance; and tertiary prevention, to minimize the damage done, if any, and to affect the necessary steps for correction. Types of situations and how they are to be dealt with are ideally discussed in detail with specific reference to examples from the course of the therapy. As earlier, it is preferable that the counsellor elicits the examples and the solutions from the clients rather than didactically advise. Elicitation from the lips of the clients is always best, because it tests and confirms the clients understanding of the therapy. This is especially relevant because clients tend to remember and accept best what they have themselves spoken of, and because the clients are more likely to select the most important clientrelevant contexts in the discussions.
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Discussion of Follow- up Sessions
It is never advisable to conclude therapy abruptly. However well motivated the clients, however sincere the counsellor, and however seemingly successful the therapy, many clients run into problems after termination. This can be attributed to issue that arised, or simply to issues that were for some reason or other unresolved during the actual therapy. It is therefore necessary for the clients to continue to maintain contact with the counsellor for continuation of assistance in
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the maintenance of the functional equilibrium. The frequency of such follow-up sessions is decided based, upon individual circumstances, and can increase or decrease depending upon the need.
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Stressing of Open Doors
Open doors refer to the continued, uncritical accessibility of the counsellor to the clients. The clients should clearly understand that they need not feel guilt in case of relapse of dysfunction - guilt that they have failed the counsellor. Instead, they should consider that the counsellor is always available to them, and that he will uncritically resume therapy as and when needed. This gives the clients the confidence that even if they relapse, all is not lost. When above is completed to the satisfaction of both clients and counsellor, the therapy is terminated formally.
Skills of a Counsellor
The counsellors are required to work with their clients across a bridge of relationship. In this helping process they certainly have to possess specific practice skills in effectively reaching out to their clients. These skills are essential for effective communication and the development of a supportive client-counsellor relationship. These skills include: a) Listening and empathy The most important component in good listening skills is the ability of the counselor to convey empathy. Demonstrating empathy helps the counsellor to establish a relationship of helping the client and a rapport is thereby formed that makes the client trust the counsellor to reveal his innermost feelings. To convey
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empathy, specific listening skills are very effective: A good eye contact that is culturally appropriate is important in showing the client concern and attentiveness to his/her problem. Body movements such as nodding of the head convey that the counselor is listening. Cues and prompts further encourage him to continue with his narration. Few and only minimally appropriate interruptions is what is best in such a situation where the client is opening up. Counsellors however need to continuously clarify and summarize for their clients. Also, paraphrasing and reflecting are very helpful techniques. In paraphrasing the counselor restates in his or her own words, the essence of what the client has said. This helps in reassuring the client that he is being heard and helps to focus on his / her problem. In the same manner, the Counsellor may reflect upon the emotions of the client, helping them to explore their reactions to these events in their life. b) Questioning Questioning is no doubt a very important aspect of the counselling process. It helps to have indepth information of the clients situation and it helps to assess the clinical condition of the client. It is important to keep the following things in mind in the process of counselling: ask only one question at a time; ask questions that serve a purpose; be brief and clear; ask questions that encourage clients to talk about their feelings and behaviours. c) Silence Effective communication is the essence of the communication process. Needless to state, silence is also an important tool in the hands of the counsellor.
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Firstly, it gives the client time to think about what to say and how to say it. It gives the client an opportunity to experience and cope with diverse emotions that emerge when he is talking about his problems. It leaves the client with the option to set the pace of the session and he does not feel that he is being rushed through the counselling process. It also offers the option of discontinuing the sharing if it becomes excruciatingly painful or disturbing for the client. d) Non-verbal behaviour Mehrabian asserts that more the half of the communications that we do are non-verbal in nature. Thus, all aspects of non-verbal communication become significant in the counselling process. Counsellors need to be aware of what their clients are communicating through their non-verbal behaviour and what they themselves as counsellors are communicating to the clients through their non-verbal behaviour. Their postures, gestures, facial expressions, eye contacts, all have a meaning. All paralinguistic indicators such as pitch and tone of the voice, sighs and grunts have to be taken note of by counselors.
Impact of Values and Attitudes of a Counsellor

We all develop our values in the social and cultural context in which we grow and mature. The attitudes, values and beliefs we uphold, influence our day to day behaviour. The manner in which we perceive the others behaviour, as well as how we interpret and explain, are guided by our value systems. It is well accepted fact that values differ within and between countries, regions and groups. Thus, it is important that those involved in the counselling process are well aware of their attitudes,
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values and beliefs. Also, they should know how to handle their responses when they have clients with different values and attitudes. This can only happen when they learn to accept their clients even when their opinions dfe. ifr Counseling never attempts to make people conform to certain sets of acceptable behaviours. Counsellors need to deal with their strong negative emotional reactions to clients and certain situations, and must be frank enough to question themselves in various situations. When difficulties emerge in the counsellor-client relationship they should resolve them through supervision, peer consultation, consultation with experts, and if necessary, even by means of referral.
Characteristics of a Good Counsellor

Everybody can offer to counsel, but not everybody has the skills to be a good counsellor. Ideally, a good counsellor must: 1 ) be fluent in the language of his client in order to guess what is unsaid, and to correctly interpret nuances in communication. understand the culture to which the client belongs; devoid of such an understanding, the counsellor may misinterpret various behaviors that the client manifests. have charisma and personality, and should inspire confidence and respect in his client. have much experience of life; without such an experience, it is difficult to put the clients problems and behavior in correct perspective, or to provide appropriate guidance. be reasonably mature and intelligent to understand the clients problems, formulate an appropriate plan
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3 ) 4 )
5 )
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of management, and carry it through; without maturity and intelligence is one who may show poor judgment when counselling clients. 6 ) have a healthy set of values; during therapy, the counsellors values inevitably percolate down to the client. have knowledge of psychology; that is, he should understand the intricacies and the workings of the human mind. be knowledgeable about the range of psychological disorders that individuals experience, and the characteristics thereof. be knowledgeable about the clients problem field; for e.g., unless a counsellor knows much about children, he will find it hard to competently counsel a parent who is having difficulties with his offspring. It will help if counsellor is also experienced, in addition to being knowledgeable in the clients problem field; for e.g., a counsellor who is a parent will be able better understand and counsel a client with parenting problems.
7 )
8 )
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10) be free of emotional problems. A counsellor who is unhappy and may not be able to give his client undivided attention. Furthermore, his judgment may be clouded by his personal problems. A good counsellor must be particularly free of problems in his clients area of difficulties. 11) be well trained with sufficient theoretical and practical exposure to counselling. 12) have good communication skills; he must know what to say, when to say, how to say it, and when it should be said; alternately, he must also know what is not to be said.
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13) be genuinely motivated to help person in distress. He should not counsel merely out of a feeling of duty. While counsellors can be of any age or sex, most clients tend to prefer their counsellors to be older than they are. Some clients may find it easier to confide in a counsellor of a particular gender or even sometimes there is preference for same-gender counsellors.
Comminication Skills af a Good Counsellor

As has already been highlighted, communication is integral to the counselling process. Counselling being an interpersonal process, good communication skills are essential if a counsellor is to be effective. Let us look into the specific communication skills, important for effective counseling. 1 . A good counsellor is conscious of his body language and the impact that it has on the client. He makes culturally appropriate eye contact with the client, nods to convey his interest to the client, and avoids signs of boredom (yawning) or restlessness (fidgeting). A good counsellor listens far more than he talks. He practices reflective listening; that is, paraphrasing every now and then to reflect the gist of what the client just said. He does not interrupt unless absolutely necessary. A good counsellor is polite, courteous and tactful. He is aware of the clients sensitivities and does not make his client feel guilty for past mistakes. He practices good timing in conveying his insights to the client. A good counsellor is clear and unambiguous in his communication. He sticks to the point, taking one
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problem (and only one) at a time. His statements are relevant and meaningful. 5 . A good counsellor encourages, he talks positively. He makes supportive and appreciative statements to his client, and gives praise wherever due.
Some frequent statements that a counsellor may make are: In enquiring : Tell me about/ tell me more. In summarizing : So, basically, what you mean is . In understanding : Is this what you are trying to say? In handling silences : Take your time, there is no hurry, (and much later after a reasonable pause) what are you thinking of?
Characteristics of a Good Client

Counselling can benefit everybody, irrespective of age, sex, culture, creed and other characteristics. Intelligence is also not a prejudicial issue, provided that the client is sufficiently intelligent to understand what is happening during counselling. In most cases clients approach the counsellor of ones own choice or through referrals. However, in most cases of alcohol and drug addiction, a client is motivated and sometimes forced to seek counselling. There are certain client characteristics, however, which can increase the extent to which a client may benefit from counselling. These characteristics describe a good client, and they are: 1 . A good client is self-motivated for therapy, and is not brought unwillingly by a friend or family member.
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A good client is flexible, and is willing to accept that his point of view may be incorrect. He is willing to consider alternate opinions that may facilitate better and effective adjustment. A good client is cooperative; he participates fully in the exercises suggested by the counsellor.
3 .
Client characteristics which suggest a favourable outcome are fewer past problems, better previous adjustment in social and other walks of life, healthy family life and healthy social life, and good medical health, ability to relax and enjoy leisure pursuits, emotional maturity and good judgment.
Conclusion
To conclude, the importance of counselling in the area of HIV/AIDS can no longer be undermined. Unlike other diseases, HIV/AIDS requires special care and attention to the client groups. Although the concept of counselling in medical services is well known, the practice of this strategy in developing countries is almost absent. In India, efforts are being made to provide counselling services at least in some of the medical institutions. The Integrated Counselling and Testing Services have become the nodal points for HIV/AIDS counseling. Counselling can help the HIV infected to live a life of dignity and also help to prevent further spread of the infection. In fact anyone who feels that he/she has been involved in risk behavior which can cause HIV infection needs counselling. Similarly those who have been already infected require counselling services which will enable them to plan their future course of action to live a meaningful and productive life.
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References
IGNOU: Counselling on HIV, September 2006. World Health Organisation (2004): Voluntary HIV Counselling and Testing, Manual for Training of Trainers, New Delhi, India. DiClemente, C.C. & Prochaska, J.O. (1998). Toward a comprehensive Trans-theoretical Model of Change: Stages of Change and Addictive Behaviors. In W.R. Miller & N. Heather (Eds). Treating Addictive Behaviors (2nd ed.). New York: Plenum Press. DiClemente, C.C. & Velasquez, M.M.(2002). Motivational interviewing and the Stages of Change. In W.R. Miller and S. Rollnick (Eds). Motivational Interviewing: Preparing People for Change, (2nd ed.)New York: Guilford Press. Jose, S. (2008). Essential Counselling Skills. In M.K.C. Nair, Counselling for Health Professionals. Jaypee Medical Publishers Pvt. Ltd.: New Delhi. (under print). Jose, Sonny. & Jyothiram, Aishwarya. (2008). Ethical Issues in HIV Counselling. Kerala Sociologist. Vol. XXXV.. No. (1) Jan-June, 2008. Maslow, A.H. (1970). Motivation and Personality (2nd ed.). New York: Harper and Row. Winiarski, Mark G. (2004): Community - based Counselling for People Affected by HIV and AIDS. Longman and Catholic AIDS Action.
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Issues and Types of HIV/AIDS Related Counselling

*Jyoti Kakkar
Introduction
Counsellors may be employed to do special tasks, such as counselling people who want HIV tests at Voluntary Counselling and Testing Centres (VCTCs), helping people take their HIV medicine correctly, conducting HIV prevention programmes, or meeting the special counselling needs of children and adolescents. This chapter looks at issues that need to be addressed by the counsellors who take on these important functions. It highlights the importance of specific interventions as per the need of the clients.
Counselling Issues
Voluntary counselling and testing HIV testing plays an important role in the fight against HIV and AIDS. Special voluntary counselling and testing (VCT) centres have been set up in many countries, including ours, and hospitals and clinics also have services for voluntary counselling and testing. Many governments, non-governmental organisations and donor organisations urge people to be tested for HIV in their efforts to control the pandemic of AIDS. People who support voluntary testing say that being tested
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helps people focus on HIV issues, whether they are found to be infected or not. In areas that have HIV medicine available, they can seek medical care after finding out that they are infected. The care may include medicine that can lengthen their life if it is taken properly, called antiretroviral medicine. In countries without antiretrovirals, a person who has been told he or she is infected can still take steps to live a healthier life. People who are tested are taught about ways to prevent HIV infection of themselves, if they are not infected, and of other people. Counselling at VCT centres requires special training. Counsellors learn to use a standard list of questions and responses when working with people who want to be tested or who want to hear their test results. The need for professionally trained counselors is high and there are not many available who are well experienced to take up this challenging task. Many who are placed in this job are given training quickly. There is little time for them to practice counselling skills. Some VCT programmes focus on the biomedical and prevention aspects of HIV, giving little or no attention to emotional, social and spiritual issues. The neglected issues could include harmful emotional responses to news of infection, mental illness, alcohol abuse and the potential for family troubles. VCT centres could serve clients better with additional attention to the emotional needs of clients. Anonymous or confidential: Testing is usually anonymous or confidential. One should be aware of the difference between the two. Anonymous testing means a test result is not attached to a persons name. At a test site, a person does not give his or her name. The person is given a code name or number to use when he or she returns for the result. Confidential testing is different. It means that the test result is put into a file,
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such as a medical record, with the patients name. This is usually what happens at a medical clinic or hospital, so doctors and nurses can better treat their patients. In this case, confidential means that only those who need to see the test result may read the clinics files. In some small communities, just being tested leads to stigma and discrimination. Some people are concerned that neighbours who work at VCT centres will gossip, or that people who work at clinics or hospitals will read the files and learn of a persons HIV infection. As a result, people sometimes travel for hours to be tested where no one knows them. VCT centres are now being located in buildings where many people do business, or in campus of universities so no one can say that someone entering the building is going to the VCT centre. The HIV test: Tests at VCT centres and clinics determine if someone has an antibody to HIV, which is a product of the bodys response to the presence of HIV. You may hear that someone is antibody positive this means that the person is HIV infected. When some one is in medical care, the person may be given a viral load test that directly measures the amount of virus in the persons body. The actual HIV test given at VCT centres and clinics will differ depending on the methods available. With one test, a clinic staff member takes blood from the person being tested. The blood sample is sent to a laboratory for testing. The client returns for the test results a week or two later. Many people, made anxious by the testing and the possibility of infection, do not return for their results. Newer tests are available in which the results are available within minutes. Because the new tests provide faster results and dont require a lot of blood, people are more likely to be tested and less likely to be anxious.
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The VCT counsellors official tasks fall into two general categories: 1. Pre-test counselling, which includes educating the client about the test and its outcome, as well as screening the person for suitability for testing depending on the propensity towards high risk behaviours Post-test counselling, which includes notifying the client of the test result. If the person is infected (tested positive), the result is explained, supportive counseling is provided and instructions given for medical assistance. Both infected and non-infected people are counselled regarding prevention of infection.
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VCT Counselling procedures: VCT counselling procedures, also called protocols, differ from country to country and even from clinic to clinic (or counselling centre). Protocols are the counselling and testing procedures set up by a clinic. Sometimes these procedures are deliberately ignored - for example, when no counselling is provided before or after an HIV test. Not providing counselling may be illegal and certainly is unethical. Counselling procedures usually emphasise a clients biomedical or physical issues. Clinics and VCT centres require employees to work through the required checklists of questions and procedures. However, counsellors still need to find time for compassion. If time and the supervisors allow, the counsellor does more, asking questions and expressing concerns about the clients emotional, social and spiritual aspects. Some checklists may not lead to a good assessment of the clients emotional situation. It may be helpful to assess several issues:
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l
Anxiety It is normal to be anxious when being tested for HIV and especially while you wait for the results. While it is normal to be anxious or nervous, if you should have a VCT client, who is so anxious that the individual is having trouble functioning, you should be curious about why this is the case. It is possible that the client has a biomedical problem, such as lack of oxygen (hypoventilation), an overdose of a medicine, a serious psychiatric condition or even strong denial, or a strong conviction that a positive test result means quick death. An excessively anxious person may be too distracted to understand the counsellors teaching. If a severely anxious client is tested, the wait between the test and the results may be too much to tolerate, resulting sometimes in a serious crisis. Depression If a person who comes for testing seems depressed, a counsellor may want to ask questions about the symptoms of depression. Depression may cause the client to react very negatively to news of infection, leading to despair, suicidal thinking or even suicide. In such cases, HIV testing should be postponed until the symptoms of depression disappear.
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Severe mental disorders People with serious mental disorders should not be tested for HIV without psychiatric support. Symptoms of severe mental disorders include: l problems recognising what is real and what is not; speech that doesnt make sense; l delusions and even unshakeable beliefs (which are not culturally acceptable) about cures, aliens, strangers and other aspects of life; l alcohol abuse and intoxication.
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The abuse of alcohol and other substances is common enough and enquiries should be made about their use when someone comes for a test or for test results. An intoxicated client seems slowed down and a bit disoriented. Signs of intoxication include slurred or halting speech, slowed thinking and actions, and walking unsteady. Such symptoms should raise several concerns about having an HIV test or receiving results: Why is an intoxicated person at the clinic? The client should be completely sober so that she can make an informed decision to be tested. It is unlikely that an intoxicated client can fully understand the counsellors instructions. Did the client think intoxication was necessary to tolerate the anxiety? Is the clients condition masking depression or a serious mental disorder? Is the client treating this serious event as trivial? Is the client addicted? Intoxicated individuals should be instructed to return when they are sober and are able to understand and work with the counsellor. The counsellor may give the person information about where to seek assistance, if any is available, for the alcohol or substance abuse problem. Facing the anxiety-causing HIV test: Being tested for HIV often makes the person extremely anxious. Even people who have little or no chance of being infected get upset at the thought of being tested or waiting for the result. Imagine the anxiety of people who think they may have been infected! Added to this is the unfortunate situation that just being tested, makes people vulnerable to stigma and discrimination in some communities. The clients social situation: A person may come alone to be tested and s/he may seem to be alone. But this individual is part of a larger system: a family. A counsellor may want to know how a test result showing
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infection will change the clients relationship with her family. Will the family learn about the result and will the family members need support and guidance if the result is positive? The counsellor is encouraged to look at the big picture and help with all the consequences. Some questions, perhaps not on an official checklist, which the counselor may raise include: Is the client currently in a sexual relationship?; Is the partners HIV status known?; Is safer sex being practised?; Does she plan to tell her partner or other family members about the test result? If not, why?; If the test is positive, and the partner learns about it, what are the predictable results? Will family members be supportive or rejecting? Is there a risk of violence? All these aspects need to be discussed and the counselor may need to help the client at every stage of problem solving.
Treatment and Drug Adherence

As countries begin to offer anti-retroviral medicines to people with HIV and AIDS, some counsellors will assist clients to take the medicines as prescribed. Some counsellors may join hospital staff and receive special training to counsel clients about their medicines. Increasingly, counsellors act as members of care teams that include the clients doctor, nursing personnel, family and others. Doctors often prescribe combinations of different types of medicines to fight the virus in different ways. These combinations are the Highly Active Anti-Retroviral Therapies referred to as HAART (say heart). There are several important reasons why clients must take their medicines in the way they are prescribed. This is the clients best chance of improving quality of life and extending life.
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Counsellors can assist their clients with HIV related medicines in the following ways: Counsellors must learn the names of the medicines, the dosage to be taken, how often, if they should be taken with or without food, and the possible side-effects. Similarly, guides are available in some countries that provide ARVs and counsellors should read them. Sometimes colour photographs of different pills are available from pharmaceutical companies, chemists, or HIV/AIDS advocacy groups. Non-governmental organisations (NGOs) should request the local distributor of ARVs to make a presentation to the counselling staff, showing the colours and shapes of the pills and capsules, describing typical dosages and explaining possible side-effects that the medicines cause. A counsellor could introduce himself to a local hospital, chemist or clinic and ask if he can learn about the medications and contact them with questions. Having a relationship with a local chemist or doctor is important because prescribing guidelines may change, new medicines may become available (or old medicines be discontinued), or other news may emerge. The counsellor who deals with medication issues should think of himself as part of a team that includes the doctor, family members and other people. He has to be in constant consultation with other team members. The relationships built on behalf of the client should be faceto-face, rather than at a distance. For example, the counsellor could accompany his client to the clinic and introduce the client to the doctor. The counsellor could then explain that he is assisting with the medicines, share the unique concerns of the client and request the doctor phone him if concerns emerge. On the same basis, he could phone the doctor to enquire about the progress.
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Medicines for HIV/AIDS can be confusing, especially for people who have difficulty remembering or reading instructions. Assisting the client with this is an opportunity to be creative. He can draw pictures and organize pill boxes for the client. However, a counsellor cannot always be with his client, but family members or special friends are usually around. Using similar methods, the counsellor can train the family members to remind the client to take the correct pill at the right time.
Youth and Children

Children affected by HIV and AIDS also have a wide range of situations that can come to a counsellors attention. Some young children may be HIV-infected and, if medicines become available to them, they will live with the infection as they grow older. Others may not be infected, but they may lose their parents or other family members and suffer great emotional pain. Data show that young people aged 15 to 24 years old account for more than 50 percent of all HIV infections worldwide (excluding perinatal cases) and more than 6000 young people are newly infected with HIV each day throughout the world (see UNAIDS, 2000). Not many of them are even aware of their positive status. Sexual activity for the young begins before the age of 15 years in many countries. However, VCT services are not designed to address the specific needs of youth. A major issue in rendering VCT services to youth is of parental or guardian consent before a medical procedure can be conducted on those who are below the age of consent. This may include HIV testing. It is important that relevant legislation be understood when these services are rendered.
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Children who are HIV infected have mainly acquired the virus through mother to child transmission. It is understood that children born to HIV positive mothers would test HIV positive till they are 18 months old with the standard testing procedure. Parents face a lot of stress and anxiety till they ascertain the actual test results. Counsellors have a lot of role to play at this stage. Other considerations that need to be kept in mind in counselling such parents and children are the age, maturity and health of the child. Sometimes, a child who is not informed about the status may have many suspicions of what is going on at home; circumstances of the child and his / her level of exposure. Counselling children and teenagers is very different from working with adults. Talking techniques that are suitable for adults are not helpful to children. Very few children have the words to describe their feelings, the patience to sit and talk seriously with an adult, or the belief that an adult will understand them. Counsellors take older children and teenagers to such places as sports venues. The belief is that the counsellor-client relationship will build as they play together and, gradually, the teenager will begin to talk about feelings. The counsellor can then begin to go deeper into the issues that need to be addressed so as to help the client. These methods are time consuming and work with one child at a time. Counsellors are taught a variety of techniques to help children improve behaviours and get over their fears and other problems. Organising services: The counsellor may have to take additional responsibilities when working with young clients. These may include: teaching parents or caregivers to care for the children better, advising on matters of discipline, ensuring that the child gets proper health care, including arranging transportation to school and play.
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Where children have lost one or both parents due to AIDS the problems are even more complicated. After the deaths of parents, other family members, including their grandparents, may take up the care for children. Media has often highlighted the trouble the old grandparents have gone through in making education or treatment available to these children. A few of these children may end up on the streets fending for them selves. New orphanages are being founded in countries where previously families always cared for children. Issues that come in the context of a counselor with regard to orphans include: the failure of welfare systems to provide for children in child-headed households, prostitution and theft for survival continuation in school; emotional problems such as depression, trauma and the likelihood of these problems to carry forth into their adulthood. Only recently have governments begun to recognise the existence of orphans. Interaction with children: Counsellors have to keep a number of things in mind when dealing with children. Firstly, they have to make use of concepts and language that are age appropriate. They must ascertain the level of knowledge of the young persons about HIV and AIDS. Give children time and chance to move at their pace, leaving a lot of space for their questions.
Injecting Drug Users

