Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

AIDS Intervention Strategies in India: A Socio-Political Approach Explaining Why They Are Ineffective – Nandini Ravishankar

India, a country with a population of one billion, is experiencing a rapid and extensive spread of AIDS. When HIV infection was discovered in India in 1986, the health authorities set up the National Aids Control Organization (NACO), which was primarily funded by the World Bank and technically supported by the World Health Organization (WHO) (9).

The current AIDS estimate suggests that the national adult HIV prevalence in India is 0.36 percent, amounting to between 2.5 and 3 million people. This number has seen a drop of nearly 50 % from the previous estimate of 5.2 million people living with HIV/AIDS (9). However despite a decrease in the overall number of people afflicted with AIDS, the current numbers are considerably high with most of the affected population losing out on the productive years of their lives. The prevalence rate for men is 0.43% while for women it is 0.29%. Prevalence is also high in the 15-49 age group (88.7% of all infections) indicating that AIDS still threatens the cream of society, those in the prime of their working life (20,23).

However, despite the work being done to tackle the crisis, there are some hurdles that may hamper the progress of the current interventions. Disparities still exist in the effectiveness and applicability of the interventions to vulnerable populations. The strategies adopted by the National AIDS Control Organization (NACO) to mitigate AIDS in India have been ineffective because social and political pressures prevent the right groups from being targeted.

1. Adolescents are not provided with adequate education about HIV/AIDS

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (1). The theory stressed that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. In Indian society, there is a high level of taboo associated with talking about sex. Much of the information is communicated through a non-verbal channel and there are estimates that about two-thirds of meaning is communicated nonverbally (13). When adolescents see their parents and other elders hesitating to talk about sex, it leads them to believe that sex is something to be embarrassed about and something that is negative in nature. Adolescents may also experience confusion as the message projected in the interventions may not be in line with their core values, the core values being ‘sex is not something to be discussed’. They are less likely to accept interventions that are against their core values and may thus dismiss the information and education provided.

As mentioned earlier, in India it is taboo to talk about sex and it is an even greater taboo for parents to talk about sex with their children. There have been many barriers that have been identified which impede parents from communicating with their children about sex and sexually transmitted diseases (STDs). Studies report that parents often feel inadequately informed, embarrassed and ineffective and have difficulty finding the right place and time for communication (12). Thus parents often do not talk about sex and the adolescent is reprimanded for asking questions about sex. Parental education allows the adolescent to incorporate the idea of sex in a way that is in line with their core values. This would enable the adolescent to be better informed and better adjusted to the concept of sex and sexually transmitted diseases. Parents can also tailor the presentation of information to the life circumstances and social and familial context of the adolescent (12).

In the absence of parental communication, adolescents often turn to other sources to get more information. Recent work has supported the position that peers are often responsible for the onset of risk behaviors in adolescents (25). This work implies that although teens acquire information regarding risk behaviors from parents, teachers and the media, peers may also play a crucial role in a child’s development by shaping his/her normative beliefs and interpretation of information regarding risk activities (24). Becoming a member of a peer group is one of the primary developmental tasks of adolescence (4). Peer groups influence adolescent socialization and identity by allowing young individuals to explore individual interests and uncertainties while retaining a sense of belonging and continuity within a group of friends (8). Although a key aspect of normal adolescent development, there may be costs associated with becoming a member of a group of people. Some have considered peer pressure the ‘price of group membership’ (3), which research has linked to a variety of potential problems including substance abuse, risk-taking behavior and delinquency as well as dating attitudes and sexual behavior. For many young persons, substance use, risk-taking behavior and sexual activity may represent efforts to ‘conform to the norms of the group and to demonstrate commitment and loyalty to other group members’ (15).

Another frequent source of information for adolescents is the media, which influences how adolescents think and is likely to have a great impact on their behavior. The modeling theory is particularly relevant to the study of mass communications because the portrayal or description of social life is a frequent subject in the media. The actors who portray real people in visual, auditory or print media often serve as role models for others to imitate (6). As seen with other behavioral influences, the negative consequences of risk-taking behavior are rarely mentioned in the media in a way that would provide adolescents with important information. In the current scenario, the message that adolescents get is that it is acceptable to indulge in risky sexual behavior without experiencing any negative consequences. This contributes to an increase in sexual risk taking behavior among adolescents as they believe in the ‘feel good’ message being projected without considering the reality of the situation (8).