Injection drug users (IDUs) inject drugs into their veins and this is usually done in groups. Needles are often shared in this activity. Sexual relationship too may be prevalent between the group members. The chances of infection through the injecting route are much higher than sexual route of transmission. Countries such as China, India, Indonesia, Malaysia, Myanmar, Nepal, Thailand and Vietnam are showing considerable rates of HIV prevalence among the IDUs.
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It is important to have an understanding of the legal and ethical factors that are applicable in a particular country. For example, the illegal nature of drug use can drive many drug users away and they may refrain from accessing services. Similarly stigma and marginalisation can lead to further isolation of the drug users. In the context of drug users the voluntary testing and counselling services have the following aims: To bring about behavioural changes among the drug users that would make them adopt safe practices both in their injecting habits and sexual behaviour. Further, in particular risk-reduction counselling aims at using techniques of interpersonal communication to help the IDUs to clarify their feelings and thoughts about their problems. Also, sometimes group counselling is resorted to for the education of the drug users. Counsellors may have to be involved in a lot of problem solving for the drug users. Issues that may be addressed can be many, ranging from identifying obstacles in adopting harm reduction practices, motivating the clients, structured therapy, assessment of post traumatic disorder and suicide risk assessment. Follow ups are of utmost importance in maintaining a sustained pattern of behaviour change.
Sex Workers
Sex workers is a term that refers to a broad section of people who may be engaged part-time or full-time in sex work. They may be men, women or transgender. They may be engaged in such sexual activity by choice or under compulsion. Sex workers are especially vulnerable to HIV infection due to their large number of sexual partners and often high prevalence of sexually transmitted infections. Also, many studies have reported
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of the difficulty faced by sex workers to negotiate safe sex with their clients and infact they may accept more payment from the clients who are reluctant to use a condom. Another dimension that has to be faced is the simultaneity of drug use and sex work. Thus prevention has to be dual - harm reduction for injection drug use, as well as the reduction of HIV transmission through sexual contact - in the same population group. STI management is also a priority issue. Given the above, the sex workers have specific needs that have to be addressed by VCT. The diversity among these groups is so large that no single model is available. In many cases, peer based education programmes have been found to be useful. The services need to be tailored to different situations. Assuring anonymity for sex workers is important to encourage them to access services and wherever possible these should be made available to them at the nearest location. The challenge is to reach out the services to the indirect sex workers, who are hard to reach. Many married men and women, especially those who are migrants belong to this category. The services broadly can then be categorized into three: Information and behaviour change services; condoms and other barrier methods; sexual health services. To reach out effectively with these services the use of informal contacts and key informants has been found useful. In the context of prevention counselling, a range of strategies and activities can be used to convey information and behaviour change messages. The objective is to provide the sex workers with knowledge about HIV transmission and ways to reduce the risk of HIV transmission. The attempt is to clarify misconceptions and clarify misunderstandings of traditional practices and beliefs.
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Next, through the process of counselling, the counselors can educate and empower the sex workers to negotiate and adhere to consistent condom use. They need to be sensitized to the neccesity of having safe sex even in the relationships that they consider are long term and safe. In addition to interpersonal counselling peer based interventions have been found to be effective. If one goes beyond prevention counselling with the sex workers, there are those who are already infected. Counsellors can help them to decide about disclosing their HIV status, the strategies they can use to disclose, ongoing support in this effort, referral to care and support programmes, and looking for means of alternative livelihood.
Men who Have Sex With Men (MSM)

The term has been developed to refer to all sexual acts between men and includes the gays and homosexuals. The term includes men who exclusively have sex with other men; men who have sex with other men but mostly have sex with women; men who have sex with both men and women and with no marked preferences, men who have sex with other men for money or else because they have no option, such as is the situation with men in prisons. Some MSMs may be highly visible where others may never reveal their identity. The implications of understanding the behaviour and psychology of this group in the context of HIV is important. In some parts of the world MSMs have been largely affected by AIDS. Their numbers in terms of HIV prevalence are higher than among the general population. Developing interventions for MSMs is not easy because of variations in the definition and perceptions of gender, sexual roles, and homophobia. Many MSMs continue to
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have sex relations with both men and women so as to decrease their chances of being identified. There are many barriers to VCT for MSMs. Main among this is the lack of dependable data on them. There is much difficulty in reaching out to them. Few counsellors are aware of the psychological issues affecting the MSMs. In some cases their own moral and religious objections and also some element of homophobia may deter them form working with MSMs. In reaching out to the MSMs the counsellors have to first of all accept them totally with all their variety of sexual behaviours and complexity of relationships. They have to take their client through the process of developing a strategy of disclosing their status to their male and female partners. They need to promote condom use for both anal and vaginal sex, and promote alternatives to penetrative sex. Educational materials have to be developed so as to reach out to the MSMs with all information regarding HIV risk and enable them to assess their risk to HIV infection. The endeavour in these interventions is to keep the whole process confidential. The programme needs to be steered by professionals who do not make value judgements about behaviours. The services have to be accessible to the MSMs and to do so it has to be kept in mind that they should be appropriate in location and also available late evenings or over weekends.
Prevention of Mother to Child Transmission

At the end of 2003, it was estimated that 2.5 million children under 15 years were living with HIV/AIDS and 700,000 children were newly infected in 2003. A large number of those who are infected have got the HIV from
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their mother at the time of labour and delivery or after birth, through breastfeeding. Anti-retroviral therapy can reduce the HIV virus concentration in maternal fluids, tissues, and breast milk, which can help in reducing the risk of infant exposure to high maternal HIV virus during intrauterine, intrapartum and post delivery. The efforts directed at PMTCT are at four levels ( ) Primary prevention of HIV infection among women a of child bearing age; ( ) Prevention of unintended pregnancy among HIV b infected women; ( ) Prevention of perinatal HIV transmission among HIV c infected women; ( ) Provide care and support to HIV infected women d and their families. The issue of an HIV test administered on pregnant women also has implications for the Counsellors For many who are anxious of their HIV status, it would be a relief to know that they are not infected. For those who are HIV infected it would mean initiating action so as to make efforts to reduce the chances of the baby getting infected through the use of antiretrovirals during pregnancy and labour. Such individuals need to be educated on healthy living, and to protect themselves from further infection. In many cases the results of the test lead to a lot of stress and anxiety. The client may not be able to cope with the report of the test, face the dilemma of sharing their status and also live with many anxieties. Also, it may result in many relationship problems and stigma and discrimination. In addition, there may be problems of continuing with job and looking for alternative sources of income. Thus, it is evident that continuous counselling and support are imperative in all these areas.
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There are many psychological consequences for women who are tested HIV positive (see WHO, 2004) For many women the HIV status comes to them after their spouse, partner or a child have tested positive, adding to an already prevalent trauma. When either of the sex partners test HIV positive it is oftentimes a disclosure that either s/he has another sexual partner and may result in domestic violence, conflict and even separation. There may be women who conceal their HIV status because they fear abandonment and consequently isolation. The women face dilemma on many fronts and would definitely need help in taking decisions. Some may even show extreme emotional reactions, such as anger towards the person who may have infected her. Her reaction to her changed health status and uncertainty about the future of her family may bring forth many emotions. She may show a lot of grief and sorrow and also a lot of anxiety in coping with these multiple issues. A number of clients may express a feeling of guilt at having made their children HIV infected. Also there are reports of a greater incidence of post-natal depression in the HIV positive women. Couple Counselling: The whole issue of testing and counselling women who are HIV positive, and faced with the issues of childbirth needs to incorporate the partner. Counsellors need to be aware on techniques of couple counselling and encourage their clients to be accompanied with their partners. Counsellors efforts have to be made towards both the partners in building a relationship of trust. Both the partners have to be given sufficient space, and counsellors have to pay full attention to their verbal and non - verbal communication. Given the fact that couples may be married or not, counsellors should show their readiness to work which ever be the case setting aside their values, prejudices and beliefs.
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Loss and Grief

Loss and death in the context of HIV and AIDS are a reality. The world has experienced loss and death to slavery, war, genocide, high infant mortality and fatal illnesses, including malaria and tuberculosis. Now HIV and AIDS have joined the killers, although too many communities have still not publicly acknowledged the death toll and the emotional trauma of so much dying and death. In some countries such as Africa there has been a widespread impact and the people there need to push the pain deep down inside themselves in order to soldier on and survive. For a counsellor, comforting people who are dying and the survivors poses tremendous challenges. HIV and AIDS counsellors must be able to talk openly with clients about dying, death and grief. The goals and plans that they decided on together must fall by the wayside when the clients health takes a turn for the worse. Then it is time for one person to sit with another. But we are all just humans and this is not easy to do. A persons own history of loss has a great impact on the way that person deals with more loss. For example, if a young woman hasnt finished mourning the loss of her own child, it would be difficult for her to face so many mothers and fathers grieving the losses. In many ways AIDS is like all other ailments. A sense of loss, and the grief that comes with HIV infection, doesnt begin with death. Probably as soon as the client finds out that he is infected with HIV, he immediately goes into grief. For any person who comes to know that he is HIV infected, the reality of life immediately is stark. Everything changes and suddenly there is so much insecurity and fear of the future. In most countries to reveal ones illness, or even to be suspected of having HIV, a woman risks losing her
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family, losing her job and her home, and being tormented by cruelty caused by ignorance and fear. The fear of discrimination makes many people move away from the place where they were residing. In one such reported case of a migrant worker employed as a rickshaw puller being diagnosed with HIV, there was total resistance by them to the wife being tested and before the counsellor could work towards convincing them, the couple ran away from their home in a slum. On further enquiry, it was revealed that they left their jhuggi and ran away to their village along with their children, hoping for anonymity there. The reactions to the reports of HIV test can be from complete denial to acceptance. Most often, counselors will find their clients in any of these states before they finally come to a stage of acceptance, which may not be complete. A person may be in a stage of complete denial. He or she may ask for a re-test or even a confirmatory test to be repeated. The counselor has to provide all the necessary information and support. Simultaneously the person may feel anger, rage, and the envy towards healthy people. When the person comes to a stage of realization he learns that he has to face up to the great loss as the time draws nearer. This depression is for himself and for those who are close to him. As much as there is diversity among people, there is a diversity in their reactions. Counsellors have to be prepared that some people face death head-on and dont go through the other stages. Others may show a combination of the different responses.
Counselling Stress and Coping

The counsellor uses his self to reach out to a client, to establish trust, to understand the client, to feel the clients feelings, and to respond with compassion and
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competence. The counsellor learns about HIV/AIDS and teaches others. In most cases the counsellors deal with other people in the clients world and addresses issues as diverse as ignorance, and hostility (stigma and discrimination). Counsellors work with their entire self in the process of counselling. They use their body of knowledge, their own professional skills and principles in working with their clients. Counsellors, qualified with specialized body of knowledge and skills to work with the AIDS afflicted, are not many. A number of them are known to take on too many clients and work for too many hours. It is often seen that people who take up the job of counsellors are mostly caregivers whose focus is on other people and not on themselves. All their attention and work is to make other people feel better. Some of them have always been like this. It goes without saying that counselling is not an easy process. No areas of health care and counselling are emotionally easy. But HIV and AIDS, at the intersection of so many problems, are especially difficult. In the context of AIDS as you have seen in this Unit, the clients situations are complicated and often cant be fixed, but only changed a little. Counsellors witness the suffering, orphaning and deaths of spouse and children. They are with their clients on a long and difficult biomedical, emotional, social and spiritual journey. There are fresh challenges each day and with each new client. Counsellors have to be alert to everything that is said or not said. The task of counselling in this specialized setting makes specific demands on the counselors. Burnout is a term that was first used by a psychologist named Herbert Freudenberger. It is now such a popular concept that many books have been written on the topic. Burnt-out counsellors are always exhausted and under
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stress. They dont relax easily. The selfless, overworked counsellor pays a high emotional price: possible burnout and loss of effectiveness in about two years if they do not take good care of themselves. The counselor then needs to recover from the emotional trauma. It is a shame to lose such good people so soon. Counsellors need to ensure that they take care of their own physical and mental health if they have to be able to work with clients for many years. This requires counsellors to focus and work on meeting their own emotional needs. It also means that organisations and institutions, however tight their finances may be more sensitive to the needs of their employees and volunteers. With most clients who suffer from AIDS, often there isnt much that a counsellor can do to make a visible and significant difference. The counsellor then feels incompetent and frustrated. At such times they should focus on the fact that they are recognising and appreciating their clients individuality and dignity. This acceptance in the counselling relationship is very important and meaningful for the clients. It is their experience, and may be the only one, that being HIV positive does not mean that they would be rejected by all. People who spend so much time meeting the needs of others, addressing issues of those who are aggrieved, may either lose touch with their own feelings, or even if they know their needs, they still neglect themselves. When people are not in touch with their own feelings, there is a danger that these feelings may emerge in different forms. For example, a counsellor working for a community organisation may start missing appointments with her clients. She offers what sound like good excuses for her absences and she believes that these explanations are true. Initially the counsellor does not understand that her absences are actually
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expressing her feeling of being overwhelmed. The absences serve the purpose of giving her relief. The frequency of her absences keeps on increasing. If a counsellor knows what she needs emotionally, what could be the reason for not asking other people to help meet those needs? It may not be culturally acceptable to ask for help. Being herself in the role of a care giver and helping clients, the person may consider this kind of help-seeking as weakness and even professional incompetence to cope with stress. Counsellors should always remember that counselling is a process to empower the client to take control of his or her own decisions and actions. Counsellors should be aware of their desire to make clients into something they are not, to rescue them or to change them. Their ambition and initiatives to resolve problems oftentimes need not translate in reality. As is obvious multiple factors operate and the clients progress may depend on the varying capacities of the client. It should not be forgotten that counselling is for the welfare of the client. If a counsellor acts on her/his rescue fantasies, and promises more than what is achievable, s/he will hurt her client. The counsellor who thinks she will transform a clients life is in an illusion. She is creating a situation that is an emotional disaster for the client. The counsellor, to meet her own need to experience success and power, may push a client to make changes that show the counsellors power. This misuse of authority in the counselling relationship may communicate to the client that s/he isnt good enough. When the client cannot satisfy the counsellor, the client feels like a failure. Consequently, the situation becomes more stressful for both the counsellor and the client. It is thus important that counsellors refrain from transmitting their feelings to the clients.
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Most counsellors, especially those in their early years are keen to see quick results. Improvements and positive changes in the clients make some counsellors feel competent and good about themselves. A more skilful approach is to help the client with small changes. Each small change should be taken note of and reinforced for sustenance. The success of the client should be of foremost importance rather than the counsellors success. Each sense of achievement transferred to the client lays the foundation for his or her empowerment. To conclude, no success achieved through the counselling process is too small to be ignored. Counsellors have a burdensome task. In this process they should keep in mind that they are not overburdened. Competent and responsible counsellors often find themselves with more clients than they can handle. Their anxiety to do their best with each client as well as to achieve perfection finds them short of time and exhausted by the end of the week. No doubt, they cannot continue to operate under pressure for long and it takes a toll on them. Counsellors, given the nature of the task at hand, should say no when the workload is beyond their capacity. Counsellors must consciously learn to resolve this situation as soon possible. The entire burden of the work to be done has to be shared in the organization. He or she is not solely responsible for all the tasks. Hence, it is better to do well as much as one can. As in helping professions it is important that counsellors working with clients on HIV and AIDS should not be expected to do a skilful job without supervision. Too many emotional issues keep arising that can push the counsellor over the edge forcing them into making mistakes. Supervision or debriefing should be seen as an opportunity to discuss emotional reactions related to clients, as well as to plan strategies, as well as to
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perfect and learn new techniques (Jose & Mani, 2000). Debriefing which is undertaken with the peers or even with the supervisor provides a forum where counsellors ventilate and share the feelings they sometimes have towards their clients, and which they find difficult to resolve and deal with. When such hindrances come, supervision plays a critical role. It is advisable that such supervision is offered not by employers but by a neutral professional person. Organisations should evolve strategies to de-stress their staff because working with AIDS afflicted and their family members takes its toll on the caregivers. There are many ways in which this can be done. Pleasant surroundings, colourful pictures, and facilities such as good cooling in summer are important. Counsellors should maintain an active lifestyle, eat and sleep well. Yoga and meditation can be taken up on a regular basis.
Conclusion
In this chapter we discussed various issues and types of HIV/AIDS related counselling. Counselling is an essential component of any intervention in the area of HIV/AIDS. The deliberations described in this unit dealt with various tasks being carried out by an HIV/AIDS counsellor. From the explanations given in this unit, we understand that a counsellor not only undertakes counselling in a particular setting, but also assume responsibilities for various aspects associated with the client which may include follow up of time schedule, taking appropriate medicine at appropriate time etc. All these issues have been dealt with while discussing on voluntary counselling and testing, treatment and drug adherence, counselling with youth and children, injecting drug users, sex workers, MSMs etc. On the whole, this unit provides most of the important issues
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and types of counselling. However, one must undertake specific training programme to be a good counsellor in HIV/AIDS related area.
References
DiClemente, C.C. & Prochaska, J.O. (1998). Toward a Comprehensive Transtheoretical Model of Change: Stages of Change and Addictive Behaviors. In W.R. Miller & N. Heather (Eds). Treating Addictive Behaviors (2nd ed.). New York: Plenum Press. DiClemente, C.C. & Velasquez, M.M.(2002). Motivational Interviewing and the Stages of Change. In W.R. Miller and S. Rollnick (Eds). Motivational Interviewing: Preparing People for Change, (2nd ed.)New York: Guilford Press. Jose, S. & Mani, S. (2000). Telephone Counsellors Handbook. Tharni: Trivandrum (ref. www.thrani.org) Maslow, A.H. (1970). Motivation and personality (2nd ed.). New York: Harper and Row. World Health Organisation (2004): Voluntary HIV Counselling and Testing, Manual for Training of Trainers, New Delhi, India. Reports Winiarski, Mark G. (2004): Community - based Counselling for People Affected by HIV and AIDS. Longman and Catholic AIDS Action. IGNOU: Counselling on HIV, September 2006. UNAIDS (2000): Report on the Global AIDS Epidemic.
15
HIV/AIDS and Legislations

*Gracious Thomas
Introduction
In this chapter we shall examine some of the legal aspects concerning HIV/AIDS at the various levels national as well as international. Due consideration will be given to legislations covering HIV/AIDS in the context of the Indian Constitution. This HIV/AIDS epidemic highlights the tensions and conflicts between health and human rights, as well as the States powers and its duties. It has also revealed weakness in our legal system and health infrastructure in India. Not much reflection, debate nor research has been undertaken in order to understand and articulate the rights of victims of HIV/AIDS, who are themselves citizens with dignity. Neither has the Government perhaps given much thought to understand its Constitutional duties towards Indian citizens affected by this epidemic nor taken much effort to tackle this problem through framing appropriate laws and schemes. The inadequacy of training of doctors, nurses, and other health workers on HIV/AIDS and human rights has sharpened the experience of discrimination among victims of AIDS. The existing laws and legal policies have revealed deep rooted biases and inherent contradictions which makes it difficult for all those vulnerable to infection, to access medical services. Protection of rights sanctioned by law is a key element in successfully dealing with HIV/AIDS.
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Trends in HIV related law making Laws are framed by governments and are enacted in order to respond to the specific needs and demands of its citizens in view of protecting and promoting their rights and for their development. Laws specify the rights and duties of citizens and also impose penalty in the event of their violations. Until 1985, no country in the world had adopted any comprehensive laws for the protection of the PLHAs. During the period, 1985-90, a large number of countries adopted legislations related to AIDS. The main objective of these laws during the initial period was to prevent and control AIDS, and the resultant law-making were related to: 1 ) 2 ) 3 ) 4 ) classification of HIV/AIDS; compulsory notification (obligatory reporting to the authorities); protection of the identity of the infected persons (confidentiality); compulsory HIV Testing on specific population categories, e.g., aliens entering the country, high risk groups- commercial sex workers, drug addicts, professional blood donors, homosexuals; access to information and education about HIV/ AIDS; prevention of discrimination against infected persons and emphasis on their human rights; providing compensation and welfare schemes to health workers infected by HIV-positive while working among the infected persons; ensuring cleaning supply of blood.
5 ) 6 ) 7 )
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In law-making related to PLHAs, several countries has taken divergent approaches to the issue of HIV/AIDS.
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Some have taken penal (coercive) approach, some have followed pragmatic (facilitative), while few others adopted the rehabilitative (compensatory) approach. Different perceptions of HIV/AIDS such as it being a disease, a catastrophe, a divine curse, etc. have also influenced the enactment of laws. In order to remedy the discrimination faced by the PLHAs, many countries have enacted laws to guarantee equality and provide protection against discrimination. International Guidelines on HIV/AIDS and human rights recommends that States should enact or strengthen anti-discrimination and such other protective laws that protect vulnerable groups, people living with HIV/AIDS and people with disabilities against discrimination in both the public and private sectors. The goal of these laws is to achieve equality for PLHAs.
Indian Laws Related to PLHAs and Constitutional Provisions

At present there is no comprehensive law in India to respond to the rights and needs of PLHAs. India is yet to take steps to fulfill its obligations under the expand UNGASS Declaration on commitment on HIV/AIDS. It has to enact a nationally applicable rights-based statute, which can provide a holistic coverage, consistency, clarity and predictability so as to enable the courts to effectively pass judgements in cases related to HIV/ AIDS. By seeking justice through courts, it can empower people to fight against the violations of rights and to establish a just social order and a humane society where sick and the poor can experience the promises guaranteed by the Constitution of India.
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Constitutional Provisions Related to PLHAs The provisions relevant to the HIV/AIDS situation in India are found in Part III and IV dealing with Fundamental Rights and Directive Principles of State policy respectively. Some of the Fundamental Rights guaranteed by the Indian Constitution will be of help to understand the rights of the HIV/AIDS patients. Since Articles 14 to 18 guarantee every citizen equality before law and equal protection of the laws, any law that isolates HIV/AIDS patients denying them treatment on any ground can be challenged before the High Courts or the Supreme Court. In the same manner, if any government hospital or dispensary refuses to admit or treat HIV/AIDS patients, of course without adequate reason, the same may be challenged as violations of the Fundamental Rights. The PLHAs are stigmatized because of the association of HIV infection with illicit or immoral sex behaviour. Such stigma is fuelled by the lack of understanding of HIV, prejudice, unavailability of adequate treatment, irresponsible media reporting, etc. Thus, stigma results in discrimination in treatment, employment, education and social relationship due to fear of HIV infection. This sort of discrimination is one of the most significant human rights abuses faced by HIV/AIDS affected persons. It includes segregation in schools and hospitals, forced medical testings and denial of the right to marry. In principle, discrimination is antithetical to equality. Article 14 of the Constitution of India guarantees equality before the law, and equal protection of the laws to all persons without any discrimination. So the state cannot arbitrarily discriminate among citizens including PLHAs. If any classification of PLHAs is made it must be rational otherwise it would be unfair and unjust and violative of their fundamental rights. This freedom from arbitrary
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discrimination is enforceable against the state and its agencies. But at present this Article does not offer any protection against private parties. According to the report of the National Commission to Review the Working of the Constitution the definition of State under Article 12 of the Constitution can be amended to include any private person or entities engaged in functions which are of a public nature. Article 15 of the Constitution of India elaborates on the principle of equality enunciated in Article 14 by prohibiting discrimination on the grounds of religion, race, caste, sex or place of birth. Similarly, Article 16 provides for equality of opportunity in public employment. But these constitutional provisions do not address the legal problems faced by PLHAs, especially against discrimination in employment and treatment. Article 19 guarantees certain fundamental freedoms. There are other freedoms too that are enforceable though not listed under Article 19. They are right to travel, right to privacy, right to receive higher or professional education, right to human dignity, right to speedy trial, right to information, etc. Under this provision, we can approach the courts seeking correct information and scientific data regarding the health care and other facilities available to the HIV/AIDS patients. Right to information on medical care is one of the freedoms that can be used to help the HIV/AIDS patients. Under Article 21, which guarantees life and personal liberty, medical care is considered as a fundamental right. In a Supreme Court case it was laid down that there is an obligation upon the state to preserve the life of every person by offering immediate medical care to every patient. Any act that endangers life, thus, can be challenged in the courts. Refusal by doctors or nurses
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to treat HIV/AIDS patients, will constitute a violation of the fundamental right of the patient. There is an urgent need to spread information regarding HIV/AIDS universally as the dreaded plague is likely to strike anyone, any time. Under this Article we can force the state to give information regarding the efforts to prevent HIV/AIDS that is assuming proportions of national calamity. Since the right to health in India is a fundamental right, every barrier to equal access to health care must be dealt with by the State. Legal duty of care-guidelines must be given by the Government to health-care workers to prohibit discrimination of any kind against HIVpositive patients and to provide them with equal care. The government must make it mandatory for all health care practitioners to use universal precautions irrespective of the patients sero-status. This policy can eliminate the need for mandatory testing before admission to a hospital. Generally speaking, only the aggrieved can approach the courts. However, with the filing of the Public Interest Litigation (PIL) under Article 32 any public-spirited person or social activist or voluntary organizations can approach the Constitutional courts to redress grievances of individuals or class of people who are disadvantaged on account of their poverty, lack of education or other handicaps. In a PIL (Rakesh vs State of Bihar), the Supreme Court appointed a committee of experts to study the issue of the mismanagement of a mental hospital in Bihar. The Bhopal Gas Tragedy, and the Narmada Dam Case, are examples of this right utilized by publicspirited persons. Action may be resorted under this Article, whenever the rights of HIV/AIDS patients as citizens are violated.
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Laws Useful to Prevent the Spread of HIV/AIDS

Municipal Laws Municipal laws in many cities require that every medical practitioner, who treats or becomes aware of the existence of any dangerous disease, should give information of the same to the Executive Health Officer. (e.g.: Section 421 of the Mumbai Municipal Corporation Act) Epidemic Corporation Act In the event of threat of an outbreak of any dangerous epidemic, and when the ordinary provisions of law are insufficient to tackle the disease, Section 2 of the Epidemic Corporation Act gives power to Health Officers of the state government to take such adequate measures including prescribing temporary regulations to be observed by the public or any class of persons to prevent the outbreak and/or spread of any such epidemic disease. The Carriage of Passengers Suffering from Infectious or Contagious Diseases Rules,1990 According to Rule (1) a railway administration should not carry persons suffering from AIDS. A person suffering from AIDS should not enter or remain in any carriage on a railway or travel in a train without permission of the Station Master or other servant in charge of the place where such person enter upon the railways. A railway servant giving such permission to any person suffering from the disease, and agreeing to pay the usual amount of fares for receiving a berth, shall arrange for his separation from other persons travelling in the same coach.
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Drug and Cosmetic Rules, 1993 According to Rule H of Part XIIB [1993, GSR 28(E)] every licensee of a Blood Bank should get samples of every blood unit tested for freedom from HIV antibodies, either from such laboratories specified for the purpose by the Central Government or in his own laboratory. The test result shall be recorded on the label of the container also. The Delhi Artificial Insemination Human Act, 1995 Under Section 10(1) the semen bank before accepting the semen for artificial insemination shall test the donor for presence of HIV - 1 and 2 antibodies by using a highly sensitive ELISA Kit, and only if found negative, shall the donor be allowed to donate. The following sections too give tooth and claw to the act: Sec. 11. stipulates that the donated semen shall be stored either by cryo preservation of liquid nitrogen freezing or any other safe method for a period of minimum three months in order to exclude window period of HIV 1 and 2 infection in the donor. Sec. 12 requires a second ELISA Test to be performed on the donor at the end of three months. According to Sec. 13, a qualified medical practitioner, Government hospital or any other private hospital or the semen bank performing artificial insemination, shall require the following: testing the recipient for HIV 1 and 2 and sexually transmitted diseases before performing artificial insemination (Clause (b)); seeking a written consent of the recipient for using the semen on the basis of a single ELISA Test being negative, where facilities for cyropreservation and liquid nitrogen for semen are not available (Clause (g)).
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Section 269 of Indian Penal Code Under Section 269 Indian Penal Code, performance of a negligent act likely to spread infection of a disease dangerous to life is an offence punishable with imprisonment for a term up to six months or with fine. In order to punish a person under this Section it must be proved that he acted unlawfully or negligently. Any HIV infected person, if after testing positive, indulges in sex without taking the precaution or using contraceptives, will be liable to be punished under Section 269 IPC. Section 270 IPC A Blood Bank, which negligently supplies blood containing HIV virus, can be punished under Section 269. Section 304-A IPC
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A doctor or a medical personnel can be prosecuted under Section 304-A of the IPC, if a patient dies on account of his negligence. If a person dies as a result of HIV infectious blood negligently supplied by a blood bank, the person responsible for the supply can be punished with at least a two year term of imprisonment or with fine.
Laws Useful to Enforce the Rights of PLHAs

Criminal Procedure Code Sections 133 to 143 Criminal Procedure Code (Cr.P.C) lays down the procedure in a criminal case. The part relevant for HIV/ AIDS comes under sections 133 to 143 of Chapter XB titled Public Nuisances. Any unlawful obstructions or nuisance at any public place or at any way or channel, which is or may be used by the public are to be dealt by
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the magistrates. The conduct of any trade or occupation or keeping goods, dangerous to the health or physical comfort of the community, is also barred. Obstructions in hospital or blood banks compounds, corridors, stairways or wards, etc. are public nuisances that comes under this chapter. Criminal Procedure Code Section 357 Another useful provision deals with provision for compensation to victims. Section 357 of the Cr.P.C provides for compensation to victims of crimes and allows compensation to be ordered after the conviction of the offender. Thus, public nuisance, annoyance and obstruction or inconvenience to life can be overcome, if the legal provisions are properly resorted to. If these laws are used, then blood banks operating without proper license, recycling of used syringes, needles and blades, hospitals flouting safety and sterilization norms, etc. can be held accountable and penalised. Hair-cutting saloons and beauty parlors have limited chances for HIV/AIDS spreading and can be effectively controlled if the provisions on public nuisance are used. Law of Torts Tort is a civil wrong independent of contract. Liability in Tort arises from breach of a duty primarily fixed by law, which is generally towards others. For example, although there is no separate contract between members of a municipality requiring that all the municipal areas to be kept clean by the municipality. The municipality, which taxes people, is duty bound to provide civic amenities. So also is the case of a hospital and a patient, implying that there will be no negligence on the part of the hospital. The hospital is bound to show due diligence in treating the patient.
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In Laxman B.Joshi vs. T.B Godbole (AIR 1969, SC 128), the Supreme Court held that a doctor, who holds himself as skilled and knowledgeable when consulted for the purpose, owes his patient certain duties of care the duty of deciding whether to undertake the case, a duty in deciding what treatment to give, and for the administration of the treatment. A breach of any of such duties will constitute an act of negligence by the doctor and the hospital. If any person dispensing medical service violates any of the provisions of law related HIV/AIDS patients, he can be sued for compensation under the Law of Torts, in addition to the remedies provided in the respective laws. The Law of Torts can also be used to discipline unethical or greedy practitioners of medicine. The government hospitals that do not care for the patients or those private hospitals or doctors offering free, but faulty medicare will also come under the Law of Torts. Consumer Protection Act, 1986 Today, we have a well-developed medical jurisprudence. Damages can be sought for unethical, deficient or negligent medicare. Medical negligence can be brought before the courts for damages under the Consumer Protection Act, 1986. This Act can also be used to fight AIDS. If contaminated blood is supplied, the amount paid can be got refunded along with the compensation. In the same manner, tattooing, faulty blood testing, side effects from medicines, misleading medical or paramedical publications or teachings, etc. are all actionable under law.
A Legal Policy on HIV/AIDS

The fear generated by the HIV epidemic has not helped the cause of HIV/AIDS patients. Sex workers, gay men
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(MSMs) and drug users (IDUs), who were among the first to be infected by HIV, are already targets of punitive legal provisions. Some suggestions made by Julie Hamblin in a UNDP paper, People Living with HIV: The Law, Ethics and Discrimination are apt in summing up this Unit. The four points that should guide the legal policy-framers are: 1. Protective and Supportive Legal Framework
The law can, and must be used, to establish a protective and supportive framework for people affected by the epidemic and not a punitive one. The element of collaboration and mutual support that emphasizes the common interest between the infected and the uninfected, and between the government and individuals, is essential. Creating a supportive legal environment can involve both negative and positive legal interventions. The negative interventions arise from the need of an absence of law in some contexts. The laws which we do not need are the laws that discriminate against the people with HIV and alienate them from their communities, making it less likely for people to share on common interests, to reduce the effects of the epidemic. Similarly, there are also positive legal interventions that can actively promote the supportive environment. The latter interventions include:
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human rights and related legislations that give legal rights such as the right to privacy, the right to protection against unlawful search and seizure, as well as rights to protection against unlawful detention. anti-discrimination laws providing redressal in the event of discrimination, denial of housing, and even access to health care, etc., for people living with HIV/AIDS (PLHAs) and their family or friends.

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protection of the confidentiality of a person who is HIV positive. right to object to forced extraction of consent, before HIV testing is undertaken. encourage appropriate workplace practices, eg: infection control procedures and HIV education for employees.
Such approach towards the constitution of a legal policy on HIV must intend to use law not as a weapon, but as a protective instrument that respects the worth of all individuals and reinforces co-operative efforts to deal with the effects of the epidemic. Of late, it has been proposed to introduce a draft HIV/AIDS Bill in the Parliament. A draft copy has been prepared in consultation with all the stake holders and is in the process of being finalized.
Rights of People Living with HIV/AIDS (PLHAs)

Several nations have legislated on HIV/AIDS. In the absence of legislation, the judiciary in many countries have issued judgments on several issues related to HIV/AIDS. These judgements reflect legal approaches to HIV/AIDS. Responses to Discrimination in Employment In the context of employment, PLHAs have often been denied jobs and discriminated against. Some private companies even dare to terminate the services of HIV positive employees. In a specific case filed by a HIV-positive school teacher against transferring her from a teaching post to an administrative post, a U.S. Court held that the mere theoretical risk of transmission of HIV was not a
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sufficient ground for change of job as she was still capable of teaching. Further, the court observed that denial of employment would do irreparable harm to the petitioner. The above judgement was based on the contention that AIDS is a progressive disease of the immune system, and that there are several stages in the course of an untreated HIV infection. During the symptomatic phase, the HIV infected individuals were capable of maintaining productive lives and could remain gainfully and productively employed, especially if properly treated. In the context of employment, the courts in Canada and the U.S. observed that if there is no significant risk of transmission, removal of an employee from his/her employment would constitute a violation of the right to equality, and the right against discrimination. However, a HIV-positive employee cannot invoke protection against discrimination if there is a significant risk of transmission to co-workers. The courts further held that if risks of comparable magnitude are acceptable in a work environment, then risks posed by a person who is HIV-positive cannot be considered significant. The South African Constitutional Court in the case Hoffman v. South African Airways (CCT 17/00; 28th September 2000), held that the Constitutional right not to be unfairly discriminated against could not be determined by ill-informed public perception of persons with HIV. The denial of employment to a PLHA impairs the individuals dignity, and constitutes unfair discrimination, violating the right to equality guaranteed by Section 9 of the South African Constitution. The Australian as well as Namibian courts have found that dismissing or excluding an officer or recruit on the basis of his HIV status constitutes unfair discrimination.
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Judicial Responses in India In the landmark case MX v. ZY [AIR 1997; Bombay 406], the Bombay High Court held that it is arbitrary, unjust and unlawful to dismiss a worker, who is still qualified and fit to perform the requirements of the job, and who does not pose a risk to others on the job. The courts have also acknowledged that mandatory pre-employment testing is not acceptable. Any rule mandating medical fitness as a prerequisite to employment must have the objective of assessing the persons capacity to fulfill the job requirements and the extent to which the individual poses a health hazard. Therefore, it is unlawful to terminate an employee on the basis of HIV status unless s/he is not medically fit to do the job, or there is a significant risk to the safety of other workers. India is also one of the few places, where compassionate employment is granted to survivors of the deceased HIVpositive employees of the State, upholding the right to earn a livelihood under Article 21 of the Constitution. Response to Discrimination in Education In Eliana Marlinez v. School Board of Hillsborough CountryFlorida [861 F. 2d 1502] a U.S. Court held that if there is a remote theoretical risk of transmission of HIV, and the student is otherwise qualified to be educated in a classroom, s/he could not be excluded from regular classes. It has also been held in the U.S. that unless there is a significant risk of transmission, it is unlawful to prevent an HIV-positive student from attending a schools regular education classes and participating in extra-curricular activities. In another case in the U.S., it was held that it is a form of employment discrimination to bar, HIV-positive students or staff members of an educational institution from accessing public documents. [Racine Unified School
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Dist. Vs. Labour and Indus Review Commission, 476 N.W. 2d 707]. Judicial Responses to Maintain Confidentiality of Health Status of PLHAS Initial responses to HIV/AIDS in many parts of the world propounded public disclosure and isolation, and resulted in stigma and discrimination, which in turn would be deleterious in controlling the spread of infection. In an epidemic that witnessed unprecedented stigma and ostracism, the disclosure of an individuals HIV-positive status exacerbated prejudices and had a devastating effect on their lives. Thus, people began avoiding accessing public health facilities, which violated the confidence reposed in it and stigmatized them further. This ultimately forced HIV-positive persons to hide their status thereby driving the epidemic underground and rendering any attempts to control it ineffectual.Quite similarly in the education sector, disclosure of HIVpositive status has also led to gross discrimination, whereby children have been expelled from school and denied their fundamental right to education. As a consequence, policies began to recognize the importance of the non-disclosure of health status as a part of a sound public health strategy and an essential human rights response to control HIV/AIDS. Confidentiality is also recognized in international instruments as a central component both of the human rights framework, as well as in the response to HIV/ AIDS. Confidentiality has been recognized as a legal principle in various forms. It has been established as a common law principle through several judgements, and also in various circumstances outside the framework of HIV/AIDS. In understanding confidentiality as a legal right and a corresponding duty, courts have found that there should be a relationship between two persons,
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the confidante and the person who confides and the relationship should be one whose nature is dependent on factors of mutual trust or knowledge or skill or with the objective of imparting services. Common law has also witnessed the evolution of further principles with respect to confidentiality. In the health care context, for instance, courts have found that a doctor is bound by duty not to disclose information obtained in his/her professional capacity, without the consent of the patient unless compelled by law to do so. Courts have also held that where a physician determines that the patient poses a serious danger to a foreseeable victim, then the physician owes a duty to warn and protect the third party. Courts have also found that the right to confidentiality is vital in cases of HIV/AIDS. This has been done by balancing the public interest to maintain confidentiality against the public interest to disclose. Courts have held that HIV-positive status falls within a legally recognized zone of privacy and that involuntary/non-consensual disclosure of HIV test results could undermine the public health interest as it discourages persons from getting themselves tested for HIV. Where a newspaper disclosed that doctors in a hospital were HIV-positive and threatened to disclose their names, the hospital obtained an injunction against the same from the court. The court found that the public interest in preserving the confidentiality of doctors with HIV outweighed the public interest in the freedom of press to publish such information, and that the latter public interest would not be impeded due to non-disclosure of the names. Courts have also held that there is an obvious public interest in preserving the confidentiality of those who are HIV-positive, particularly health care workers who report that they are HIV-positive. If health care workers are to be encouraged to notify their status, then it is
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essential that all care be taken to protect the confidentiality of such reports. In a landmark case in South Africa (Jansen van Vuuren and another NNO v Kruger 1993 (4) SA 842 (A)), where a physician shared the patients HIV-positive status with the patients dentist over golf without the consent of the patient, the court found that the physicians duty to maintain confidentiality was axiomatic. The court observed the disclosure as unreasonable and awarded damages worth 5000 Rands (Jose & Jyothiram, 2007). Where a health-care worker revealed a patients HIVpositive status and identity without the patients permission, but with approval of her superiors, she and her employer were found liable. Where a health care institution failed to maintain the HIV-positive status of a surgeon in their employment, it was held to be a breach of his right to confidentiality. Some courts have even gone to the extent of holding that a municipality, which did not train its employees in the need for confidentiality of HIV/AIDS-related information, would be liable for improper release of that information. Examining the body of jurisprudence on this issue, it is evident that legislatures and courts have gone to lengths to protect the confidentiality and have often found that the same must be protected on grounds of privacy and public interest. However, confidentiality is not a principle without exceptions, and statutes and judgements have enunciated these as well, yet always conscious of the fine balance required to be maintained between general protection and exceptional disclosure. The law also envisages situations, where it may be necessary to disclose the HIV-positive status of an individual irrespective of the consent being obtained. Such exceptional situations are list:
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a ) b ) c ) d ) e )
Cases where notification to public authorities is required by law; Cases where disclosure is necessary in the public interest; Cases where disclosure is administration of justice; necessary for the
Cases where disclosure is necessary for treatment of the patient; Cases where disclosure is necessary to protect another person (from harm).
Response to Maintenance of Confidentiality in India There is no specific law to maintain confidentiality of the health status of PLHAs in India. According to the judicial interpretation of the Supreme Court, Article 21 of the Constitution of India guarantees every citizen including PLHAs the right to live with human dignity and to safeguard his/her privacy. The concept of confidentiality is related and derives from the fundamental right of privacy-that every person has the right to a sphere of activity and personal information that is exclusive to her/him and that s/he has the right to disclose or not to disclose such information the individual considers in her/his best interest. In India however, the judicial developments in the sphere of confidentiality related to the health status of PLHAs are very limited. In one case [Mr X v. Hospital Z, (1998) 8 SCC 296] the Supreme Court suspended the right of HIV-positive persons to marry. Although the judgement recognized the right to privacy and the duty of physicians to maintain confidentiality, it held inter alia, that the Code of Medical Ethics formulated by the Medical Council of India creates an exception to confidentiality when public interest was at stake, and
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where there is an immediate or future health risk to others. The court found that the disclosure of the appellants HIV-positive status to a prospective spouse was not violative of the principle of confidentiality since the spouse was saved by such disclosure. The Court, however, failed to lay down any conditions and protocols by which such disclosure was to be made. It also added that an HIV-positive person who marries and transmits the infection to the spouse, would be criminally liable under Sections 269 and 270 of the Indian Penal Code, which criminalise those who perform a negligent or malignant act likely to spread a disease dangerous to life. In 2002, however, the Supreme Court set aside its own observations vis--vis the right for marriage, privacy/confidentiality and criminal liability, but also stated that in the facts of the particular case, the appellants right was not affected due to revelation of his HIV-positive status to relatives of the prospective spouse. Although jurisprudence roots confidentiality in the principle of privacy, this has not been the interpretation of courts within the constitutional framework, nor has it been reflected in statutory law, thus making it purely a common law principle. The few regulations that do deal with the issues of confidentiality in India, do so with an abject insensitivity and lack a thorough analysis. Principles and Suggestions to Enact Laws to Maintain Confidentiality India immediately needs a specific legislation to protect the right of privacy and confidentiality. It must incorporate in the law certain provisions based on the following principles and suggestions:
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every person has the right to privacy, i.e., the right to determine for themselves as to when, how and to
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what extent information communicated to others.

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every person has the right to confidentiality of personal information including the HIV status, sexual and drug use practices, gender expression, sexual orientation, livelihood, etc. the right to confidentiality should be ensured in various settings including diagnostic testing centers, counselling services, health-care institutions, the workplace, during research, educational institutions, the judicial system, the insurance sector, during adoption and in childrens care homes, in the media and any other settings that may access and record information on HIV and/ or vulnerable status. Data protection mechanisms should be provided in all settings to ensure the maintenance of confidential information. Disclosure of HIV-positive status may be permissible in very specific circumstances. when the person concerned gives information and written consent for disclosure of her/his status. when such disclosure is in the best interests and welfare of the patients treatment. when HIV-positive status is required to be revealed to a court for the administration of justice. when disclosure is necessary to protect another person, who is in imminent risk of being infected. when disclosure of HIV-positive status outweighs the public interest to maintain confidentiality. when disclosure is required by statute. disclosure of HIV-positive status in the aforementioned circumstances is only permissible
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after following a specific and detailed protocol as prescribed.

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an HIV-positive individual who knows of her/his status has a duty to inform the same to her/his sexual partner, needle-sharing partner, blood bank, adoption agency (in case s/he wishes to adopt); an adoption agency has the duty to inform a childs HIV-positive status to prospective parents.
Legal Strategy Required for HIV/AIDS Law

We need an AIDS law to stop the spread of the disease and in curbing all sorts of discriminative practices. We need a comprehensive legislation taking the form of an HIV/AIDS Prevention and Rehabilitation of Victims Act. Various points in strategy for enacting AIDS laws in India, are suggested below: It must: 1 . 2 . 3 . 4 . 5 . 6 . harmonize state laws with the National Policy on HIV/AIDS; regulate public health standards for sex workers; provide for privacy, and redressal against discrimination at their work place; ban compulsory testing for HIV of specific groups; promote ethical values related to sex; frame laws on HIV/AIDS, based on up to date scientific knowledge of the disease, its cause and effects; supplement and complement the medico-social strategy to fight the disease; replace punitive approach with preventive and rehabilitative approach;
7 . 8 .
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9 .
frame laws in conformity with the human rights jurisprudence;
10. protect communities from life threatening infections such as HIV/AIDS; 11. recognise the basic needs of the AIDS patients and protect them from unjust and inhuman discrimination; 12. encourage people to undergo voluntarily testing for HIV; 13. advocate for awareness through education for prevention; 14. protect confidentiality and privacy of the HIV/AIDS positive; 15. create a well equipped communication system and a centralized information service on HIV/AIDS; 16. allow tax relief to persons and organizations who support and serve those infected with HIV/AIDS; 17. establish a central agency to co-ordinate the efforts of those working to prevent HIV/AIDS. 18. identify priority areas for HIV related legislations, and formulate suitable policies. Some of the legal provisions that must be included in the HIV/AIDS related laws are listed below: 1 . 2 . 3 . 4 . 5 . 6 . means to check the spread of AIDS; emphasise the rights and dignity of the AIDS patients; encourage voluntary testing among the people; setting up AIDS surveillance clinics; prohibiting isolation of AIDS victims; maintaining confidentiality about the identity of the HIV/AIDS afflicted;
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7 .
preventing any sort of discrimination by the State on the ground of an individuals HIV status in matters of employment, education, travel, etc; regulating the services to the patients by medical personnel; insuring medical personnel working among HIV positive persons or AIDS persons;
8 . 9 .
10. penalising breach of confidentiality regarding the identity of the HIV-positive/AIDS persons; 11. mandatory screening of HIV in manufacture of blood related products; 12. Providing facilities for confidential testing, security and rehabilitation of the victim; 13. Compulsory testing of blood donated; 14. incurring severe penalties to intravenous drug users for sharing needles and other drug equipments with other users; 15. initiating disciplinary action against health-care workers and other medical personnel refusing to provide adequate care to patients suffering from HIV/AIDS; 16. declaring AIDS patients or HIV positive patients as disabled, entitling them special protection; 17. ensuring education of the masses on AIDS by the state; 18. punishing HIV-positive/AIDS patients for sexual contact with another or donating blood, organs or transfer of body fluids such as semen, blood, vaginal secretion, tissues after knowing fully well about their AIDS/ HIV-positive status; 19. regarding special care to special children born out of HIV-positive mothers;
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20. persuading persons engaged in commercial sex work to undergo test for HIV voluntarily.
Conclusion
In this chapter the reader has been exposed to judicial responses to various issues related to HIV/AIDS, especially in matters related to the discrimination of HIV/AIDS affected persons in employment, and the requirement to maintain confidentiality of health status of PLHAs. We also had a review of the laws useful to prevent the spread of HIV, useful laws to enforce rights of PLHAs, rights of people living with HIV/AIDS, and various aspects pertaining to a legal policy on HIV/ AIDS. This Unit also explains the legal strategy required for an AIDS Law.
References
Jose, Sonny & Jyothiram, Aishwarya, Ethical Issues in HIV, Kerala Sociologist. Vol. XXXV, No. (2), Jan June 2008) Mathew, P.D. (1998). AIDS and Law, Indian Social Institute, New Delhi. Thomas, Gracious, et.al (1997): AIPS, Law and Social Work, Rawat Publications, New Delhi. Legislating an Epidemic HIV/AIDS in India, The Lawyers Collective. Universal Law Publishing Co. Pvt. Ltd. AIDS, Law and Humanity. Interdisciplinary International Conference, New Delhi, December 610, 1995. Indian Law Institute, New Delhi.
16
Theories and Models of Stigma and Discrimination