2. Social Stigma attached to HIV/AIDS

In many Asian countries including India, homosexuality is still a taboo. The social ostracism is also evident from the fact that homosexuality is considered a crime by the Judicial System in India. The statute does not directly state the ban on homosexuality but follows a law that was set by the ruling British Government in 1860. The Indian Penal Code (Section 377) states that: “Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine”. The punishment for this crime ranges from 10 years to life imprisonment. The word ‘carnal intercourse’ being vague, it has often been used against homosexuality (21). To bring about change in the current status of the HIV/AIDS epidemic in India, drastic changes need to be brought about not only at the societal level but also at the judicial level.

Goffman (1963) defined stigma as any condition, attribute, trait of behavior that symbolically marked off the bearer as ‘culturally unacceptable’ or inferior with consequent feelings of shame, guilt and disgrace (10). There is a high level of stigma that is associated with HIV/AIDS and very often, people do not confess that they have the illness which explains why the heterosexual partner, in most cases the woman is afflicted with the virus as well. The spread of HIV in India has been at its peak in the Western and Southern part of the country (19). Stigma associated with HIV-AIDS negatively impacts people’s decision regarding whether and when to be tested for the virus (26). Stigma therefore is a crucial aspect that needs to be understood in the management of people with HIV/AIDS. Stigma not only exists in the general community but also exists within the homosexual community itself. Results of a study indicated that many HIV-positive gay men perceived a division within the gay community related to HIV/AIDS. Their perceptions that HIV-negative men held stigmatizing attitudes toward HIV-positive men included feelings of sexual rejection and discrimination (5).

Social stigma and ostracism against homosexuality are held not only by society, but by the families as well. Homosexual men often are faced with the difficulty of dealing with the cultural expectations of their parents. They experience parental pressure to get married, have children, carry on the family name and traditions and not bring shame to the family by individual behavior choices and nonconformity (2). As a result of these expectations, many homosexual men choose not to come out of the closet. This prevents them from obtaining and having access to the right preventive information regarding HIV/AIDS. The perceived failure of meeting parental expectations associated with the role of the son, as well as the shameful stigma associated with homosexuality often leads the gay son to hold negative emotions like guilt, shame, low self-esteem, social inhibitions and insecurities (2). Very often, homosexual relations are maintained in secret without the knowledge of the family and in such situations, safe sex and the use of condoms take a backseat as keeping the relationship secret becomes the first priority. Choi et al. (1998) also conducted another study where they found that family obligations and homophobia in the community, along with negative sterotyping, marginalization contributed to low self-esteem and in turn resulted in risk-taking and lapses to unsafe sex (2).

The law criminalizing homosexuality has led to interventions that are designed to tackle HIV/AIDS but have not taken into account the needs of the gay community. Few published research studies have delved into the lives, the minds and the hearts of gay men to understand their feelings, attitudes, experiences and values. As a result, the public health interventions have failed because they have not targeted the core values of one of their target audiences: the gay community (18). One example of a shortcoming evident in the HIV/AIDS intervention programs that stems from a lack of insight into the lives, feelings and experiences of gay men is the virtual disregard for risk reduction as opposed to risk elimination strategies and the reluctance to candidly discuss, rather than merely dismiss as deviant, unsafe sex. As a consequence of the failure of the interventions, a sense of hopelessness and complete lack of control has arisen among gay men (18). Because they do not really believe that they will use a condom each time, many men assume that they are destined to become infected and therefore see no point in using condoms at all (11). This is an important issue to consider when initiating HIV/AIDS interventions. The needs, feelings and attitudes of the gay community must also be included. Thus, to tackle the HIV/AIDS crisis in India, interventions must not only focus on the heterosexual population and youth but must also address the fears and concerns of the gay community.

While it is important to address the individual behavioral factors that contribute to HIV/AIDS, it is also important to contextualize the risk factors, that is, attempt to understand how people come to be exposed to the individually based risk factors to design more effective interventions. By this, interventionsists must use an interpretive framework to understand why people come to be exposed to risk factors and the circumstances that shapes their exposure to the risk factors (14). For example, it is important in the framing of interventions to contextualize the risk factors for HIV/AIDS which would give a better understanding of why some people cannot avoid the risk. In a patriarchal society like India, it is important to understand the reasons why commercial sex workers are unable to get the men to practice safe sex which consequently may lead to an increase in the levels of HIV/AIDS in the sex workers.