*Neil Abell
Introduction
Stigma and discrimination are multi-layered responses concerning differences among people. In the context of mental and physical illness, they shape the understanding of such conditions by those who are diagnosed, their family members and communities, and the professionals attempting to meet their needs. Many influences impact the experience and expression of stigma, ranging from the nature of the illness itself to the characteristics of those who bear it and the social and cultural contexts in which they find themselves. Political, economic, social, and religious factors add to the complexity of assigning meaning to mental and physical illness, and nowhere are these more potent than among those dealing with HIV/AIDS. In this chapter, we will overview core constructs and definitions, identify primary theories and variables influencing our understanding. We shall also consider the moral and ethical implications of interpreting illness not simply as a physical condition, but as a broad statement about the deservingness and character of the afflicted. As we will see, the roots of these reactions to conditions we fear and are tempted to judge run deep. Seeing this clearly is the essential first step in moving from reactivity to intentional action, as we serve those infected with and affected by HIV/AIDS.
* Prof. Neil Abell, Florida State University, USA
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Core Constructs and Definitions

In modern social science, stigma was first described by Erving Goffman in the context of mental illness, physical deformities, and other socially deviant behaviors (Goffman, 1963). He defines stigma as an attribute that is deeply discrediting resulting in reducing the targeted person from a whole and usual person to a tainted, discounted one (USAID, 2005). Phrased in this way, the attribute triggering this association may be a diagnosis of mental illness (i.e. schizophrenia), or behaviours viewed as unacceptable based on the conventional social norms (i.e. commercial sex work or injection drug use). The process of devaluing persons carrying these characteristics is known as stigmatizing. Taken a step further, discrimination is unfair or unjust treatment of an individual based on his or her real or perceived status (UNAIDS, 2003). This underscores the fact that the individual may not actually have the characteristic in question, but merely be assumed by others, to have it. Consequently, beliefs about another, whether they are true or not, may be enough to trigger treatment, putting their fundamental human rights at risk, and compromising them politically, economically, socially, or psychologically. Discrimination can manifest as shaming others for their condition (whether or not they can control it), or blaming them for having the condition in the first place (assuming they could have behaved in ways that would have prevented it). Gregory Herek summarized how this process might be applied to persons infected with or affected by HIV, defining AIDS-related stigma as prejudice, discounting, discrediting, or discrimination directed at people perceived to have AIDS or HIV, and the individuals, groups, and communities with which they are associated(Herek, 1999). Noting that such
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discrimination could manifest as personal rejection or even violence, he identified four characteristics associated with HIV/AIDS that were likely to evoke stigma. These included:
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The assumption that those infected with HIV, bore the sole responsibility for their illness (i.e., they could have avoided it). HIV/AIDS is an illness that is unalterable, and generally degenerative. Although the quality of life continues to improve with advances in medical treatment and distribution of antiretroviral medications, HIV-related illness remains incurable, and is viewed by the general public to be fatal. HIV is a condition that is contagious, and with the potential to cause harm to others in ways that are not clearly understood by them. Decades of prevention education and HIV/AIDS awareness campaigns have not eliminated widespread belief in myths or misunderstandings regarding how HIV is transmitted, or skepticism about the effectiveness of barrier methods or various universal precautions as tools for prevention. Finally, HIV/AIDS can disrupt social relations and may be viewed by others as repellant, ugly, or upsetting (Herek, 1999). While HIV-related disease may remain hidden from view for many years, in its advanced stages, it causes PLHA to appear notably ill, weak, losing their stamina, and triggering distress in others.
Varying Presentations Stigma and discrimination appear in varying forms, and are associated with a range of motivations representing differing aspects of fear. Shaming and blaming are very common. While these and other motivations are not
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unique to HIV/AIDS, they will be illustrated throughout this Block largely in that context. Ann Jacoby distinguished experienced stigma versus expressed stigma, associated with the undesired differentness (Goffman, 1963, in Jacoby, 1994, p. 269) of people with epilepsy. Adapted to the context of HIV/ AIDS, this guide us in differentiating processes that are felt versus enacted. Felt stigma is (or at least, by the perpetrator, is thought to be) held within; experienced as an emotional reaction to or cognitive judgment about the person thought to be HIV+, but not revealed directly through words or actions. Enacted stigma, on the other hand, is directly expressed. Perpetrators may or may not be aware of it, but someone observing their actions or body language, or listening to their words, would see or hear discrimination being expressed towards another. The relation between the felt and enacted stigma and discrimination, and the potential disconnect between what we think we are saying or doing, and what others perceive in the context of HIV/AIDS, is crucial. Just as stigma may be attributed to others based on perceptions (rather than realities) of how they actually are, social workers may be viewed as stigmatizing others whether or not they are aware of it or see themselves as doing so. People with good reason to believe they are marked for unfair or unjust treatment (as if PLHAs), are likely to be very sensitive to the least suggestion that they are being thought of or treated differently, and react accordingly. While we need not take the blame for things we have not done, being aware of the high likelihood of PLHAs being mistreated by others, can heighten our resolve to make sure we are not adding to the problem, on purpose or otherwise.
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The notion of internalized stigma (sometimes called selfstigma), is an additional twist on these dynamics. In such cases, stigmatized individuals or groups may accept that they deserve to be treated poorly and unequally (USAID, 2005). Unfortunately, this is partly the result of successful shaming and blaming, wherein PLHAs conclude, based on accumulated social and institutional pressures, and value judgments, that they are in fact responsible for their condition, and could or should have done something to prevent it. We shall return to this notion as an issue for public health ethics later below. For now, it is important to note that while internalized shame and blame can sometimes motivate positive change, it can just as likely inhibit PLHA from believing they deserve to be treated well, and restrict them from seeking services or meeting their needs. Finally, Herek (1999) specifies two components of HIV/ AIDS stigma that may worry those who interact with PLHA. The first of these is instrumental stigma - the fear that we might contract the virus from someone who is HIV+. Social workers, family members, and friends, or members of the wider community may be concerned about the risk of becoming HIV+, simply through casual contact with PLHA. Sexual partners, injection drug users and their partners may have objective concerns that interacting with the PLHAs would increases their risk of becoming HIV+. In contrast, symbolic stigma arises from the social meanings attached to HIV/AIDS, and has the fear that if others know that the individual had contact with PLHA (in professional or informal ways), they will be treated with the same judgments and discrimination directed towards PLHA. Whether we are concerned about catching the virus, or being treated as if HIV+, or both, these two forms of stigma would shape our interactions with PLHAs, in powerful ways.
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Theoretical Foundations: Social Psychology and Expanded Sociological Views

Various other notions regarding stigma can be usefully framed in social psychological terms, in order to help deconstruct the process, and hopefully make it easier in understanding and addressing the same. Link and Phelans (2001) original work, later adapted with associates (Link, Yang, Phelan, & Collins, 2004; Yang, Kleinman, Link, Phelan, Lee, & Good, 2007), provides us a strong, primary, theoretical framework. In the most basic formulation, Link and Phelan (2001) describe social psychological processes illustrating a sequence of steps in stigmatising and discriminating. Each of these steps, require a perpetrator (the person engaged in judging or acting), and a target (the person being so judged or treated). In the instance of internalized stigma, these two roles are both enacted by the targets, who takes on external views held in the larger society, and carries them as negative self-judgments within. People can only be successfully stigmatised if they lack power - social, economic, or political - in comparison to the perpetrator (Link & Phelan, 2001). Jonathan Mann, the founding director of the World Health Organizations Global Programme on AIDS, insisted that in each society, those people who before HIV/AIDS arrived were marginalized, stigmatized, and discriminated against, become those at highest risk of HIV infection.... (Shoofs, 1998). In other words, those who are already looked down upon by society, are at greatest risk of infection. And, once infected, they are at even further risk of being cast out. The first step in the stigma process is labeling. This includes using names for others, that are deeply discrediting and reduce them from a human whole, to a
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tainted or discounted one. Calling someone who uses injection drugs a junkie, or someone who is sexually attracted to others of the same gender a pervert, strips them of their other roles and functions (i.e. father, mother, employee), and strongly identifies them with something considered outside the social norm. The second step in the process is stereotyping. It implies overlaying co-existing judgments about others, assuming that the labels assigned to them carry associations with other personal attributes (i.e. immorality or promiscuity), which further discount or discredit them. Stereotypes sometimes originate in observations (i.e., noticing that someone is unfaithful to a spouse or partner), but ultimately aim to create a broadly negative impression of the person being targeted. If someone was already marginalised because of sexual orientation, poverty, or social class, becoming HIV positive only exaggerates the negatives, in the eyes of the others. As the list of negative impressions regarding the other grows, it becomes much easier, to justify thinking harshly about them. Thus, they become increasingly more likely to be mistakenly associated with them. These two processes lead to the third step, that is the creation of outgroups, thereby separating us from them. In this process, perpetrators attempt to reinforce the distinctions between themselves (us - people, who are not negatively labelled or stereotyped) and others (them - people, who are labelled or stereotyped), in order to create a sense of distance and safety. During this stage, perpetrators may attempt to convince people, whose opinions they value (i.e. co-workers, family members, fellowships or fellow-worshipers), that they are not like the threatening others by exaggerating their moral superiority, making harsh statements about the others, or choosing to keep quiet when PLHAs are being targeted.
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The fourth step is to broadly discriminate, treating others in an unjustifiably different manner (i.e. distinguishing, excluding, restricting, shaming, or blaming) based on suspecting or knowing they have HIV/AIDS. In effect, having labelled someone as unacceptably different, exaggerating their characteristics, by piling on real or imagined stereotypes, and making sure that others know we are not like them, a circle is drawn around the other, making it easier to justify targeting them for unfair treatment or abuse. For the most part, these processes are driven by fear. Such fears emerge from concerns, that we will get HIV from someone who has it, or risk being treated like they are treated in society, unless we clearly distance ourselves from them and their perceived characteristics. Emotions play a large role during each step, clouding our thinking, and heightening the anxiety of being infected or of being associated with others, who are cast out. It is easy to see this as a trap, difficult to escape, as breaking the cycle requires the ability to see circumstances objectively, the confidence to understand where we truly are and are not at risk, as well as the willingness to effectively confront the social, political, and communal circumstances that reinforce such hurtful treatment of others. The stigma process is further complicated by very fear of losing control over the core values, held by ourselves or our societies. This additional moral dimension to understanding stigma and discrimination, helps us recognise that, while many of the outcomes are hurtful and damaging, the roots of these processes are not exclusively bad (Yang, et al., 2007). In fact, they can be motivated to a certain degree, by desires to retain traditions viewed as essential to the well-being of society. And this brings us back to the notion of HIV/AIDS as the great teacher. The overwhelming impact of the
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virus, and the threats posed to public health by our inabilities to restrain it, force us to reconsider which parts of our upbringing and cultural values truly are essential to well-being, and which, on reflection, may actually stand in the way of effectively protecting us from harm. Writing on the similarities between stigma and prejudice, Phelan, Link, & Dovidio (2008) note that stigma and discrimination serve three functions:
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exploitation and domination (keeping people down) norm enforcement (keeping people in), and disease avoidance (keeping people away) (2008, p. 358).
Clearly, each of these play a significant part in protecting us (the uninfected) from them (the infected or identified at risk). The challenge is to introspect clearly, when these processes do more damage than good; to recognize when the resulting discrimination itself becomes a violation of acceptable social norms; and to act intentionally to promote equal access to social resources while protecting public health. Social work values require us to look deeply into our own biases and judgments, and to initiate steps to recognize and protect the rights and dignity of our clients.
Implications for Health Care and Social Service Delivery

Stigma and discrimination, as defined above, are both background and context for the delivery of health care and social services. PLHAs, their family members and friends, and those at risk or simply assumed to be at risk for acquiring the virus, are all potential targets. They may be shamed for who they are or who they are thought to be, and blamed for being HIV+, or for having
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characteristics associated with greater risk. Others may fear becoming ill, or being outcast, or both, as a result of interacting with those, targeted based on their HIV status or associations. Health care and social service workers are no exception to these attitudes and behaviours. On the one hand, they are at risk for secondary stigma; being judged or discriminated against not because of their own status, but, because of the status of those whom they work with. Not everyone who choose such occupations, do so because they understand HIV/AIDS, or have consciously decided to work with those suffering from its effects. Sometimes, they unexpectedly find themselves working with PLHAs (i.e., they didnt imagine PLHA would be part of their caseload), and are largely unprepared to manage their own lack of knowledge or emotional reactions to such a reality. Such workers are not immune to the human factor, or the tendency to judge or discriminate against that which we misunderstand or fear. For this reason (as will be see in greater detail in later units in this Block), social service and health care providers must be exceptionally dedicated to noticing and understanding their own reactions, and initiating the necessary steps to minimise the unanticipated, negative impacts on their services. Parker and Aggleton (2003) emphasized the importance of reframing stigma and discrimination in the broader contexts of power and domination, encouraging recognition that social inequality is a driving influence in creating and sustaining the maltreatment of some members of society. Viewed in this way, we can see that the very structure of health care and social services flows from underlying notions of threats to the social order, and responses necessary to protect it. Such dynamics determine decisions - political and social about who deserves the service, what they should be
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offered, and how. Thus, services made available to or withheld from PLHAs, are shaped by concrete and identifiable social actors seeking to legitimize their own dominant status within existing structures of social inequality (Parker et al, 2003). Those persons in charge of designing and directing health care and social services, are no less at risk of being caught up in such processes, than those who deliver these services on a daily basis. In the most innocous sense, they are merely reinforcing what is good and necessary for the well-being of their families, communities, and society. More dangerously, they are unconsciously contributing to reinforcing such systems meant to punish those who have strayed from socially constructed understandings of right and wrong, and have only themselves to blame for their misfortune. Somewhere in the middle, Bayer (2008) has called for an improved understanding of the ethics of stigmatising. Summarising from a complex position, he proposes that in some circumstances, shaming or blaming others for perceived misbehaviour may protect important aspects of the social order, without unduly violating the rights and dignity of others. It may even be possible to use these influences for promoting desirable change in social norms over time. He observes, shaming and blaming those whose sexual behaviours involve violence or abuse, may ultimately lead to positive change and therefore be ethically acceptable, while doing the same to those whose behaviour merely fails to conform to conventional standards of morality (Bayer, 2008) may not pay off. Obviously, issues raised in this manner are intensely personal, and depend heavily on the cultural contexts and values in which we live. This is all the more reason to remember that service providers are not immune from shaming or blaming their clients, or for limiting access
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to services to those they view as objectionable. As we will see in later units, those who fear being stigmatised are less likely to seek HIV/AIDS education or testing, to return for test results once tests are undertaken, to ask for medical care and adhere to antiretroviral therapy, or even disclose their HIV status to others. All of these are threats to public health, since people who do not know their status or seek treatment when they do know, are more likely to increase the spread of the virus to others. And ultimately, the family members and loved ones of social workers, nurses, and doctors, who stigmatise and discriminate in the course of service provision, are like everyone else in society, at greater risk as a result. Guidelines for Media Coverage in India Recognizing the risks to public welfare associated with negative labelling and stigmatising of PLHAs, the Press Council of India recently formally acknowledged that biased reporting resulting in stigma and discrimination, was a particular concern in stories involving HIV/AIDS (UNAIDS, 2008). Following a court case where such reporting led to discrimination against a child, the Council revised its Guidelines on HIV and Media (October 2008) to include the following recommendations for journalists, sub-editors, and newsroom staff in all media: 1 . 2 . 3 . 4 . 5 . 6 . be objective, factual and sensitive ensure accurate language and terminology demystifying myths related to prevention of HIV and miracle cures uphold confidentiality and obtain informed consent avoid discrimination ensure gender sensitive reporting
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7 . 8 . 9 .
ensure sensitivity on child-related stories ensure balanced and responsible coverage ensure regular training on HIV for media
10. adopting the existing stylebook or guidelines on HIV reportage The overall aim of these guidelines was to remind media professionals, that their story is objective, factual and sensitive, even more so when they are reporting on HIV. This includes highlighting positive stories where appropriate, without underplaying the fact that HIV is a serious issue. Telling the whole story means giving it a human face, and allowing the voices of people living with HIV/AIDS (PLHAs) to be heard (UNAIDS, 2008). These guidelines represent an important integration of the ethics of stigma and discrimination, recognising that not all behaviours are socially acceptable, and also that exaggerated or distorted reporting can do more harm than good.
Prioritizing Stigma Interventions in International Responses to HIV/AIDS

The UNAIDS (2007) observes that although they are pervasive challenges to public health and human rights worldwide, HIV/AIDS related stigma and discrimination remain seriously neglected issues in most national responses to HIV. Peter Piot, the executive director of UNAIDS states since the beginning of the epidemic, stigma, discrimination, and gender inequality have been identified as major obstacles to effective responses to HIV. Yet, there has never been serious political and programmatic commitment to doing anything about them (UNAIDS, 2007). This is despite major campaigns by numerous regional and national non-governmental organizations (NGOs) designed to raise awareness
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regarding the issues and to promote interventions addressing them. In its executive summary, the report identifies seven specific recommendations for national AIDS authorities, international NGOs, and other partners, directed at addressing these challenges. They are:
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building an understanding commitment to stigma and discrimination reduction by using existing tools to measure them and their impact on programmatic responses to HIV inspiring leadership, understanding, and high level commitment, on the necessity of reducing stigma and discrimination in national AIDS responses facilitating inclusion of stigma reduction strategies in national HIV strategic planning, funding, and programming using or promoting approaches that address the root causes of stigma and discrimination advocating multi-faceted national approaches, including initiatives such as know your rights campaigns, social change communications, social mobilization, participatory education, interaction between PLHA and key audiences, celebrity champions and media campaigns, and legal support to those affected by stigma and discrimination. promoting and facilitating systematic approaches such as programme evaluation and operational research
The broad span of these proposals reflect the wideranging impact of stigma and discrimination in the longterm fight against HIV/AIDS, and the gathering momentum for effectively addressing them. As we will see, many of these recommendations have implications for social workers on all levels, from better
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understanding of our own responses to PLHAs, especially in shaping the programmes and policies of the organizations where we work, and also in order to advocate for meaningful change in the acceptance and management of illness in our families, communities, and societies. Thus, with our help, those facing this life-threatening disease will be more confident, asking for and receiving what they need to be well, in environment that help, rather than hinder.
Conclusion
HIV/AIDS related stigma and discrimination, represents the second pandemic associated with this global health crisis. While there has been much progress in medical care and in the distribution of antiretroviral medications, the social aspects of HIV-related disease are persistent and severe. Many people shame or blame PLHAs, and reject or distance themselves from those they imagine might have the virus. Through labelling, stereotyping, separating, and discriminating, they show their fear of acquiring the disease and/or being treated by others as if they have it, or both. While many of these processes are intensely personal, they also operate on broad social levels, and reflect impulses to hold power over others, and dominate those who are already marginalized or otherwise live outside the established social norms. Social service and health care providers are also likely to reflect some of the same tendencies when interacting with their clients or patients. Considerable attention is being brought to bear on these problems and increasingly, national and international organizations are joining campaigns to raise public awareness and reduce the negative impacts of stigma and discrimination. Recognizing that public health is threatened when ill people fear learning their status,
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disclosing it to others, or seeking testing and treatment for their disease, programmes are now being developed to recognize stigma and discrimination, and promote programmes to reduce it. In subsequent units, we will learn more about how these issues manifest within and across differing levels of society and culture, how they are expressed in social service and health care settings, and what social workers can do to improve circumstances and outcomes for their clients at risk for or living with HIV/AIDS.
References
Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social Science &Medicine, 67, 463-472. Goffman, E. (1963). Notes on the management of spoiled identity. Englewood Cliffs, N.J. Prentice Hall. Herek, G. M. (1999). AIDS and Stigma. The American Behavioral Scientist, 42(7), 1102-1112. Link, B.G., & Phelan, C.G. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, pp. 363385. Link, B.G., Yang, L.H., Phelan, J.C., & Collins, P.Y. (2004). Measuring mental illness stigma. Schizophrenia Bulletin, 30(3), 511-541 Joint United Nations Programme on HIV/AIDS (UNAIDS) (December, 2003). Stigma and discrimination fact sheet. Retrieved November 9, 2008 from http:// www.unaids.org Parker, R., and Aggleton, P. (2003). HIV and AIDS-related stigma and discrimination: A conceptual framework and implications for action. Social Science & Medicine, 57, 13-24.
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Shoofs, M. (1998). Remembering HIV/AIDS pioneer Jonathan Mann. Retrieved December 11, 2008 from http://www.thebody.com/content/art2779.html UNAIDS (November 19, 2008). New guidelines for media reporting on HIV in India. Retrieved November, 20, 2008 from: http://www.unaids.org/en/KnowledgeCentre/ Resources/FeatureStories/archive/2008/2008111 new_guidelines_media_India.asp UNAIDS (2007). Reducing HIV stigma and discrimination: A critical part of national AIDS programmes. Geneva: Joint United Nations Programme on HIV/AIDS. Retrieved on October 2, 2008, from: http:// www.unaids.org. United States Agency for International Development (USAID) (June, 2005) Working report measuring HIVstigma: Results of a field test in Tanzania. Retrieved November 6, 2008 from http://www.popcouncil.org/horizons/ORToolkit/ AIDSQuest/instruments/stigindicators.pdf Yang, L.H., Kleinman, A., Link, B.G., Phelan, J.C., Lee, S., & Good, B. (2006). Culture and stigma: Adding moral experience to stigma theory. Social Science & Medicine, 64, 1524-1535.
17
Social Stigma: Universal and Culturally Specific

*Neil Abell
Introduction
HIV/AIDS stigma and discrimination appear in multiple forms within and across cultures and societies. Whether felt or enacted, tendencies to think or behave in ways that label, stigmatise, alienate, or discriminate against others are seemingly universal human traits. These have profound influence on both the experience of HIV-related disease and on personal and professional responses to it. The effects are so wide ranging that PLHAs may experience self-stigma, shaming and blaming themselves for their condition, thereby limiting their willingness to tell others of their HIV status or ask for needed services and support. In this chapter, we will examine how stigma and discrimination manifest on multiple levels within the family, community, and society. Considering that each of these areas is appropriate for social work intervention, an understanding of what PLHA and those at risk for HIV may experience is crucial. Hence major considerations would include: How is it that traditional sources of support may break down, adding distress to circumstances that are already challenging? What can be done to increase awareness of unhelpful thoughts and behaviours, and enhance the likelihood that PLHAs can find the care and support they need much?
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While some have argued that responses to stigma and discrimination have been lacking, much good work has been done on national and international levels to recognise the nature of the problem and build an understanding of what is needed to help. Some international researchers have concluded that enough is now known about the nature and expression of stigma across cultures to enable us to move ahead with constructive, practical responses. If, as they propose, stigma iscommon at its core, what are the elements we should all be aware of, and how should we begin the task of educating others? The present Unit will review some of those common principles, and gain an understanding of the important work that lies ahead.
Stigma within the Family, Community, and Society

The Academy for Educational Development (AED), International AIDS Alliance (Alliance), and the International Center for Research on Women (ICRW) have supported numerous studies on the nature and impact of HIV/AIDS stigma, resulting in the publication of a Toolkit for Action (AED, Alliance, & ICRW, 2007). Several important observations and illustrations from the Toolkit are included throughout this Block, beginning here with observations on the causes, forms and effects of stigma across family, communal, and social systems. The Toolkit, available as a free downloadable document (refer Suggested Reading), consists of text briefly covering each topic, accompanied by group exercises to be used in workshops on HIV stigma and discrimination. As indicated in Figure 2.1, one such workshop encouraged reflection and discussion on the roots of stigma, how it is expressed and experienced, and some of the consequences that flow from blaming and shaming others.
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The workshop participants hailing from an African nation were encouraged to think of a stigma and discrimination tree consisting of roots, trunk, and top branches. Prompted by some introductory questions, they applied these concepts and, through reflection and discussion, identified the following points as the causes, forms and effects of stigma: Causes (Roots) The workshop participants were made to discuss why people stigmatized. The discussion revealed that people invariably held a moralistic view that PLHAs were sinners, promiscuous, unfaithful, sleeping around. Peoples also held strong beliefs about pollution, contagion, impurity, etc. Ignorance and misconceptions made people fear physical contact with PLHIV as reflected in the words fear of infection, fear of the unknown, fear of death. Subtle issues such as
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gender and poverty figured out considering the fact that women and poor people more stigmatised than men and the rich. Prejudice too manifested as with the tendency to judge others. Indepth analysis on causes An in depth analysis of the cause of stigma revealed the following points: Poverty
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Poverty can lead people to stigmatise; being perceived as poor is indeed a stigma Poor women are forced into transactional or commercial sex Poor people who appear malnourished or emanciated and hence are most likely to be stigmatized. They cannot hide their HIV condition in the manner that a rich person can since there are no walls to hide them causing them to be easily seen by neighbours
Ignorance
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Lack of knowledge on the modes of HIV transmission, can increase the possibility of the person contracting HIV, through casual contact There are others who believe that casual contact with PLHAs can cause infection Some others have the knowledge, yet dont believe it. They think that they can still get HIV through casual contact.
Forms of stigma (Trunk) Stigma acted out finds expression in the following forms of discriminatory practices: name-calling, scape-goating, finger-pointing, teasing, ridiculing, labeling, blaming,
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shaming, judging, backbiting, rumour-mongering, gossiping, making assumptions, neglecting, rejecting, ignoring, isolating, refusal to share utensils, avoiding or staying at a distance, harassing, inflicting violence (physically), abuse, etc. There are other forms of stigma:
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self-stigma - blaming and isolating oneself stigma by looks or appearance associated stigma - stigmatizing family and friends for simple reason of being associated with the HIV positive
Effects or consequences (Top Branches) The following are the consequence of stigma: shame, denial, self-isolation, loneliness, neglect, loss of hope, resignation, depression, suicide, alcoholism, isolation. Self-rejection implying giving up on oneself, may manifest in the form of self-blame, self-pity, self-hatred, anger, violence, wiithdrawal from public activities (e.g. church membership), stonewalling (stop communicating). Others sense a feeling of worthlessness, manifested as feeling unproductive, impotent, useless or not being able to contribute. Still worse others are alienated, being forced to leave community or experiencing family disruption in the form of divorce, separation, or being abandoned or kicked out of family. Quarrels ensue within the family, with its members arguing over who is responsible for this situation and who will take care of the PLHA. Bieng at the receiving end their property is grabbed by relatives or even the society. Yet others, get alienated at the workplace, by being terminated or fired from work, loss of promotion. Some also get evicted from rented accommodation. Children lose scholarships, experience scholastic
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backwardness, or even eventually, dropout from school. In the wake of AIDS death children are also orphaned and are often forced to take to the streets. Abuse or illtreatment by relatives is not uncommon. The HIV+, are often deprived of medical care too. The health care staff perceive any service done this way as a waste of resources. In the wake of discrimination, they eventually stop making use of clinics, give up on medical compliance, refuse to attend voluntary counselling and testing programmes, and for that matter, even home-based care programme. Others in denial are reluctant to take medication, suspend treatment and eventually turn out their vengeance by spreading the infection (Alliance, 2007). As we can see, many of the causes, forms, and effects reflect painful circumstances with implications for the PLHA, as well as the family, their loved ones, and community. Reflecting on these statements, it is possible to conclude that the social aspects of HIV/AIDS can be just as devastating as the physical illness itself. For people struggling with such realities, there are seemingly numerous motivations to (self)-isolate or withdraw, leading to increased suffering and further complications related to the disease. When non-infected people witness or participate in such treatment, even if they do so silently, they may also decide that if they ever fear being exposed to HIV, they will not get tested. And if they do for real, test HIV+, they will keep it to themselves, and not ask for treatment or support. These are the general circumstances, social workers must first learn to recognize, and then determine to address in themselves, their families, and communities on both personal and professional levels. The Toolkit is divided into various modules addressing different aspects of stigma and discrimination. In Module
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D, emphasizing the family, a report from a church volunteer participating in a workshop for community developers, described her experience with a PLHA in a rural community: (on finding him to be HIV positive and empathetic to his plight)they built him a small hut, where he lay day and night, waiting to die. Hardly anyone visited him to socialise. They would only to put food on the floor and leave. Initially, when the social worker visited him, no one allowed him to enter his room. But when the worker insisted, they obliged. The woker describes that when she opened the door to get in, the stench was horrible! She went outside, fetched some water and warmed it, and later bathed him with the help of two young men in the family. They sat him in the sun - something he had not done for months together. They cleaned his room and washed his clothes, which were caked with filth. While they were cleaning the room, porridge was cooking on the fire. After the cleaning, the worker sat there, feeding him porridge and talking to him. The social worker kept on seeing, bathing and feeding him almost every day. Seeing this, the relatives too started doing the same. He died three weeks later, not an outcaste, but one loved and created in Gods image. The worker reminisced how, when she told him God loved him, he held her hand tight (Alliance, 2007b, p. 3). This story helps to demonstrate how the academic and professional understanding of stigma and discrimination could be translated into something more deeply personal, profound and dynamic. No doubt, the family of this PLHA was very distressed and conflicted, feeling in some ways that their loved one had brought shame and suffering on himself and them. When the church volunteer
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recognized his need, and demonstrated that it was possible to care for him without also contracting the virus, the family members taking her example, joined in supporting the client, realising that he was indeed in need of their support. In Unit 4, we will return to these themes as a basis for cultivating personal and professional compassion. Taking this illustration a step further, we can see that the family may also have had realistic fears regarding caring for their loved one. As the Toolkit illustrates, stigma expressed towards the family is also a serious concern. When workshop participants in Zambia, Ethiopia and Tanzania were asked to reflect on how neighbours, and other community members responded to families of PLHAs, they identified a broad range of issues and examples as cite below: Forms of stigma towards families living with HIV Stigma may manifest in the form of isolation and rejection of families suspected to have HIV and AIDS. They are subjected to name-calling, finger-pointing, gossip, rumour-mongering, backbiting, etc. Rumours about HIV and AIDS, were used as a weapon to denounce families. Speculations were made about other people, based on observed symptoms. Stigma was also said to have been triggered by visits or food relief provided by HBC workers. Others experienced severe shame, suffering loss of family honour, as voiced in the comment, You have discredited/shamed our family. Yet others snooped; people visited out of mere curiosity, to witness the condition of the PLHAs as if asking whether s/he was finished. Many did not allow children to play with (PLHA) neighbours children, while others refused to share things with the family (pots, stools, containers, etc.).
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How do neighbours treat households they think have HIV? The neighbours insist with the landlord, to evict the family out of rented accommodation. They stop the family or family member living with HIV (PLHA) from using the community toilet, and gossip about anyone who frequently used the communal toilet. Paradoxically, others stop visiting the affected family, but worry about being blamed for not visiting. Many neighbours stop exchanging foodstuffs with the family. In Africa, it was not unusual to remark and joke about the patient dying, hinting that he wont live until Christmas! Why do neighbours behave this way?: Rationale Neighbours often behave irrationally, due to misplaced fear of infection about sharing the same toilet, and of children being infected through contact with families taking care of PLHAs. This may be rationalized due to the ignorance, or a lack of sympathy about the heavy burden on the family caring for the PLHA. Neighbours The following are the comments commonly raised by the neighbours. we fear our children will get infected, so we stop children of the affected family from playing with ours; if the family is a member of a community group, we kick them out; this family brings disgrace to community/village. More candid was the remark, We visit for a while, then at intervals and finally we stop altogether. Others were honest and commented, We are sympathetic that they are spending all their money on medicine. Others are judgmental and remark cruelly, She was unfaithful so she is reaping what she sowed.
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Family The family affected rationalised their distancing on grounds of fear of isolation, fear of losing contact with the (other) neighbours, or being called names behind our backs. They perceived that the others pretended to be nice, but behind our backs they are judging us. The affected families witnessed that If they were ask about the PLHAs, they would say that PLHA was fine; this is said only to stop them judging the family. Further, they discouraged people from visiting; and if they came, they would keep them in the sitting room, and the PLHA in the bedroom in the back. They even discourage visits to the hospital; if someone comes to visit, they would say, Sorry, she is sleeping (Alliance, 2007). From the above illustrations, we can appreciate the very real fears families experience, risking being misunderstood, or even shunned by people who would otherwise be their friends. This is a big price to pay, especially when family members may regard the harsh treatment by the community was brought on to them, by a family members misbehaviour or immorality. Much understanding and support is needed for families, neighbours and communities to absorb the distress accompanying HIV/AIDS. Dealing with the unavoidable physical and health consequences is hard enough; suffering rejection and shame, even risking loss of work or exclusion from social networks may be too much for some to bear. For social workers, these become opportunities for education, providing examples of safe and supportive care, and advocating for social justice and access to necessities of living.
International and National Scenarios

Edwin Cameron, a South African judge, who happened to be HIV+, has written that stigma is perhaps the
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greatest dread of those who live with AIDS and HIV stigmas irrational force springs not only from the prejudiced, bigoted, fearful reactions others have to AIDS it lies in the fears and self-loathing, the selfundermining and ultimately self-destroying inner sense of self-blame that all too many people with AIDS or HIV experience themselves (Knight, 2008). As one consequence, PLHAs worldwide have found themselves isolated and struggling to gain access to services and basic human rights, as many countries have no legal or policy frameworks supporting the establishment of networks of PLHAs. This is especially true for traditionally marginalized people, as evidenced by the fact that nearly half of the countries included in the United Nations Secretary Generals 2007 report on human rights noted, existing policies prevent stigmatised groups such as sex workers and injecting drug users, from accessing prevention programmes (Knight, 2008). We have already seen illustrations of stigma and discrimination drawn from sub-Saharan Africa. Similar stories could just as easily be drawn from central Europe (Kelly, et al., 2004), the islands of the Eastern Caribbean (Abell, et al., 2007), or North America (Florida Department of Health, 2007). In each society, differences in culture, ethnicity, gender, and social class shape, but do not substantially change the risk that PLHA, their family members and loved ones will be subjected to, as a consequence of HIV status. Knight observes that the cultural taboos associated with common routes of viral transmission (same sex relationships, sex work, and injection drug use) have played a critical role around the globe. Knight (2008) writes, If HIV were transmitted in some other way, through some innocuous means, the world might well not be experiencing todays pandemic. But prejudice leading to stigma has silenced
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politicians and other leaders for too long, and everywhere action has come too late. Addressing the national scenario, Mawar, Sahay, Pandit and Mahajan (2005), citing multiple sources, write that: In India, public health officials until recently, held that only women in prostitution, homosexuals, or intravenous drug users (IDUs), could contract AIDS, largely ignoring a dramatic rise in new AIDS cases among monogamous, married women. Even diseases like tuberculosis (TB) carry stigma, as children with TB were not permitted to return to classes, even after successful treatment due to misconceived notions that they would still spread the disease to others. The HIV/AIDS scenario appears to be even worse as this still remains an incurable disease. The persons suffering from stigmatized diseases are assumed to have violated certain social norms and taboos and thus (be) responsible for it lessons learnt from the successful experiences dealing with stigma associated with other diseases, must be borne in mind, when HIV/AIDS related programmes are developed, as it amounts to denying the rights of the infected individuals. The authors note that the National AIDS Control Organization (NACO) has recognized the importance of this issue, and promotes provision of community and family based care in an enabling environment free from stigma and discrimination. At the same time, they express concern that specific strategies and programs addressing these concerns are lacking, particularly regarding vulnerable populations including youth, people with sexually transmitted infections, men who have sex with men (MSM), and those who use injection drugs (IDUs). Mawar et al. (2005) observes that social norms such as subservience in marriage (often reinforced by violence),
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can impair womens abilities to protect themselves. Women are often blamed for bringing HIV into the family, and sometimes accused of being prostitutes or drug users. They carry the double burden of caring for themselves in addition to their families. IDUs, especially prevalent, for example, in Manipur, risk being quarantined if HIV+, and may be required to undergo mandatory testing, and subsequently tattooed for identification. PLHA deciding to disclose their HIV status to others risk disgrace, disharmony, concern about insurance and employment, (and share) a desire to protect oneself and others emotionally and from violence (Mawar, 2005). The authors conclude that a human rights approach lies at the heart of any HIV/AIDS programme that seeks to prevent HIV transmission and supports those already infected (Mawar, 2005). Common at its Core Scholars writing with support from the International Center for Research on Women shared concerns about the nature and expression of HIV/AIDS stigma, particularly the question as to whether, and to what extent experiences differed across cultures. Clearly, each society and community expresses uniquely identifying characteristics and cultural practices, but how much do these shape the forms of stigma encountered in various settings, is to be considered? Following an extensive review of the literature and hands-on empirical research in four countries (Ethiopia, Tanzania, Vietnam, and Zambia), researchers found that HIV and AIDS-related stigma is far less varied and context-specific than may have been imagined (Ogden & Nyblade, 2005), concluding that differences are largely superficial and need not stand in the way of developing programs and interventions.
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The good news, then, is that social workers can get to work, confident that the major issues have been identified. Strategies for addressing stigma can be focused on both individual and structural change, with emphasis on two key underlying causes(Ogden and Nyblade, 2005): 1 ) 2 ) knowledge and fear, and values, norms, and moral judgments
Ogden and Nyblade emphasize that. it is not sufficient to intervene only at the structural levels. While power relations that foster inequality are structural, they are perpetuated by individuals, individuals who are well placed to institute change if motivated to do so and given a supportive environment. We thus call for an intervention that starts with the conviction that individual attitudes can and do make a difference, and that long-term and far reaching stigma reduction can start with individuals. Depending on the context, it may be necessary to intervene with people in positions of power and influence; people who determine to a large extent what messages are delivered and how; people who have the power to institute anti-discrimination laws and policies; and, people who are in charge of carrying out these laws and policies. In all contexts, it will be appropriate and necessary to intervene at the community level with community members, including health care workers, people working with faith-based and community-based organizations, and people living with HIV and AIDS and their families (Ogden and Nyblade, 2005). As the learner will see in Units 3 and 4, social workers can draw much good guidance from existing research, adopting and adapting current strategies to best suit the particulars of their own environments. While the challenges are great, and the problems persistent and
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deeply rooted, we have good reason to be encouraged that a map has been drawn showing us both a starting place and a destination as we work to reduce the impact of stigma on HIV/AIDS services. Recognizing the magnitude of the problem As we have seen, HIV/AIDS is a tremendously complex problem posing challenges for families, communities, and society. As indicated in Figure given below, a broad range of factors influence the prevalence of the disease.
Figure: Factors that reinforce or help reduce HIV/AIDS prevalence
Factors that reinforce HIV/AIDS Gender inequity & male domination Poverty & continuing impoverishment Increasing urbanization & migration Lack of information & epidemiological data Inadequate & isolated institutions Isolated & marginal civil society Oppressed & disadvantaged communities Disconnected or authoritarian government often in conffict with voluntary organizations Lack of political commitment Reactive & fragmented approach Source: Hall, 2007 Factors that reduce HIV/AIDS Gender awareness, sensitivity & sexual equality Mobilization of resources Integrated & supportive communities Strategic Information Multi-sectoral approach & sharing of information Civil society engagement Empowered communities Committed government & voluntary sector involvement Political leadership & advocacy Proactive & holistic approach
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From gender inequities to pervasive poverty, oppression, and incomplete social and governmental responses, all must be considered respectfully in light of prevailing cultural values and realities. Hall (2007) argues that social workers are uniquely positioned to address such concerns. In their training and work experience, social workers develop the necessary knowledge, skills and values, needed to support people as they cope with stresses, changes and crises, including those triggered by illness, marginalization and discrimination. Many other professions and individuals are involved with psychosocial care and emotional support, including nurses, psychologists, doctors, community activists, volunteers and family members. However, the social work profession, by virtue of its holistic perspective, is capable of responding to the needs of vulnerable populations, helping people gain more control over their lives-in partnership with them-and addressing major political, social and economic issues (Hall, 2007). Particularly in impoverished settings, social workers are challenged to address basic elements of human rights and dignity. Citing an early International Federation of Social Workers (IFSW) policy statement on HIV/AIDS, Hall (2007) concluded that, there is need to ensure through proactive advocacy that all people affected by HIV/AIDS have proper food, housing, education and health care, and be able to exercise their rights in this regard without hindrance. The task will not be easy, warranting recognition of stigma and discrimination as the third phase of (the) HIV pandemic (Mawar, et al., 2005). Indeed, Knight has identified the need for an exceptional response, quoting Peter Piot, former UNAIDS Executive Director: The impact of AIDS is exceptional because of its impact now and the future threats it poses. It primarily kills adults in their prime, those who drive economic growth of a
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nation, and provide care for the very young and the elderly. Too many countries, especially in sub-Saharan Africa, are being stripped of this generation; the labour force is being steadily wiped out, and in severely affected countries, the result could, over another two generations or so, be detrimental to economic and social development the key factor here would be the cumulative weakening, from generation to generation of human and social capital Within the next five years, every sixth or seventh child in the worst affected sub-Saharan countries will be an orphan, largely because of AIDS apart from chronic armed conflicts, such as in the Democratic Republic of Congo there is arguably no other cause today of such utter economic and social regress (Knight, 2008). Over a decade ago, Jonathan Mann declared that HIV has its worst impact among populations who are already marginalized in any society. Echoing that theme, Knight notes our obligation to work not only with individuals, but also with the institutions that shape their lives. AIDS flourishes in poor societies because illiteracy and penury make people vulnerable; success against the virus depends partly on broader progress. As President Paul Kagame of Rwanda told the Washington Post, theres no use in giving someone antiretroviral drugs if he has no food (Knight, 2008).
Conclusion
In essence, social workers must draw on all their skills and training to navigate the deep waters and the challenges posed in the context of HIV/AIDS related stigma. While the experience of being stigmatized or discriminated against is intensely personal, such encounters arise from fears and inequities based in ageold practices and social structures that bind
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communities together, and give life within them value and meaning. The intrusion of this life-threatening disease into the very fabric of our communities, force us to look more deeply into how we live, what we value, and why. Ultimately, we will succeed or fail in our attempts to control the spread of HIV/AIDS, based upon how clearly we see these connections, and how creatively and respectfully we unravel their more damaging influences on public health.
References
Abell, N., Rutledge, S.E., McCann, T.J., & Padmore, J. (2007). Examining HIV/AIDS provider stigma: Assessing regional concerns in the islands of the Eastern Caribbean, AIDS Care, 19(2), 242-247. Academy for Educational Development, International Center for Research on Women, International HIV/ AIDS Alliance (June, 2007). Understanding and challenging HIV stigma: Toolkit for Action (Revised Ed.). Retrieved November 6, 2008 from http://www. aidsalliance.org/custom_asp/publications/ view.asp?publication_id=255 Florida Department of Health, Bureau of HIV/AIDS (2008). Organizing to survive: The HIV/AIDS crisis among Floridas women. Retrieved on August 26, 2008 from http://www.doh.state.fl.us/ disease_ ctrl/aids/Docs/HIV AIDS Womens Report_4 2008.pdf Hall, N. (2007). Why dont we care? Social workers, the profession, and HIV/AIDS, Social Work, Health, & International Development, 44(1), 55-72. International HIV/AIDS Alliance (Alliance)(2007a). Understanding and challenging HIV Stigma:
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Introduction andModule A. Retrieved on November 8, 2008 from: http://www.aidsalliance.org/ graphics/secretariat/publications/ 1Stigma_Intro&A.pdf International HIV/AIDS Alliance (Alliance)(2007b). Understanding and challenging HIV Stigma: Module D & E. Retrieved on November 8, 2008 from: http://www.aidsalliance.org/graphics/secretariat/ publications/3_Stigma_D&E.pdf International HIV/AIDS Alliance in India (September, 2008). Together now India Newsletter, 1(1), p. 3. Retrieved on January 24, 2009 from: http:// www.aidsalliance.org/graphics/secretariat/ publications/Together_now_India_Newsletter1.pdf Kelly, J.A., Amirkhanian, Y.A., Karakchieva, E., Csepe, P., Seal, D.W., Antonova, R., Mihaylov, A., & Gyukits, G. (2004). Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study, AIDS Care, 16(2), 231-246. Knight, L. (May, 2008). UNAIDS: The first 10 years, Joint United Nations Program on HIV/AIDS (UNAIDS): Geneva, Switzerland. Retrieved November 9, 2008, from: http://data.unaids.org/pub/Report/2008/ 200810_first_10_years_en.pdf Mawar, N., Sahay, S., Pandit, A., & Jahajan, U. (2005). The third phase of HIV pandemic: Social c on se q ue nc es of H I V/ AI D S st ig m a an d discrimination and future needs, Indian Journal of Medical Research, 122, 471-484. Ogden, J., & Nyblade, L. (2005). Common at its core: HIV-related stigma across contexts. Retrieved September 9, 2006, from
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h t t p : / / w w w . i c r w . o r g / d o c s / 2005_report_stigma_synthesis.pdf#search= %22common%20at%20its%20core%22 UNAIDS (April, 2004). Three ones key principles, Conference Paper 1, Washington Consultation Retrieved November 9, 2008 from http:// www.unaids.org/UNA-docs/threeones_keyprinciples_en.pdf
18
Provider Stigma: Social Service and Health Care Providers

*Neil Abell
Introduction
In the preceding units, we have seen how HIV/AIDS stigma and discrimination are conceptualized, and gained an appreciation of their critical impact on the global pandemic. In many ways, these dynamics, expressed by individuals, as well as within families, communities and societies, overwhelm scientific and medical breakthroughs. Recognizing this, we have reconsidered the impact of personal fears and concerns, and noted how both individual and structural influences shape the public health environment that PLHA and those considered at risk for HIV encounter. In this chapter, we continue this investigation, examining how health care and social service providers might engage in the same thoughts and behaviours as others in society. As we will see, professionals and paraprofessionals may unintentionally add to the stigma and discrimination felt and enacted in service settings. When they misbehave with others in these despicable ways, they may undermine their best and most professional intentions. As a result, people who are infected or affected with HIV may disguise their concerns, hide their HIV status, or stay away from settings where they might otherwise receive the
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information, services, and support they are in dire need of. As noted in the Framework for Action developed by the Caribbean Epidemiology Centre (CAREC, 2004), the resultant obstacles include:
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increasing spread of HIV and co-occurring illnesses such as TB; reduced use of condoms or other prevention behaviour for fear that doing so will cause others to suspect or reveal anothers HIV status; forcing people to pretend they are heterosexuals, even if they have same sex relationships (gay); preventing communities and families from providing education, care, and support to PLHAs, or those who are vulnerable to HIV; negatively affecting the quality of care provided to PLHA; and preventing national authorities from getting a true picture of the burden of the epidemic because people will not come forward for testing, care, and support.
The good news is that providers around the world are becoming increasingly aware of these issues, and beginning to take steps to address them. Before turning to intervention strategies (as we will do in chapter 19), let us take a closer look at the nature of HIV/AIDS provider stigma.
Stigma Among Professional Service Providers