3. Political factors impede HIV/AIDS Interventions

In a developing country like India with a population of one billion, there are structural inequalities that come with the treatment of HIV/AIDS. There are often other diseases and illnesses which take precedence over AIDS and the social taboos often play a role in influencing political agenda as well (16). Parker (2002) reported that a range of structural inequalities intersect and combine to shape the HIV/AIDS epidemic. There is an increasing gap between the rich and poor states with regard to public resources available for health, with resultant disparities in health outcomes (16). A major political concern that interventions need to consider and address is the reduction in the role of the central government in health care delivery. With decentralization and privatization being the answer to fill the gap in health care delivery, safety nets for the poor, especially those in the rural areas are being threatened. According to the WHO, India continues to bear the burden of the highest number of tuberculosis patients (7). With TB being an overwhelming burden and the leading cause of death in the country, there is less emphasis and priority given to HIV/AIDS. NACO programs are also supplemented by state level agencies, with great variabilty in terms of emphasis given by each state to the HIV/AIDS crisis. Many states are still in denial about the spread of HIV/AIDS within the state and thus are unwilling to provide money to tackle the crisis (7). Thus in order to address these concerns, more HIV/AIDS interventions need to be conducted at the state level to ensure that all citizens of the country have access to the same level of services and state governments must be required to co-ordinate activities in accordance with NACO. The partisan views of the various political parties must be addressed and modified for any effective change to occur in HIV/AIDS interventions at the political level.

Framing according to Tversky and Kahneman (1981) is ‘focusing the attention of people within a field of meaning’. Framing theory suggests that how something is presented (‘the frame’) influences the choices people make. The agenda setting theory is also closely related to the Framing theory (22). This theory states that agenda setting not only tells individuals what to think of an issue but also how to think about that issue. The agenda setting theory states that in order to get people to pay attention to the information, they have to view it as important and relevant (27). Thus, the moral, core values and principles of the current ruling political party determine how the crisis of AIDS will be tackled. The framing and agenda setting theory explain why conservative political parties would be more likely to promote the thinking that commercial sex workers are the most high risk populations as this is in line with social thinking and is likely to garner them more election votes. Thus by projecting AIDS as an issue among heterosexual individuals, the conservative political parties ignore the presence of AIDS among the homosexual population.

The Health Belief Model (HBM) was developed to explain health-related behavior at the level of the individual decision maker. The Health Belief Model (HBM) proposes that individual health beliefs associated with a disease or medical condition (i.e. perceived vulnerability to HIV/AIDS) determines their likelihood of engaging in preventive health actions (eg: use of condoms to prevent exposure) (17). The interventions developed by NACO also operate on the same rationale. It is believed that as long as individuals are provided with the interventions, they will utilize it based on their health beliefs. However the model and the consequent interventions fail to take into account socio-cultural factors. According to Choi et al., HBM has limited utility in addressing environmental factors affecting HIV risk because they ignore the wider social context within which the individual must circulate such as the family, and any communities of which an individual may be a member (2). Furthermore, the model assumes that all behavior is the result of a cost/benefit analysis, of calculated rational thought following the principle of self-interest. The Health Belief Model views the individual as devoid of emotion even though interacting with the wider social environment may entail situational and emotional difficulties for the individuals that consequently affect HIV risk (2). As seen with the model, there is a tendency for those in power to operate with an ‘inside the box’ rationale and an unwillingness to explore new avenues for progress. Combined with the bureaucratic and political pressure, there is an increased likelihood of interventions being built on top of earlier interventions with few modifications. While this may work for a certain period of time, it is important to acknowledge that interventions need to change with the changing times.

Implications for Future Interventions and Policy Decisions

In the light of the above mentioned factors, future interventions undertaken by NACO must therefore take into account socio-political factors. The crisis of AIDS can be successfully addressed only when all individuals who are at risk of contracting AIDS are targeted to receive the interventions. By excluding a particular group or ignoring important factors that may impact the prevalence of AIDS, the current interventions exhibit a lack of informed implementation. Despite being the largest democracy in the world, India still faces political hurdles that diminish the effectiveness and applicability of public health interventions. With the AIDS epidemic being a threat to the population of the country, more steps need to be taken to tackle the concerns at the grass root levels. While the current interventions have been shown to be marginally effective, it becomes more imperative to develop interventions that don’t just follow what has been done before but which incorporate the concerns of the diverse at-risk populations. Changes must originate at the grass roots level and must address individuals in the rural and urban areas. Changes need to be brought about at the societal and the judicial level for the gay community to feel accepted and acknowledged. Only when interventions addressing all populations and all concerns are developed will the battle on HIV/AIDS be successful.


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