In many ways, tendencies to stigmatize or discriminate can be understood as normal responses to the personal and social fears triggered by HIV/AIDS. Imagining that they might become deathly ill or to be treated as outcasts if they interact with PLHA, health care and social service
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providers are not immune to reactions that blame or shame those they hold responsible for these risks. After all, we social workers are only human. Service providers are, in part, gatekeepers for medical care, social support and prevention education, and beyond their own personal fears and reactions, may also feel they must uphold larger community and social moral standards (Rutledge, Abell, Padmore, & McCann, 2009). Deviating from dominant attitudes or behaviours in their communities can lead to loss of funding for agencies or NGOs, as well as threaten the livelihoods of organizations and workers. Consequently, providers may feel they have little choice but to join in the stereotyping of those who break social taboos, reinforcing views that it is the will of God that homosexuality, marital infidelity, and promiscuity lead to AIDS (Rutledge et al, 2009). These pressures are sometimes experienced as emotional reactions to patients or clients habits and needs, or to the stress of providing services in hostile community environments. Community norms can influence how providers express their emotions in daily interactions, shaping how events are interpreted (i.e. as good or bad), guiding behaviors that influence other people (for instance, being publicly accepting or rejecting), causing reactions to the events and actions of others (by conveying comfort or distress), and maintaining socially shared interpretations of interactions and events (Varas-Diaz & MarzanRodriquez, 2007). Feelings are very powerful, and may cause providers to think or act in particular ways. Emotions can contribute to stigmatization by indicating whether strong reactions to PLHA (including violence) are acceptable, and by keeping unchanged the socially shared negative definitions about (PLHA). Health professionals, as part
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of (the) social scenario, are also active participants in the use of emotions as sources of meaning and guides of behavior (2007, p. 1249). Their emotional states may influence how PLHA react to them, and model how PLHA should be thought of or treated by coworkers or other community members. The truth of living with HIV is a constant reminder of the lack of acceptance and rejection found in our societies. Living with HIV demands silence and secrecy, because even in the best of cases people perceive rejection and lack of acceptance even from health care providers, including psychologists (Varas-Dias & Toro-Alfonso, 2007).
Stigma and Discrimination Among Health Care Providers: International Illustrations

Although it seems illogical, having good information about HIV transmission is not, in itself, enough to guarantee that people will remember and act on that knowledge when encountering PLHA. On an island in the Eastern Caribbean, a well-established leader of an international NGO participating in an anti-stigma workshop once told the story of his own behaviour to a group of student nurses. He described visiting an infectious disease ward in a local hospital, and becoming aware in the middle of his stay that he was walking around with both hands stuck in his pockets. Surprised to find himself behaving in this way, he thought I know better than this.I am sure I cannot get HIV by touching any of these patients, and yet I am unconsciously protecting myself by keeping my hands out of reach. He was embarrassed to catch himself acting in such a way, and aware that in doing so he was sending a nonverbal message to patients, their visitors and staff that, he, an educated man, feared the people on the
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ward. Still, he bravely chose to use himself as an example in the training of the nurses. In this way, he generated a learning experience first for himself, then others, and modelled the courage and compassion of becoming aware of a limitation and growing from it through openness and insight. Ogden and Nyblade (2005) observed similar disconnects between knowledge and behaviour in their study of health care providers in Africa and South Asia. This fear of and preoccupation with contracting HIV through impossible or highly unlikely routes persists across all four countries despite high levels of knowledge about how HIV is transmitted respondents know, or at least can easily recite, the three correct modes of HIV transmission (sex, blood, and mother-to-child). However, correct knowledge does sometimes coexist with incorrect beliefs and there is often a lack of confidence about how HIV is not transmitted (p. 17). A provider in Vietnam stated: I am a health professional; I know that HIV is transmitted only in three main ways. But when I come into contact with them [people living with HIV and AIDS] I still worry and feel nervous. ... In my case it is my duty, my responsibility to work with them, to go to them. But in fact, I am fearful. Differential treatment of PLHA was reported in health care settings, including:
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excessive and unnecessary precautions by health care staff; scuffle between providers to avoid caring for HIV+ patient; denial of health services; provision of treatment below standards;
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use of separate medical tools for people with HIV or AIDS; and segregation of patients with HIV, in separate rooms (Ogden and Nyblade, 2005).
In a qualitative study in the Eastern Caribbean, Rutledge et al. (2009) examined whether patterns of stigma and discrimination among health care providers could be mapped using the social cognition concepts introduced in Unit 1. First, they asked whether health care workers labelled PLHAs. They found that female sex workers were referred to as commercial sex workers, prostitutes, or skettels; but the latter term also referred to female promiscuity. When referring to gay men, some participants used (hurtful) terms (e.g., bullers, chi-chi men), whereas others used languageneutral expressions (e.g., gay, homosexual). Providers also referred to gay men as MSM. secondly, they asked whether such labels were associated with negative stereotypes. One example included the conclusion that PLHA did misbehave, and acquired HIV as a consequence. In a focus group in Trindad, two MSM commented on providers beliefs about them: First participant : Some people believe [AIDS] occured from God because they werent behaving themselves.
Second participant : You have to understand that we are . . . basically a religious society. . . . either you are gay, or youre sleeping around . . . you must have committed some great sin and then youre blamed for having committed this great sin. Thirdly, they examined tendencies to separate us from them, and learned that a common view among health
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care providers in the Trinidad was that AIDS happens to others, not us: it was first diagnosed among the same-sex community, and so, it immediately became a disease that was only for same-sex community members ... we got more information on drug use, and they said, Well, Im not a drug user and Im not a homosexual, so Im not at risk for HIV/AIDS. But even then with the progression of HIV/AIDS in the heterosexual community, we still continue to put up those barriers people say, Well, Ive been married for the past 20 years, I am not at risk because my husband is faithful to me, Im faithful to him. But that might not be true and we exclude ourselves. We, of course, exclude ourselves cause we go to the gym and we are fit and we are good Catholics there is always something that prevents us from being at risk for HIV/AIDS, but even despite all of that, there is a general negative view of HIV/AIDS and the types of persons HIV/AIDS is associated with. Finally, they asked whether instances of discrimination took place in clinics and hospitals. PLHAs described how, scorn in medical settings, was sometimes expressed non-verbally, with staff demonstrating disgust by the manner in which they delivered routine care. Even seasoned doctors could react badly if taken by surprise. I went to . . . a place where they treat all sexually transmitted disease. I had a wart on the inside of my gum, and they sent me to this specialist doctor, a lady from India there she give me some cream. And after two weeks the cream wasnt working and I went back to her and I went very early but [by] 12 oclock or 1 oclock nobody wasnt seeing me as yet. So I see the doctor passing . . . and she didnt hear me. So I just went and I just touch her like that [gestures touching
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her shoulder] . . . I say, DOCTOR! and she says screaming], Dont touch me! Dont touch me! I just bolt out from the place. . . . [A]nd she is a doctor in a venereal disease place! (p. 25). Another form of discrimination included violating the PLHAs confidentiality. As is common in small communities, gossip and story-telling about the lives of friends, family and neighbours is common. And as we have seen, providers are in many ways just like others in the community. Because it was very likely that members of the community knew each other, either directly or indirectly, providers who knew someones HIV status would sometimes feel a duty to warn others, even when they knew that doing so was unprofessional or even illegal. Several providers discussed this in a focus group. First participant : The culture is that I know she and she know me so he might be my husband, but the nurse on the ward might be his sister-inlaw or my sister-in-law.
Second participant : So information would flow. Third Participant : By the time I get to him, he would know that I was on the ward and Im HIV because his sister-in-law would have told either her husband or somebody the husband know.
When the researchers asked a PLHA in Grenada, a neighbouring island state, how he learned his HIV status, he said as he was walking towards the clinic to get his test results, he saw people on the street pointing to him, exclaiming There goes The AIDS Man!. Despite the health providers best intentions (in this case, the
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lab workers knowledge that he was legally bound to keep test results a secret), human nature and the pressure of community norms, lead to thoughtless and insensitive handling of the PLHAs. It is easy to imagine that as this gentleman told his story to others in his life (who likely were also at risk for the virus), they would think twice before deciding whether to go and be tested themselves. Stigma and discrimination among social service providers: International illustration In a mixed group of providers throughout the islands of the Eastern Caribbean (Abell, Rutledge, McCann, & Padmore, 2007), participants in a stigma workshop responded to questions about their attitudes towards PLHA. On an analysis, six major constructs pertaining to attitudes emerged. They include:
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Warmth: feeling favourably towards infected or affected persons, including children, adults, MSM, IDU, and caregivers; Comfort: ease in interacting with PLHA, in school, at work, shopping and sharing tableware; Distancing: minimizing contact or association with PLHAs; Condemnation: judging or wishing to control PLHA; Transmyth: (belief that) HIV acquisition (was possible) by sharing glasses, using public toilets, or being coughed or sneezed on; and Counsel: perceived ability to effectively educate and support others regarding prevention, testing, and treatment.
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Participants responses were analyzed after sorting them into those who generally were, or were not likely to (physically) touch PLHAs during their normal
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interactions. Those studied, whose jobs did involve touch, and were generally directly involved in providing health, e.g., nurses, dentists, caregivers; while those whose jobs did not involve touch, and who functioned in a variety of social service roles included Peace Corp Volunteers, police officers, prison officers, HIV/AIDS Counsellors, Social Workers, CEOs, Administrators, and HIV Educators. Researchers found that despite their professional training, participants across both groups still included significant numbers who were not completely sure that scientists and doctors could be trusted with regard to the truth about HIV/AIDS. Many wonder whether expert opinions about risks associated with casual contact were true. Participants in both groups also were aware that testing for HIV could lead to discrimination, and a significant percentage stated that the risk of being discriminated against would influence their own decision to be tested. Think of the implications: if people whose jobs include counselling others to be tested, or even administering the actual test were themselves afraid to be tested, what emotional message are they likely to convey to their clients or patients? This illustrates the overlap of social and community standards (specifically, the fear of being blamed or shamed by others) on decision making by service providers. Their ability to do their jobs is somewhat compromised by fears of what they would have to manage if they tested HIV+, and of how others would treat them if they knew. In general, relations among the six constructs conformed with expectations. More warmth was associated with increased comfort, stronger belief in counselling effectiveness, less distancing and condemnation, and less belief in transmission myths. Greater reported comfort was associated with increased confidence in
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counselling abilities and reduced tendencies to distance, condemn, or believe in myths. Respondents with greater counselling confidence were less likely to distance, condemn, or believe in myths, and those who distanced themselves the most from PLHA were more likely to condemn them or believe in myths (Abell, Rutledge, McCann, & Padmore, 2007, p. 244). On the other hand, researchers did not expect to find that social service providers (who were less likely to touch PLHA) were also less likely to condemn or distance from them, and more likely to feel comfortable around them. One explanation is that, despite their education regarding HIV risk and transmission, health care providers (who were more likely to touch) continued to feel less safe around, and more likely to judge and reject PLHA.
National Scenario (India)

In India, as elsewhere, AIDS is perceived as a disease of others of people living on the margins of society, whose lifestyles go against social norms and are often considered wrong or sinful. Social reactions have been quite negative; for example, 36 per cent of respondents in one study felt it would be better if infected individuals killed themselves (Mahendra, et al., 2007). Given the central role that service settings and providers play in making testing, treatment, and care available to PLHA, it seems critical to understand the damaging consequences of stigma and discrimination and to avoid engaging them as much as possible. As in other cultures, HIV/AIDS discrimination in India is often perpetrated by well-educated people (Paul, 2006). In Kerala, a parish member who died of AIDS was refused burial rites by a local church, and children found to be HIV+, have been denied admission to schools. Although
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it is now illegal to refuse employment based on HIV status in India, many organizations still perform HIV screening tests on prospective employees, and workplace discrimination continues to be reported. PLWHA also continue to face discrimination in hospitals. Gujarat, with a concentrated epidemic, reports an average of three cases of medical discrimination against the PLWHA a month despite the presence of over 5000 physicians trained in HIV management. Similar reports have surfaced from other areas. In addition to being denied timely medical attention, healthcare discrimination forces PLWHA to approach quacks, or to hide their seropositive status from attending physicians (Paul, 2006). Examining practices by health care workers in hospital settings, Mahendra, et al (2006) uncovered four types of discriminatory practices: 1. Testing patients for HIV without informed consent and proper counselling
I dont think consent matters that much. Theoretically, it is nice to talk about consent, but practically it is not possible. Many people do not know how to read or sign. In that case, consent does not really matter 2. Routinely informing families about a patients HIV status
The responses include the following: If the result is positive, then the doctor tells the patient as well as his relatives; Everybody, starting with doctors, nurses, sweepers, to the ward boys, who work with patients, all come to know about the status of the patient; and All the staff in the ward knows my status. The doctor tells the nurse, the nurse tells the ward staff, and they tell everyone else about me.
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3.
Breaching patient confidentiality by the use of markings or labels on beds and files
Labels such as High Risk, Barrier Precautions, and DANGER were posted on top of patients beds. A mother wailed, Bed labels were put up for my baby. All who could read the label knew the status of my baby. A health care provider confessed, We move the HIV positive patient outside the room into the corridor so that he is kept separately from other patients. According to one doctor, You are concerned about human rights of people who are going to die soon (but) they are only a small fraction of patients. What about my right as a doctor dont I have the right to survive? 4. Taking unnecessary precautions
Sometimes, these are due to the lack of adequate supplies for infection management; other times, they appear to be very extreme steps. Some of the responses reflecting this is, We burn the linen of the patient. Even utensils of HIV-infected patients are thrown away. Mahendra and colleagues (2006) also reported on health worker attitudes toward PLHA, including blaming, shaming, and disparaging patients social class. One doctor commented high risk population usually means, lower class people they live in slums, in unhygienic conditions. These people sleep with anybody. Among this class of people, extramarital affairs are common, and so also are drug users and sex workers (Mahendra et al, 2006). The International Center for Research on Women, in a study conducted in Andhra Pradesh, focused on community-based health care providers (HCPs), who often provide primary care to PLHAs, who are poor and living in rural environments (ICRW, 2006). Key baseline findings from the study concluded that over 70 per cent
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of HCPs avoid treating PLHA, because they fear infection. Some claim that they can cure AIDS, thereby misleading their communities. Most discriminate against PLHAs in hospital settings, and gender-based violence is considered normal and acceptable. One HCP asked Why are you wasting my time by asking these questions? Men beating their wives is normal, an everyday occurrence. Why are you worried about it?
Implications for Social Workers

There is an old saying, originating in mindfulness, stating when conditions are sufficient, something will arise. Essentially, this means that whatever manifests can be understood better by examining its root conditions. As we can see from topics addressed in this Unit, there is much to be understood, and more importantly, much to do in response to stigmatizing and discriminating circumstances surrounding HIV/AIDS. For social workers, developing an awareness regarding the true nature of the problem is a necessary, but insufficient start. As we will see in Unit 4, strategies and techniques are available, showing the way to addressing these critical social concerns at many levels. Much good work is underway to counter the disturbing practices of shaming and blaming. The ICRW project goals of increasing knowledge, awareness, and sensitivity of HCPs regarding HIV/AIDS and genderbased violence, building capacities, and commitment of HCPs to address these issues within their practices and their communities, and designing training materials to assist in achieving these ends are but a start. Mahendra and colleagues (2006) are similarly working with the Horizons Program, SHARAN (an Indian NGO), and the Institute for Economic Growth in collaboration with the National AIDS Control Organization (NACO), to improve responses to HIV/AIDS stigma in the Indian context. A
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registered medical practitioner in the ICRW project states the challenge for social workers clearly: We should pass on these ideas to people in the workplace, at the water tap, in tea shops, and in womens meetings. We can only solve these problems if we get others involved. There will be no change unless the whole community is committed to change.
Conclusion
HIV/AIDS health care and social service providers are, in fact, human just like anyone of us. They live in the same communities, grow up in the same families, and are taught the same values and expectations about leading a good and honourable life. As a result, providers are also prone to the same tendencies to stigmatize and discriminate against PLHA and vulnerable populations. In this unit, we have seen examples of such thoughts and behaviours, and considered their emotional aspects. What we feel often determines how we think and behave, even when it counters our best intentions. We have also seen that education, in itself, is not sufficient to overcome many of these negative potentials. Exposed to a life-threatening virus, and risking judgment and rejection by our communities and loved ones, it is understandable that social workers would sometimes lapse into behavior they know to be irrational and even regrettable. Through understanding the universal, and crosscultural manifestation of these responses to fear, we can achieve a starting point in readiness to change. In chapter 19, we look more closely at international projects developed to improve the environment surrounding HIV/ AIDS services, identify goals for future work, and consider a model helping us to grow personally as we develop professionally as social workers.
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References
Abell, N., Rutledge, S., McCann, T., & Padmore, J. (2007). Examining HIV/AIDS provider stigma: Assessing regional concerns in the islands of the Eastern Caribbean, AIDS Care,19(2), 242-247. Caribbean Epidemiology Centre (CAREC) (2004). A health promotion approach to reducing stigma and discrimination: A framework for action. Retrieved March 21, 2005 from: http://www.carec.org/pdf/ sdframework.pdf International Center for Research on Women (August, 2006). Reducing HIV/AIDS stigma, discrimination, and gender-based violence among health care providers in Andhra Pradesh, India. Information bulletin. Retrieved November 13, 2008 from: http://www.icrw.org/docs/ 2006_ib-reducingviolenceandstigma.pdf. Mahendra, V. S., Gilborn, L., Bharat, S., Mudoi, R., Gupta, I., George, B., Samson, L., Daly C., and Pulerwitz, J. (2007). Understanding and measuring AIDS-related stigma in health care settings: A developing country perspective, Journal of Social Aspects of HIV/AIDS, 4(2), 616-625. Mahendra, V. S., Gilborn, L., George, B., Samson, L., Mudoi, R., Jadav, S., Gupta, I., Bharat, S. and Daly C. (2006.) Reducing AIDS-related stigma and discrimination in Indian hospitals, Horizons Final Report. New Delhi.: Population Council. Retrieved November 9, 2008 from: http://www.popcouncil.org/ pdfs/horizons/inplhafriendly.pdf Ogden, J., & Nyblade, L. (2005). Common at its core: HIV-related stigma across contexts. Retrieved September 9, 2006, from: http://www.icrw.org/docs 2005_report_stigma_synthesis.pdf#search=%22common%20at %20its%20core%22
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Paul, N. (2007). Discrimination against people living with HIV/AIDS in India: Educated persons as Perpetrators. Journal of Infection, 54(1), 103-104. Rutledge, S.E., Abell, N., Padmore, J., & McCann, T. (2009). AIDS stigma in health services in the Eastern Caribbean. Sociology of Health Care & Illness, 31(1), 17-34. Rutledge, S., & Abell, N. (2005). Awareness, acceptance, and action: An emerging framework for understanding AIDS stigmatizing attitudes among community leaders in Barbados, AIDS Patient Care and STDS, 19, 186-99. Varas-Diaz, N., & Marzan-Rodriguez, M. (2007). The emotional aspect of AIDS stigma among health professionals in Puerto Rico, AIDS Care, 19(10), 12471257. Varas-Diaz, N., & Toro-Alfonso, J. (2007). Similar epidemics with different meanings: Understanding AIDS stigma from an international perspective, Interamerican Journal of Psychology, 4(1), 1-6.
19
Response Strategies for Social Workers

*Neil Abell
Introduction
In the preceding chapters, we have examined the roots of stigma and discrimination, and considered how they have evolved in the context of HIV/AIDS. Acknowledging the common features of shaming and blaming across cultures, we have also seen many specific illustrations of how felt and enacted stigma harm both the individuals targeted for discrimination and the settings they may turn to for education, testing, and treatment. The impact is far reaching, and compounded by previously existing tendencies to marginalize those who by tradition, behaviour, or social characteristics are already treated as lower class or outcast. As Knight has noted, The epidemic will be halted only if AIDS is placed firmly in mainstream development work. Major drivers of the epidemic such as poverty, inequality, especially of women in most societies, and stigma have to be tackled (Knight, 2008). In this chapter, we shall attempt to look closely at what can and must be done to improve the climate of service and care for PLHA, as well as those thought to be most at risk for HIV. As previously indicated, much good work is already underway, and a rapidly expanding literature, much of it available freely online, offers many guidelines, principles and practices that can be applied
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or adapted right away. The first obstacle, in many ways, is the lack of will and determination to move forward. Subsequent to the identification and overview of some of the major tools available to confront stigma and discrimination, we will consider factors that inhibit or enhance social workers readiness to better understand their own tendencies and fears, and to act constructively to address them. From these will emerge anti-stigma strategies social workers can consider as they take on more professional and influential roles in their communities. As we will see, working with stigma and discrimination requires a deeply personal capacity for reflection, understanding, and compassion. Success requires determination to encourage governmental and nongovernmental service organizations (NGOs), and the communities they serve, to more fully embrace the needs of those afflicted with HIV/AIDS. This is not an easy job, nor will lasting results be quickly achieved. Success in fighting the social and medical aspects of the pandemic depends upon long-term commitment to individual, institutional, and cultural change.
Existing Models: What to Include and Where to Start

Over time, successes and false starts with stigma interventions, have begun to yield some lessons learned, helping us focus our efforts and move efficiently towards positive change in ourselves, and in our communities. Researchers at the Royal Tropical Institute in The Netherlands have identified a set of stigma reduction strategies associated with specific levels of intervention (see Figure a). Each of these suggest opportunities for social work involvement, and implies points of entry for reducing stigma and creating
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Level Intrapersonal level
Strategies Treatment counselling Cognitive-behavioural therapy Empowerment Group counselling Self-help, advocacy and support groups Care and support Home care teams Community-based rehabilitation Training programmes (New) policies, like patient-centred and integrated approaches Education Contract Advocacy Protest Legal and policy interventions Rights-based approaches
Interpersonal level
Organizational/ institutional level Community level
Governmental/ structural level
Figure a: Stigma Reduction Strategies Source: Heijnders, M., & Van der Meij, S., 2006.
safer environments for PLHAs. The various strategies link to a range of social work roles, from individual or group counselling, through education, advocacy, and policy-based engagement. Each has a part to play in improving the context of care, and challenges us to understand our own prejudices and fears as we work with others to eliminate obstacles to accessing needed resources. The Toolkit for Action In previous units, we introduced the combined efforts of the Academy for Educational Development, International Center for Research on Women, and the
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International HIV/AIDS Alliance (AED, ICRW, & Alliance, 2007) as an example of progress in confronting HIV/AIDS stigma. Their Toolkit for Action, available online at no charge, was founded on broadly-based international research, and designed in its original version to address both individual and structural causes of stigma. In the beginning, workshops were intended to create safe environments where participants could talk freely about difficult issues, and to help them address the following goals:
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exposing stigma and assist in resolving contradictions, such as those between intentions and behavior; enhance practical knowledge to reduce fear of casual transmission; provide a safe forum to discuss sensitive topics (sex, death, drug use, inequity); agreeing to talk about stigma; enhancing the capacity of people living with HIV and AIDS (PLHAs) to challenge stigma in their lives; provide a process to determine appropriate and feasible individual and community responses to stigma; and provide comprehensive, flexible tools for organizations, to strengthen staff skills and develop or strengthen interventions to reduce HIV-related stigma (Ogden & Nyblade, 2005).
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As the Toolkit has evolved, emphasis has been expanded to include twelve steps to stop stigma (refer Figure b). These steps reflect the awareness that stigma and discrimination, even among health care and social service providers, can only be successfully addressed when the problem is approached comprehensively,
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including attention to individual, family, and community dynamics. As one registered medical provider in India stated (in terms that clearly apply to social workers), We should pass on these ideas to people in the workplace, at the water tap, in tea shops, in womens meetings. We can only solve these problems if we get others involved. There will be no change unless the whole community is committed to change (ICRW, August 2006).
Figure b: Twelve steps to stop stigma
1 .
create a sense of community, and build openness and safety to talk about HIV and AIDS, stigma and sex name the problem - get people to describe how stigma occurs in different contexts getting people to own the stigmatising disease; realising We are all part of the problem and helping people read and reflect on their own words, attitudes and actions towards PLHIV. help people see the effects of stigma on PLHIV, families, children and communities - how it hurts those stigmatised and indirectly hurts those who are stigmatising analyse the root causes of stigma - e.g. fears and misperceptions about HIV and AIDS, moralising attitudes, power and poverty - and how it particularly affects women, children and poor people address fears and misconceptions about getting HIV through non-sexual casual contact, and what it means to live with HIV and AIDS challenge the judging and blaming built into stigma and help people explore their own attitudes
2 . 3 .
4 .
5 .
6 .
7 .
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8 . 9 .
build commitment to changing attitudes, and doing something significant about stigma. help PLHIV overcome self-stigma, build up selfesteem and develop skills necessary to provide leadership on anti-stigma action
10. help family members learn the attitudes and skills needed to provide care and support for PLHIV and children living with HIV and AIDS (CLHAs). 11. develop strategies and plans for taking action against stigma 12. action and the monitoring of action
Source: International HIV/AIDS Alliance (2007). Understanding and challenging HIV Stigma: Introduction and Module A.
And as we have seen in previous units, the common experience of knowing, but not quite believing that HIV can only be transmitted through specific sex, blood, or mother-to-child exchanges (Ogden & Nash, 2005), must be continually addressed by trusted and powerful sources. Experience shows that repeated exposure to accurate information in a relaxed manner, is essential to overcome providers fears that they risk acquiring the virus through casual contact. This return to basics, illustrates that stigma interventions must respect subjective interpretations of medical information. Ultimately, while facts are facts, what we make of them is more important. Because so much of the stigmatizing process is emotionally driven, and enacted in community contexts, where many strong beliefs compete with evidence in shaping social norms, social workers must frequently re-asssess the attitudes and views of their intended audiences. They must tailor their interventions to repeat the basics, as much as needed to establish trust and comfort.
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Engenderhealth With support from the United States Agency for International Development (USAID), Engenderhealth has developed a training module titled Reducing Stigma and Discrimination Related to HIV and AIDS: Training for Health Care Workers (Engenderhealth, 2004). This document, available free of charge online as both a trainers manual and a participants handbook, starts with the assumption, that not all the health care providers fears are unreasonable. A good many of them are based on real risks due to their lack of access to supplies and training in infection prevention and standard precautions (Engenderhealth, 2004). Providers, they note, are subject to the same myths and pressures as their community counterparts, and seldom receive the support they need to rise to the challenges encountered daily in HIV/AIDS services. As a provider in Tanzania said, Health workers are expected to know, feel, and act in certain ways. But what has prepared them for this (HIV/ AIDS)? Many health workers have the same information the man in the street has(that) the disease is fatal! Knowledge and skills, yes, that they have. It is part of many training programmes. But what about preparing them to come to terms with their fears and anxieties about their own sexuality and morality, their prejudices? (Engenderhealth, 2004) Driven by such concerns, health care providers are at risk of reacting, by:
l l l
blaming or mistreating patients; breaching their confidentiality; failing to cooperate with colleagues known to be HIV+;

l
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demanding clients be tested for HIV as a precondition of providing services; discharging them immediately (regardless of health status), once the test results are known; segregating or isolating them from other patients, even when there is no clinical compulsions to do so; or Withholding, or reducing the quality of treatment in comparison to that given those who are not HIV+.
Social workers might raise the same concerns about their professional preparation, and be at risk of similar misbehavior as a way of managing the resulting distress. The Engenderhealth manuals respect the realities of these concerns, and provide many workshop sessions combining elements of theories in social psychology, summarized in earlier units with scenarios and questions designed to encourage greater awareness and understanding. These are paired with small group activities and brainstorming sessions designed to identify not only causes of undesirable reactions, but also possible remedies or alternatives. In a unit titled Moving beyond us and them, for instance, workshop participants would be offered two vignettes, one negative, and another positive. The first vignette illustrated the following (Engenderhealth, 2004): A woman came to the hospital in labour. At a certain point in her care, the doctor found out that she was HIV+, and refused to assist in the delivery. He didnt say anything to her. He just left the hospital. She was forced to seek care elsewhere. The second illustration was as follows: A man came to the health post because he had a troublesome cough that would not go away. He worried all the way there about telling the nurse that he is HIV+.
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He thought they might ask him to go away. In the end he told her, and she praised him for doing so, as it was important to know. She treated him just like she would any patient, with dignity and respect, in a caring manner. After reflecting on these two stories, participants were engaged in discussion. The first round focussed on feelings, and featured questions such as how would you feel in this situation, what would your reaction be, and, if you left, what would you do for care? The second round encouraged generating solutions, such as what can we do in our facilities, to make sure that positive experiences are the norm for our clients? Materials such as these have been tested in settings around the world, and are showing promise, as tools for raising awareness about stigmatising processes, and encouraging reflection on ways that discrimination can be reduced in healthcare and social service environments.
Awareness, Acceptance and Action: Mindfulness Principles Applied to Practice

Building awareness of inner thoughts and feelings is not as easy as it sounds. Some social service and healthcare providers are more inclined than others to look within, just like friends and family members in the communities around them. In the same way that our fears may block us from accepting medical information about how HIV is and is not transmitted, they may also inhibit us from fully appreciating the prejudices and attitudes we carry within. And even when we do not notice them, or accept their implications for the quality of our work with others, PLHA and other vulnerable populations are often very aware of how our thoughts and feelings shape our abilities to serve them in a positive manner. As we noted in chapter 18, when
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conditions are sufficient, something will arise. Our awareness of our own internal processes and acceptance of their implications for our treatment of others, creates conditions determining whether positive or negative interactions will follow. To better understand these dynamics, Rutledge and Abell (2005) proposed the Awareness/Acceptance/Action Model (AAAM) (refer Figure c), introducing three steps for responding to HIV/AIDS stigma. These strategies, based on the Buddhist philosophy, suggest a strategy for better understanding self and situation as a precursor to responding, rather than reacting, to life experiences (p. 190).
A ctio n A cc ep ta n ce A w a re ne s s
Lo ok ing D e e ply L istenin g W ell
Figure c: Awareness, Acceptance and Action Model
Awareness As Rutledge and Abell (2005) describe, the AAAM suggests a framework for intentional response in health care and social service settings. Following mindfulness principles, we would concentrate first on cultivating awareness. In mindfulness training, this implies two related steps: looking deeply and listening well.
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Imagine a social service provider encountering a PLHA in an advanced stage of HIV-related disease. She or he may appear emaciated, or be actively coughing or sneezing. Looking deeply involves paying attention to the full range of ones initial experience, so as not to respond prematurely. Some of the considerations may include: How am I feeling?, What thoughts and associations do I have?, How are these impacting my choices about how to deal with this person or situation?, In the beginning of our practice of awareness, these initial questions may seem overwhelming, and understandably so. HIV/AIDS presents a mixture of triggers uniquely associated with sex and death. One may introspect: How did this person get this way? Should he or she be blamed?, What risks am I taking by having contact with him or her?, Could I become sick, too?, Am I risking disease, social isolation, or even death for others and myself? Such serious, normative reactions, can contribute to spontaneous, and sometimes poorly considered choices. While it is tempting to advise the provider to get over such responses, or act maturely, human nature suggests otherwise. In mindfulness, ignoring the full expression of our initial reactions can set the stage for ill-considered and unintentional reactions, leading to discrimination against PLHA, and inhibiting us from effectively performing our roles. The second step in awareness is listening well. Whereas looking deeply begins with understanding self in encounters with others, listening involves paying undistracted attention to a set of cues communicated by another. When attempting to understand the PLHAs needs and wishes, we must track speech content and tone, emotional expression, and body language. In mindfulness terms, preparation for listening sometimes references the notion of emptiness. In this context, it
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means not a vacuum or void, but a readiness to suspend prior judgments and learn from another through careful observation. Listening without bias can be exceptionally challenging. Many aspects of HIV/AIDS, filtered through a variety of personal and social lenses, position us to view PLHA with suspicion or fear. Prior assumptions about sexual orientation, drug use, and morality may lead us to prejudge PLHA and their circumstances, restricting our abilities to hear them completely and to respond to their actual, rather than imagined needs. In contrast, social work values emphasize starting where a client is, rather than where we imagine him or her to be. Taken together, looking deeply at our own preconceptions, understanding their sources and implications, and listening well to PLHA may reduce the potential for misconceptions, and minimize the initial impact of stigmatizing thoughts and beliefs on service provision. Educating ourselves about the nature of HIV, the routes and means of transmission, the implications for testing, treatment, and caregiving, and the psychosocial complications faced by family, friends, professionals, and community members can enhance our ability to respond, based on facts rather than misinformation. Acceptance The second major component of the AAAM recalls a phrase made popular by ACT UP, an AIDS activist organization in the United States that popularized the slogan Silence = Death. To this, we add Denial = Delay to emphasize that time spent underestimating how we stigmatize PLHA inevitably slows our efforts to provide the best possible service. Whereas acceptance fully acknowledges the true nature of our
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stigmatizing attitudes and behaviors, denial (and the accompanying silence) represents our tendencies to close our eyes, or turn our backs on unpleasant and frightening realities. Acknowledging the contradictions between what we know intellectually and feel or enact interpersonally can further complicate accepting the truth of our experience. HIV/AIDS stigma has encouraged many seemingly universal motivations to minimize or ignore the truth about ourselves in relation to others. Imagining that HIV infects and affects only others (whom we identify as deserving because of who they are or how they behave) delays accepting how generalized an epidemic has become. Furthermore, because they are inferior, we can justify delays in providing prevention, education, and care. This can be literally fatal to the infected, and unintentionally damaging to those who think they are beyond reach of the virus. Coming to grips with the full extent to which they are us, calls for a literal transformation of our self-awarness of who we are. Whereas we might once have thought service to be a one-way transaction, it now becomes part of creating health-enhancing community environments. Consequently, practicing acceptance means that once we have become more fully aware (of the nature and prevalence of HIV, of our own biases and fears, and of the social and cultural attitudes and institutions that keep them going), we may become more focused on creating compassionate communities that support everyones well-being and health. This includes acceptance of our own unintentionally hurtful responses to PLHA. Wishing we were free of prejudice seldom makes itso.
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Action The final AAAM component emphasizes translating awareness and acceptance into intentional responses, rather than ill-conceived reactions, to PLHA. On the most personal level, individual action can include deepening awareness of our own prejudices, setting the stage for clearer thinking about HIV/AIDS services. How do my attitudes cloud my ability to see this situation as it actually is, rather than as I imagine it to be? On an interpersonal level, action means committing ourselves to a compassionate service option. This includes respecting others as they are, and striving to listen deeply to their true circumstances before making an action plan. Admittedly, this is extremely challenging when we have limited resources, fearful or hostile families and communities, and demanding or needy clients. Finally, the AAAM encourages social action. This includes attending to social policies and institutions that, intentionally or otherwise, pose barriers to necessary and constructive responses. In the spirit of mindfulness, action is the necessary translation of awareness and acceptance into constructive and compassionate behavior.
Implications for Social Work Roles in HIV/AIDS Service Delivery

A number of strategies for reducing HIV/AIDS stigma were listed in Figure a. Here, we elaborate on just a few real life situations, emphasizing social work roles and its impact of stigma and discrimination.
l
Prevention Education and Public Policy
In one North Indian city, a Chief Medical Officer expressed concern that the only way to successfully
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control the growing HIV/AIDS epidemic, was to quarantine everyone in the country who was HIV+. He knew for sure, that such people were not literally a public health threat to any of the citizens under his care, and that taking such a step would almost certainly backfire by causing those who knew their own status (or feared they might be positive), to hide or keep quiet rather than risk exposure. Still, his fear of being overwhelmed by a rapidly expanding health crisis, caused him to think of drastic reactions, rather than intentional actions. Social workers might be of assistance by helping the CMO see the futility of his proposal, while at the same time expressing understanding for his concerns. Appealing to both his humanity and his sense of reason might ease tensions, so better alternatives for improving his communitys health could be developed.
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Counselling
Working with commercial sex workers requires that social workers gain access to hidden aspects of a community, assure those involved in desperate and high risk activities, that social workers can be trusted to concentrate on health concerns above all else, and associate with gatekeepers, who may find social workers difficult to trust. Knowing that sex workers may have grown accustomed to being threatened and mistreated by others, social workers must work hard to overcome presumptions of judgment and stereotyping, and not imagine that clients will quickly trust them with the truth. This is only one example of circumstances reminding us that relationship building is a necessary first step in meaningful counselling, and that it may take repeated contacts over time to establish bonds making it possible for clients to share fears and concerns, and for social workers to offer meaningful resources and support.

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Continuity of Care
An HIV/AIDS hospice and treatment center in South India provided excellent, compassionate care. The social worker directing the agency insisted on inclusion of women first as family members responsible for the aftercare of their husbands, and second as primary patients themselves. He appealed initially to concerns about whether women who were excluded could be wellinformed regarding the nutritional and other needs of their loved ones, and ultimately refused admission to males who kept their wives away from the health care environment. The result was an array of life-enhancing services for both men and women. Where once there had been only facilities exclusively for helping men in the end stages of AIDS, the community now enjoyed a fully functioning clinic, where some were returned to health and sent home to loving, capable families.
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Advocacy
In Northeastern states, social workers found themselves caught in a dilemma. They could only move freely about the urban area they served if they first obtained permission from the insurgents who controlled the local drug trade. On the other hand, the police assumed that if the social workers obtained such permission (which they knew was essential to come and go in the community), then they must be part of the insurgency. In this complex context, the social worker attempting to advocate for the needs of PLHA had to persuade the insurgents that it was in their best interests to allow community members health to be looked after, while convincing the police that in doing so, they were not collaborating in illegal activity. Advocacy becomes an even more challenging role, when the person is a member of the group being stigmatized
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within the community. For this reason, social workers need special respect for sexual minorities or others facing serious risks of rejection or punishment when they make their status known while advocating for the rights of PLHA. When these advocates are also HIV+, the risks are further compounded.
Long-term Strategies for Urgent Problems

Jonathan Mann, writing over twenty years ago on the evolution of the HIV/AIDS epidemic identified three phases (Mawar, Sahay, Pandit, & Mahajan, 2005). First, the silent phase, when the virus spreads unnoticed, and develops over many years without being widely recognized or understood. Second is the epidemic itself, taking years to mature, characterized by the rapid spread of infectious disease within and across populations. Finally, in the third phase, the virus rises into public awareness, and explosive social, political, and cultural responses are characterized by exceptionally high levels of stigma, discrimination, and denial. These are the circumstances in which we currently find ourselves, and to which this block has been devoted. In India, HIV/AIDS stigma is now imposing severe hardships on the people who are its targets and it ultimately interferes with treatment and prevention of HIV infection (Mawar, et al., 2005). While these issues require urgent attention, addressing them will take a long-term commitment. Critical concerns include: a ) b ) attempting to theologically and morally blame a PLHA use of presumed risk group categories to give false assurance that they, and not we, are vulnerable to the virus, and problems related to enforcement of civil and human rights.
c )
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The latter lies at the heart of prevention and treatment programme success (Mawar, 2005). Advocacy and enforcement of human rights would minimize erosion of social, economic, cultural and political impacts of the pandemic. As indicated at the start, none of this will be easy. Human nature may be as old as the human race, and maturation into a full appreciation of the rights of others as equal to our own, will require stamina and determination to achieve.
Conclusion
Social workers play a central role in responding to social problems. In this chapter, we have seen that despite their best intentions and motivations, they may also contribute to the very problems they seek to address. Stigma and discrimination are deeply rooted in the human condition, as we seek to manage our fears by identifying targets to blame and shame for our discomfort and distress. Since the virus takes no notice of our human limitations, the longer we deny the truth of our situation, higher the chances of its spread. In the context of HIV/AIDS, these dynamics have developed into a worldwide pandemic threatening the well-being and stability of entire societies. Fortunately, as we have seen, there is much that can be and is being done to address the medical and social aspects of this disease. As a result, we have the opportunity to learn much about ourselves as individuals, and to better understand the aspects of our communities and cultures that are truly lifesustaining rather than life-threatening. In turn, as professionals, social workers are uniquely situated to take advantage of this knowledge, and convert it into strategies for confronting the crisis posed by HIV/AIDS. By looking to our own resources and creativity, and drawing liberally from the wealth of resources and
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strategies now emerging in the professional literature, we have the chance to truly make a difference in the public health challenge of our age.
References
Academy for Educational Development, International Center for Research on Women, International HIV/ AIDS Alliance (June, 2007). Understanding and challenging HIV stigma: Toolkit for Action (Revised Ed.). Retrieved November 6, 2008 from http:// www.aidsalliance.org/custom_asp/publications/ view.asp?publication_id=255. Engenderhealth (2004). Reducing stigma and discrimination related to HIV and AIDS: Training for health care workers. Retrieved November 8, 2008 from: http://www.engenderhealth.org/files/pubs/ hiv-aids-stis/reducing_stigma_ participant_ English.pdf International Center for Research on Women (August, 2006). Reducing HIV/AIDS stigma, discrimination, and gender-based violence among health care providers in Andhra Pradesh, India. Information bulletin. Retrieved November 13, 2008 from: http:/ /www.icrw.org/docs/2006_ibreducingviolenceandstigma.pdf. Heijnders, M., and van der Meij, S. (2006). The fight against stigma: An overview of stigma-reduction strategies and interventions. Psychology, Health, & Medicine, 11(3), 353-363. International HIV/AIDS Alliance in India (September, 2008). Together now India Newsletter, 1(1). Retrieved on January 24, 2009 from: http://www. aidsalliance.org/graphics/secretariat/ publications/Together_now_India_Newsletter1.pdf
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International HIV/AIDS Alliance (2007). Understanding and challenging HIV Stigma: Introduction and Module A. Retrieved on November 8, 2008 from: http:// www.aidsalliance.org/graphics/secretariat/ publications/1Stigma_Intro&A.pdf Knight, L. (May, 2008). UNAIDS: The first 10 years, Joint United Nations Program on HIV/AIDS (UNAIDS): Geneva, Switzerland. Retrieved November 9, 2008, from: http://data.unaids.org/pub/Report/2008/ 200810_first_10_years_en.pdf Mawar, N., Sahay, S., Pandit, A., & Jahajan, U. (2005). The third phase of HIV pandemic: Social c on se q ue nc es of H I V/ AI D S st ig m a an d discrimination and future needs, Indian Journal of Medical Research, 122, 471-484. Ogden, J., & Nyblade, L. (2005). Common at its core: HIV-related stigma across contexts. Retrieved September 9, 2006, from http://www.icrw.org/ docs/2005_report_stigma_synthesis.pdf#search=% 22common%20at% 20its%20core%22 Rutledge, S., & Abell, N. (2005). Awareness, acceptance, and action: An emerging framework for understanding AIDS stigmatizing attitudes among community leaders in Barbados, AIDS Patient Care and STDS, 19, 186-99. Sartorius, N. (2006). Lessons from a 10-year global programme against stigma and discrimination because of an illness, Psychology, Health, & Medicine, 11(3), 383-388. UNAIDS (2007). Reducing HIV stigma and discrimination: A critical part of national AIDS programmes. Geneva: Joint United Nations Programme on HIV/AIDS. Retrieved October 2, 2008 from http:// data.unaids.org/pub/Report/2008/jc1420stigmadiscrimi_en.pdf
Nemthiangai Guite
20
Best Practices in HIV/AIDS Prevention and Education

*Nicole Cesnales
Introduction
HIV prevention programs have been developed and tested worldwide since the onset of the epidemic, beginning in North America and spreading across the globe. As we will see in this chapter, much has been learned through trial and error about best practices, and so now, the exchange of information is bidirectional, as social workers from around the world strive to learn from each other, on how best to serve their clients. In every country, a primary challenge has been determining what is needed, and adapting methods responsive to the specific cultural, social, economic, and political climates, in which they must be implemented. In the previous units on HIV/AIDS, we have explored the basics of viral transmission and examined how certain segments of any population come to be seen as at high risk for acquiring the virus. Here, we will examine how evidence-based techniques for helping such persons understand their risk and how to minimize it, have been identified and applied. We will note specific techniques developed for women, drug users, men who have sex with men (MSM), and youth. Briefly, we will overview their origins, use, and demonstrated effectiveness in the United States and India, appreciating
* Nicole Cesnales, Florida State University, USA
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the similarities and differences across cultures. Additional readings are identified for those seeking further detail.
A Brief History of HIV Prevention Programs in the United States

In 1981, the first cases of what is now known as HIV were reported in the United States. The populations hit hardest in the United States were men-who-have-sexwith-men (MSM), intravenous drug users (IDU), women (especially commercial sex workers and partners of IDUs), and ethnic minorities. Because of the stigma associated with risk factors for infection, there were (and continue to be) great barriers to overcome in developing effective prevention programs. In the beginning, the Centers for Disease Control and Prevention (CDC) worked to identify the cause of the infection, developed and disseminated treatment guidelines for infection, and worked to prevent the spread of further infections. Historically, these efforts focused on three approaches (Wolitski et al., 2006): ( ) prevention activities directed at persons at high risk 1 for contracting HIV; ( ) HIV counseling, testing, and referral services, and 2 ( ) prevention activities directed at improving the 3 health of persons living with HIV and preventing further transmission Primary Prevention In the United States, prevention activities directed at those most at-risk for HIV started as grass-roots efforts among gay men in large metropolitan areas. The goals of these programs were to increase awareness about HIV/AIDS, dispel myths and ease fears about the spread
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of the disease, and most importantly, impart knowledge about how people can take precautionary measures against infection. The CDC followed these efforts in the mid-1980s by generating public health messages tailored to youth, persons at increased risk for HIV including MSM and IDU, racial and ethnic minority populations, pregnant women, as well as health-care workers. These messages stressed the importance of abstinence, the consistent and correct use of condoms, avoiding sharing needles when injecting drugs, perinatal testing and treatment, and universal precautions in the medical field. While these messages were essential in initiating behavior change, infection rates continued to increase among those most at risk for infection. As a result, behavioural interventions were subsequently developed and refined to provide more intensive and targeted prevention techniques. In 1999, the CDC developed the Compendium of HIV Prevention Interventions with Evidence of Effectiveness (revised in 2003), to disseminate effective prevention methods to community agencies. The present unit would expose the reader to a brief overview of techniques studied and reported in the Compendium, and compares them to current efforts being carried out in developing nations. While each study reviewed here varies on the research methodology, each meets a standard of scientific rigour of best available evidence. HIV Counseling, Testing, and Referral Services In 1985, the US Food and Drug Administration (FDA) implemented wide spread testing for HIV-antibodies in blood banks, health departments and health clinics throughout the United States. Testing of individuals includes anonymous or confidential screening, risk reduction counselling and, on HIV+ results being available, referral for treatment. Originally, testing
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required two visits. First, the individual was screened for risk factors, counselled on risk reduction, and a blood sample was drawn. In about two weeks, the individual would return for results. This two week long delay, often resulted in attrition, with as many as 50 per cent of the individuals failing to return for their test results (Branson et al., 2006). Since that time, many developments in testing procedures have occurred. Most promising is the development of rapid testing. An oral swab collected during the screening, allowed results to be provided within 20 minutes. During the 20 minute wait, risk reduction techniques are discussed. While this new test has greatly reduced attrition in testing and screening, there was still concern that not all individuals at risk for HIV, were being screened. To address this concern, the CDC has recommended that HIV screening be adopted into routine medical care for all individuals. Recommendations further support the development of programs to make HIV testing and counselling more attractive to those at highest risk. This often involves testing in non-traditional settings such as juvenile detention centers, churches or temples, and on the street through mobile health education. Prevention with HIV Positive Individuals Historically, prevention efforts in the United States focused on educating those at risk for infection, aiming to reduce their risk and further prevent the spread of HIV. Public health campaigns and messages were directed to individuals who were not infected, but at risk for infection; gay men, intravenous drug users, and women, for example. However, in 2003, the CDC made recommendations to shift prevention efforts to HIV+ people. Often referred to as secondary prevention, these efforts aim to reduce transmission of infection among those at highest risk for infection (the known partners of HIV positive individuals) and to also reduce the risk
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of re-infection among positive individuals. The impetus for this change was that despite twenty years of prevention efforts, diagnosis of new infections in the United States held steady at an estimated 55,000 individuals per year for the last decade (Hall et al., 2008). Furthermore, evidence revealed that while individuals reduced their risk for infection after receiving prevention messages and counseling, the change in behavior was not sustained over time (del Rio, 2003). The goals of secondary prevention are to promote selfprotection, partner protection, and disclosure to partners, and the early detection and referral for treatment. While studies suggest that prevention with positives is possible in India (Mcgrath et al., 2007) overcoming stigma to implement this type of intervention is a challenge.
Prevention with Women

United States Prevention efforts in both the United States and in developing nations have targeted women for many reasons. Women often live in situations that do not afford them the same power as men. Furthermore, women are biologically at higher risk for HIV infection than men, due to more accessible permeable membranes during sexual penetration. Finally, to reduce mother to child transmission, prevention interventions target women who are pregnant or may become pregnant. Interventions with women in the United States vary. The most frequently employed intervention involves group level cognitive-behavioral risk-reduction skills training. Group interventions that stress gender pride, personal responsibility, sexual assertiveness and communication, condom use, and coping skills showed improvement in consistent condom use among African
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American women (DiClemente & Wingood, 1995). The most notable of these interventions is the Sisters Informing Sisters About Topics on AIDS (SISTA) intervention. Participants in the SISTA program increased condom use and assertiveness with partners (DiClemente & Wingood, 1995). The overwhelming evidence supporting this intervention has resulted in the CDC adopting and promoting this intervention. Research demonstrated that group sessions with innercity, single, pregnant women also resulted in an increase of condom (Hobfoll, Jackson, Lavin, Britton, & Shepherd,1994) and a decrease in unprotected sex (Kelly et al., 1994). These group interventions incorporated role playing and viewing short videos, and stressed skill building and behaviour change. Baker et al (2003) demonstrated that skills training is more effective in reducing sexually transmitted infections than health education alone. India Many socio-economic factors contribute to increased risk for HIV among women in India. Strict gender roles that limit a womans power in sexual relationships can lead to violence and sexual exploitation. Women in India have limited control in negotiating safer sex practices. Furthermore, women may have limited access to information regarding HIV, and preventive and protective resources, such as condoms and health care. Women living in rural areas of India are not utilizing prenatal testing for HIV (Sinha et al., 2008). Reasons include lack of information and inadequate resources for HIV testing. Another concern is the social costs incurred by women who test positive for HIV. Women are often blamed for spreading HIV to family members and face exclusion from their husbands household. Clearly, the stigma associated with an HIV diagnosis for women can be
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devastating. Pant Pai et al (2008) highlighted the barriers to HIV testing, and intervened by providing on-demand rapid testing to all women who appeared at one rural hospital for delivery. Rapid testing was available 24 hours a day, seven days a week. Ninety-eight percent of the women approached for this study accepted HIV testing, with 15 women testing positive. These women were provided with prevention of mother-to-child HIV transmission (PMTCT) measures. As a result, 13 infants were HIV negative at birth, and at one and four months follow-up. Two infants were HIV positive at birth and died within a month of delivery. The implication here is that HIV prevention counselling and testing with pregnant women is essential for the prevention and control of HIV infection among the unborn children. While this most recent study demonstrates that testing of pregnant women in rural hospitals is feasible, The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme was started in India in 2002. It offers counselling and testing to pregnant women in 11 major hospitals in the five high HIV prevalence states (NACO, Prevention of Parent to Child Transmission section, para. 1). The National AIDS Control Organization (NACO) in India, has identified female sex workers (FSW) as one of the populations at highest risk for infection, and has developed targeted interventions. These aim to provide awareness of HIV and promote safer sex techniques, through peer-led community outreach and referral for STI treatment; as well as through empowerment involving advocacy, education, crisis management, and ownership of prevention services by FSWs. The most notable intervention with FSW in India is the Sonagachi Project (Jana, Basu, Rotheram-Borus, & Newman, 2004). Based in Calcutta since 1991, the Sonagachi Project addresses community, group, and
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individual factors. Community level interventions identified sex workers as key stake-holders and stressed political advocacy. Group-level interventions employed peer-outreach workers who develop social relationships with FSW. The outreach workers inquired about the immediate health problems of the FSWs, assisted in resolving them,disseminated HIV information as well as distributed condoms, as well as provided medications to FSW for STIs. Individual interventions emphasize skills and competencies, social cognitive perceptions, and social service delivery to eliminate barriers (e.g. illiteracy and financial stress). The skills and competencies stressed by the Sonagachi Project include HIV and STI awareness and prevention techniques, including correct and consistent condom use. Outreach workers modelled positive outcomes, most importantly, self-respect. Empowerment of FSW is the foundation for success. Changing perceptions involved adopting a set a rights for FSW. These include the right to speak out, good health, freedom of movement, fulfillment in a relationship, and the right to educate their children (Jana et al., 2004). Changing the FSWs self-image resulted in enhanced hope, as well as empowerment to change high-risk behaviors. Program designers stress that effective prevention efforts, must be cost effective, useful, realistic, evolving, and sustainable (Jana et al., 2004). Until treatment for STIs is more common and available, efforts such as the Sonagachi Project are rare, but essential in changing risk behavior for HIV infection.
Prevention with Drug Users

United States Considering the fact that drug users are at an increased risk for HIV infection, studies have evaluated prevention
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interventions tailored for them. Though still dramatically stigmatized in the United States, substance abuse treatment is available. Treatment frequently entails inpatient detoxification and psychological counselling. It is during this treatment that HIV counselling and screening may be undertaken. However, many drug abusers do not seek this treatment, limiting opportunities for HIV prevention interventions and requiring creative alternatives. One early study (Des Jarlais, Casriel, Friedman, & Rosenblum, 1992) employed group sessions to non-injection heroin users in a community store front located in a high drug trafficking area. The groups presentations and role playing that ensued, resulted in the participants being less likely to inject drugs. Other effective group interventions include women in methadone maintenance programs (El-Bassel & Schilling, 1992). The five-session curriculum entails HIV transmission and prevention, condom use, and assertiveness training. Assertiveness training advocates for the expression of the right to refuse sexual advances and to negotiate safer sex practices. At the end of the sessions, women reported increased condom use with their partners. While this model may not be appropriate for women living in India, there are components that can be adapted in a culturally sensitive manner to those most at risk. More recent interventions include the Self-help in Eliminating Life-Threatening Diseases (SHIELD) Project (Latkin, Sherman, & Knowlton, 2003), incorporating social networking and peer outreach among both HIV positive and HIV negative current drug users. Participants were trained to provide outreach and riskreduction counselling. SHIELD stresses on developing a sense of community for current drug users, and emphasizes harm reduction aiming to decrease the potential dangers and health risks associated with risk
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behaviour while at the same time recognizing that the risk behaviour itself may not be eliminated entirely. Throughout the intervention, participants were encouraged to conduct HIV education and advocate risk reduction among their sex and drug partners, family and friends, and other community members (Latkin et al., 2003, p. 334). Participants reported less sex and drug risk behaviors six months following the intervention. India NACO has identified IDUs as being at highest risk for infection in India, endorsing detoxification and rehabilitation, needle exchange, and access to health services to IDUs to reduce risk and prevent further disease transmission. Partners of IDUs are also at increased risk for infection. A study in Manipur demonstrates how much these individuals are at risk. Within seven years of the onset of an explosive HIV epidemic among IDUs, 45% of the wives of HIV positive IDUs acquired HIV through sex within monogamous marital relationship (Panda, Azim, Rehman, Poudel, & Chaudhuri, 2007, p.896). Clearly, prevention interventions among IDUs are needed. Methods to achieve prevention goals are similar to those employed with FSW; peer led community outreach and information dissemination, referral health services, and communitybuilding. Still, the stigma of substance use is a formidable barrier to effective prevention efforts. Community building calls for involving key stakeholders, including IDUs, local officials, and health care providers to communicate issues and concerns and developing consensus. Hangzo et al. (1997) developed an intervention with IDU in Manipur. To successfully implement the intervention, researchers first worked with community officials to prevent police and military
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harassment of outreach workers and IDUs. Next, outreach to IDUs utilising the social networks was undertaken and it included family and friends. Outreach workers from varying ethnic backgrounds were trained to conduct prevention outreach in the community. Outreach workers distributed prevention information and made referral for medical care, meeting IDUs in shooting galleries, drop-in centers, treatment centers, and jails. This study clearly demonstrated that a community level intervention with IDUs can be implemented. Finally, the Society for HIV/AIDS and Lifeline Operation in Manipur (SHALOM) located in Churachandpur, is a community-based organization that conducts a syringe and needle exchange program (SNEP). Components of SNEP include a facility where IDUs can go to exchange used syringes for new ones and get free condoms, and outreach workers who assess social and medical needs. While this program is effective in reaching those IDUs, more than three-fourths of the users of SNEP were HIV positive and reported engaging in high-risk sexual behavior (Eicher, Crofts, Benjamin, Deutschman, & Rodger, 2000). These researchers encourage SHALOM SNEP to expand their outreach efforts to newer IDUs, and to increase sexual risk prevention education.
Prevention with MSM

United States In the United States, HIV first involved men-who-havesex-with-men. The most common empirically supported methods for interventions include outreach in the community and small, peer-led groups. Kegeles, Hays, and Coates (1996) combined community outreach, a social marketing campaign, and a small peer-led group intervention to demonstrate that participants reduced
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frequency of unprotected anal intercourse. Small group interventions often employ role-playing and lectures to develop risk reduction skills. HIV risk reduction, behavioural self-management, assertiveness skill training, relationship skills and social support development are components of an effective intervention with MSM, resulting in reported reduction of unprotected anal intercourse and an increase in condom use (Kelly, St. Lawrence, Hood, & Brasfield, 1989). In addition to skills-training, some small group interventions work to promote the social acceptability of safer sex (Valdiserri et al., 1989). Outreach efforts must be creative and adapted for the targeted population and intervention setting. Frequently, interventions take place where MSM socialize. Training gay men to effectively promote HIV risk reduction behaviors followed by disseminating this message to peers proved an effective intervention in gay bars (Kelly et al., 1991). Other times, individual counselling may be the most appropriate intervention. Because MSM in the United States have been the most frequently targeted population for HIV prevention messages, interventions can become stale. Prevention fatigue has been cited as one possible reason that MSM continue to engage in high-risk behavior. To address this issue, Dilley, et al. (2002) adapted prevention messages during counselling and testing with MSM to create a new intervention with this population. Participants were asked to keep journals of sexual encounters between counseling sessions, and to indicate reasons for engaging in unprotected anal intercourse. The primary focus was how participants justified unprotected sexual activity. At follow-up, participants reported a decrease in unprotected anal intercourse.
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Clearly, both group and individual level prevention interventions MSM are feasible and effective in reducing unprotected sexual risk behavior. Determining whether these reduce rates of infection is harder. EXPLORE (Koblin, Chesney, & Coates, 2004) consisted of ten individual counselling sessions focusing on risk behaviour, including sexual and substance abuse. These sessions were highly intensive, and incorporated motivational interviewing and cognitive behavioral therapy (CBT). On completion, participants registered 18.2% fewer new HIV infections (Koblin et al., 2004). India Men-who-have-sex-with-men is a description of a sexual activity between two men. It does not address the sexual identity or orientation of the males involved. MSM may see himself as homosexual, bisexual, or heterosexual. He may have both male and female partners regardless of his sexual identity. If he is a sex worker, he may see his sexual activity as merely a means to earn money and support his family. He may perceive sexual activity between men as an expression of his masculinity or femininity. Regardless of how the MSM thinks of his behavior, often times, MSM are stigmatized, discriminated against, and even criminalized. Complex cultural, religious, moral, and political structures impact the lives of MSM. The result is often an invisible population of men at high-risk for HIV. The frequent discounting of MSM in India may result in inaccurate or conflicting estimates of the rates of HIV infection. For years, researchers have recognized that government estimates of the number of MSM and their HIV prevalence in India are inexact (Godbole & Mehendale, 2005). In response, a randomized crosssectional analysis was conducted in Chennai in 2001, demonstrating that 5.9% of the men surveyed reported
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that they have had sex with men and were more likely to be HIV positive than men who did not report samesex encounters (Go et al., 2004). Other cross-sectional studies demonstrated that in rural regions of India, nearly 10% of single and 3% of married men had had unprotected anal sex with a man (Verma & Collumbien, 2004, p. 1854). In addition, there have been very limited empirically supported studies of HIV prevention for MSM, though there are qualitative and ethnographic studies, often focusing on the anthropological phenomenon of identity development, Hijras, and Kothis (Boyce, 2007). Other studies explore the sexual behaviors and experiences of MSM in India (Chakrapani, Newman, Shunmugam, McLuckie, and Melwin, 2007; Sri Krishnan et al., 2007). NACO nevertheless identifies MSM as a high-risk population. Targeted interventions to MSM are designed to minimize the spread of infection to the general population, as was seen with FSW. Prevention interventions with MSM emphasize the importance of peer educators, promotion of behaviour change, access to and the use of condoms. One organization that has been essential in prevention efforts with MSM in India is Naz Foundation International (NFI). Since its inception in 1996, NFI has worked to assist communities in capacity building for the advocacy for the rights of MSM and HIV prevention. While there are other NGOs that conduct prevention and outreach to MSM (e.g., Sahodaran, The Social Welfare Association for Men and The Indian Community Welfare Organization) there are no identifiable evaluations of the efficacy of these agencies and interventions. One possible explanation is that these agencies face many barriers, including harassment from police and other government officials (Safren et al., 2006).
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Still, preventative interventions must continue in order to curtail the spread of HIV. One highly effective intervention is male circumcision. Studies have demonstrated that male circumcision is effective in reducing the spread of HIV. Comparing rates of infection between circumcised and uncircumcised men, one study demonstrated that among Indian men, circumcision resulted in a 6.7 fold reduction in the rate of infection (Reynolds et al., 2004). Clearly, there is a demonstrated need for prevention with this population. Despite the overwhelming barriers faced by MSM and MSM outreach workers, there are interventions that are effective. However, it may be the process of tackling the barriers to prevention with MSM that proves to be the most significant task.
Prevention with Youth

United States Prevention efforts with adolescents and young adults in the United States began in the 1980s. A large literature exists on effective interventions designed for youth. Youth are at an increased risk for HIV due to biological, psychological and social factors, including peer pressure and the natural tendency to explore a developing sense of sexuality. Culturally and ethnically appropriate group interventions are often used. One such intervention for adolescent males held at an inner-city school on a Saturday morning incorporated games, videos, and exercises. Students were taught about safer sex practices including condom use and abstinence, and participants reported more frequent condom use and fewer sexual partners (Jemmott, Jemmott, & Fong, 1992). Other culturally appropriate interventions for lowincome African Americans have been implemented in
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recreation centers in public housing developments (Stanton et al., 1996). One involved peer group learning during multiple group sessions. Discussions focused on values, goal setting, HIV transmission and prevention, human development, and contraception. Storytelling and role playing were also employed, and sexually active adolescents reported greater condom use after participation. St. Lawrence et al. (1995) also studied the effects of a cognitive behavioral intervention with African American adolescents. The Becoming a Responsible Teen (BART) intervention is an eight week intervention for inner city youth at a public health clinic for low-income families. Topics included AIDS education, sexual decisions and values, technical skills, social skills, cognitive skills, and empowerment. Findings showed greater condom use, reduced frequency of unprotected intercourse, and delay in sexual activity onset. Other interventions include adapting school curriculum. Reducing The Risk (Kirby, Barth, Lelan, & Fetro, 1991) addressed the need for HIV education in large school districts. Based on social learning and cognitive behavioral theories, it develops social skills to reduce sexual risk taking behaviour, and employs role playing activities in the classroom. Students learn how to communicate with partners about delaying sexual activity. Students receiving the intervention were less likely to initiate sexual activity and to engage in unprotected sexual intercourse. These interventions demonstrate that youth can be reached in a variety of settings, including the school, the health care facility, or the neighborhood. A small group intervention to runaway youth in New York City (Rotheram-Borus, Van Rossem, Gwadz, Koopman, & Lee, 1997) was designed based on social learning theory, and focused on reinforcing positive behaviors.
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Participants were taught about HIV transmission and prevention, used role playing to develop social skills, explored available resources, and discussed attitudes and norms. Results included less unprotected sexual encounters and a reduction in substance use following this intervention (Rotheram-Borus et al., 1997). Clearly, designing, implementing, and evaluating interventions for youth is challenging. The following guidelines for interventions targeted to youth have been recommended (DiClemente et al., 2008):
l
tailor interventions to meet the needs of the population; target those behaviors most amenable to change; utilising the family as a behavioral change agent; expand the scope of STI/HIV intervention programs, beyond individuals; incorporate long-term maintenance strategies into interventions; incorporate biological outcomes as a measure of program efficacy; and yranslate and disseminate effective STI/HIV interventions.
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These recommendations for best practice are clearly visible in the Sistering, Informing,Healing, Living, and Empowering (SiHLE) Project (DiClemente et al, 2004), serving African American adolescent females recruited from community health centers. The intervention involved four group sessions which stressed ethnic and gender pride, HIV transmission and prevention, skills building, communication and healthy relationships. Participants reduced new sexual partners, and improved consistent and correct condom use. As a result, SiHLE Project has been adopted by the CDC as a model for
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effective intervention with adolescent African American females (Wingood & DiClemente, 2006). India The United States Presidents Emergency Plan for AIDS Relief (PEPFAR) provides funding for HIV treatment and prevention in developing nations. A key component to PEPFAR funding is implementing the ABC approach to prevention. ABC stands for Abstinence, Be Faithful, and Correct and Consistent Condom Use. While ABC is not an actual intervention or program, it is a fundamental philosophy embraced by PEPFAR to guide population specific interventions globally. The principle components include delaying sexual activity for non-married individuals, ending casual sexual activity, eliminating cross-generational transactional sex, focusing on marital fidelity, adopting correct and consistent condom use and HIV counseling and testing. PEPFAR supports NACO in its prevention efforts, including efforts directed toward youth. There are a disproportionate number of youth infected with HIV in India; 31% of the identified cases with HIV occur in individuals, between the ages of 15 and 29 years (NACO,, Youth section). Young people are faced with many challenges which place them at high risk for HIV including changing bodies, family concerns, social and cultural influences, gender imbalances, economic and financial struggles, and the pressures of a changing world. Globalization and urbanization compete with traditional cultural values and beliefs, and teens are often conflicted. Young girls face different pressures than boys based on differing socially accepted gender norms. Starting at a young age, youth may need to contribute to the family income, be forced to work long hours, and sacrifice formal education for family survival. These contributing factors lead to an increased vulnerability for HIV among youth in India.
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To address these needs, several initiatives have been endorsed by the Indian government, including the National Population Policy, the National AIDS Prevention and Control Policy, the National Youth Policy and the Reproductive and Child Health (RCH) Programmes. NACO has created multiple interventions targeted towards youth, both in and out of school, which promote healthy, responsible lifestyles. The Adolescence Education Programme (AEP) incorporates HIV/AIDS prevention education into life-skills training curriculum delivered to school-aged youth. Included in this programme is the School AIDS Education Programme. The curriculum focuses on family life, human growth and development, abstinence, and life skills. Other programs include the Red Ribbon Club, HIV education programmes on college and University campuses, and Youth Unite for Victory on AIDS, providing life skill education and counselling to adolescents. Recently, a research team conducted brief HIV education intervention in seven villages in Western Rajasthan involving 78 girls between the ages of 12 and 19. Educational sessions consisting of visual aids were presented in local dialects. Topics included HIV transmission, prevention, and management. Myths about HIV were also discussed. A post test revealed significant increases in HIV knowledge among adolescent girls living in rural villages (Trivedi, Joshi, & Levine, 2008). These examples are just a few of the initiatives and programs designed to address the HIV prevention and education needs of youth living in India. For a more extensive review of these initiatives and other programs not discussed here, please refer to Young Peoples Sexual and Reproductive Health in India: Policies, Programs, and Realities, a regional working paper produced by the Population Council (Santhya & Jejeebhoy, 2007). Till
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date, there are few empirically supported studies evaluating the effects of these education programs, and results vary (Chhabra, Springer, Rapkin, & Merchant, 2008; Ghosh, Chhabra, Springer, & Sharma, 2008). Even fewer identifiable studies examine the efficacy of prevention interventions with high-risk adolescents in India. There is a dire need and great opportunity for social workers to develop, implement, and evaluate prevention interventions with high risk adolescents in India.
Conclusion
This chapter briefly outlines the history of HIV prevention efforts in the United States, and provides an overview of empirically supported prevention interventions for populations at highest risk for infection. Efforts currently implemented in India are also reviewed. The evaluation of the intersection of Western and Indian techniques provides a basis for adapting successful strategies for the unique population and cultural characteristics in India. You should now be able to identify the populations most at risk for HIV in India and begin generating ideas for social work supported prevention interventions for these people.
References
Centers for Disease Control and Prevention (2001, August 31). 1999 Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Retrieved September 2, 2008 from http://www.cdc.gov/hiv/ resources/ reports/hiv_compen dium/pdf/ HIVcompendium.pdf.
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HIV/AIDS: Stigma, Discrimination and Prevention

Editor Prof. Gracious Thomas

School of Social Work

Indira Gandhi National Open University, 2010

Social and Economic Implications

Socio-Cultural Context of HIV and AIDS

Treatment and Care, Vaccine Issues

Modes of Transmission and Prevention of HIV

HIV/AIDs among Women and Children

Hiv/Aids Prevention and Control: Governmental and United Nations Initiatives

10. Social Work Intervention in Prevention and Control of HIV/AIDS

11. Communication in HIV/AIDS Prevention

12. Models of Behaviour Change

13. Counselling For HIV/AIDS: Nature and Process

14. Issues and Types of HIV/ AIDS Related Counselling

15. HIV/AIDS and Legislations

16. Theories and Models of Stigma and Discrimination

17. Social Stigma: Universal and Culturally Specific

18. Provider Stigma: Social Service and Health Care Providers

19. Response Strategies for Social Workers

20. Best Practices in HIV/ AIDS Prevention and Education

AIDS: Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

Ways in which one can be infected with HIV:

AIDS, Nature and Demography

It is not possible to become infected with HIV through:

HIV/AIDS: Stigma, Siscrimination and Prevention

History and Origin of HIV/AIDS

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

The Hunter Theory

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

Minor Signs a . b . c . Generalized lymphadenopathy Oropharyngeal candidiasis Repeated common infection

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

Demography and Prevalence of HIV/AIDS

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

HIV/AIDS: Stigma, Siscrimination and Prevention

AIDS, Nature and Demography

Social and Economic Implications

Social and Economic Implications

HIV/AIDS: Stigma, Siscrimination and Prevention

Household Level Impact of HIV

Social and Economic Implications

HIV/AIDS: Stigma, Siscrimination and Prevention

Social and Economic Implications

HIV/AIDS: Stigma, Siscrimination and Prevention

Social and Economic Implications

HIV/AIDS: Stigma, Siscrimination and Prevention

Social and Economic Implications