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The groups most affected by HIV/AIDS
Migrants
Sex Workers
Injecting Drug Users (IDUs)
Truck Drivers
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 is moving beyond these groups in some regions and into
the general population. It is also moving from urban to rural
districts.
"In some parts of India, particularly the states
that are reporting the higher prevalence, the tipping point is long
past. I think there is absolutely no doubt that the virus is moving
into the general population." Dr. R. Feachem, executive director of
the Global Fund to Fight AIDS, Tuberculosis & Malaria
In July 2003, Dr. Meenakshi Datta Ghosh, project
director for NACO, stated that HIV/AIDS no longer affects only
high-risk groups or urban populations, but is
"gradually spreading into rural areas and the
general population."
The epidemic continues to shift towards women and
young people. It has been estimated that 38% of adults living with
HIV/AIDS in India as of 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.24 The increasing HIV prevalence among women can
consequently be seen in the increase of mother to child transmission
of HIV and paediatric HIV cases.
The majority of the reported AIDS cases have occurred in the
sexually active and economically productive 15 to 44 age group. The
predominant mode of HIV transmission is through heterosexual
contact, the second most common mode being injecting drug use.
Previously blood transfusion and blood product transfusion were also
major causes, but blood safety measures are now in place to prevent
such transmission.
The majority of the reported AIDS cases have
occurred in the sexually active and economically productive 15 to 44
age group. The predominant mode of HIV transmission is through
heterosexual contact, the second most common mode being injecting
drug use. Previously blood transfusion and blood product transfusion
were also major causes, but blood safety measures are now in place
to prevent such transmission.
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Migration of economically productive sections of the
population is a common phenomenon all over India. According to the
1993 National Sample Survey in India, 24.7% of the population had
migrated, either within India, to neighbouring countries or
overseas. Applying this percentage to the mid-2003 population 25
about 264 million Indians are mobile.
"Being mobile in an of itself is not a risk factor
for HIV infection. It is the situations encountered and the
behaviours possibly engaged in during mobility or migration that
increase vulnerability and risk regarding HIV/AIDS."
Most of the migrant workers are highly mobile and
often live in unhygienic conditions in urban slums. Long working
hours, relative isolation from the family and geographical mobility
may foster casual sexual relationships and 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. Cultural and language barriers worsen their lack of
access to such services as do exist. Returning or visiting migrants,
many of who do not know their status, may infect their wives or
other sex partners in the home community.
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Although sex work is legal in some states,
associated activities including soliciting and brothel keeping are
penalised. Often women get involved with sex work because of poverty
or marital break-up or they are forced into it.
Mumbai has the country's largest brothel based sex
industry, with over 15,000 sex workers. It is estimated that in the
region of 70% of the sex workers in Mumbai are HIV-positive. Sex
workers in Mumbai are controlled by madams, pimps and moneylenders
and because of this, reaching sex workers with HIV prevention is a
major challenge. A study in Surat found that HIV prevalence among
sex workers had increased from 17% in 1992 to 43% in 2000.
A positive outcome of a prevention program amongst
sex workers can be found in Sonagachi, in central Kolkata
(Calcutta). The education program initially targeted about 5,000
female sex workers. A team of two peer workers carried out outreach
activities including education, condom promotion and follow-up of
STI cases. When the project was launched in 1992, 27% of sex workers
reported condom use. By 1995, this had risen to 82% and in 2001, it
was 86%.
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HIV infections among IDUs first appeared in Manipur.
In Manipur City, the level of HIV infection increased from 61% in
1994 to 85% in 1997 and in 1998 it was 80.7%. Injecting drug use is
also a major problem in urban areas such as Mumbai, Kolkata, Delhi
and Chennai.
In India drugs are often used in open public places
such as the roadside, parks, playgrounds and market complexes.
Although India does not appear to have a widespread culture of
professional injectors or 'street doctors', as in some Asian
countries, there do appear to be shooting galleries where IDUs come
to inject.
Generally, syringes and needles are purchased from
pharmacies without any need for prescriptions, and although they are
regarded as inexpensive many drug users tend to focus on buying the
drug rather than purchasing new injecting equipment. The sharing of
equipment among India's IDUs is widespread. Recent data indicate
that most IDUs had at some stage shared their needle and syringe.
The majority of drug users in India are male.
According to a study in the capital of Manipur, the prevalence of
HIV infection in female IDUs was 57% compared to 20% among female
non IDUs.31 However, use of drug treatment data may underestimate
the number of female drug users, with women addicts being
predominately a hidden population. In the northeast of India, there
are increasing numbers of young widows of addicts, many who are
HIV-positive as a result of having been infected by their
husbands.32 With the reported increase of HIV infection among wives
and children of IDUs, this is highlighting the crucial need to reach
the sex partners of IDUs with prevention, education, care and
support services.
There is no government policy for harm reduction,
leading to a lack of coordination in designing and implementing
interventions. Some states, such as Manipur, have adopted their own
harm reduction policies and consider that:
"Harm reduction is the urgent, practicable and
feasible HIV prevention method among Injecting Drug Users and their
sex partners."
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India has one of the largest road networks in the
world and an estimated 2 to 5 million long distance truck drivers
and helpers. The extended periods of time that they spend away from
their families place them in close proximity to "high-risk" sexual
networks, and often results in them having an increased number of
sexual contacts.34 During their journeys the drivers often stop at 'dhabas',
roadside hotels that usually provide food, rest, sex workers,
alcohol and drugs. They pick up the women, use them and leave them
at some other 'dhaba', where they are used by other drivers and
local youths. As a result, truck drivers are crucial in spreading
STDs and HIV infection throughout the country. A study published in
1999 showed that 87% of the drivers had frequent and indiscriminate
change of sexual partners, and only 11% of them used condoms
although their AIDS knowledge was fairly good.35 HIV prevalence
patterns in truckers have tended to mirror the local epidemics.
"There is no entertainment. It is day-in-day-out
driving...When they stop, they drink, dine and have sex with women.
Then they transfer HIV from urban to rural settings".
There have been a number of major HIV/STI prevention
projects aimed at truckers. Some of these projects include not just
truckers, but also other stakeholders such as gas station owners and
employees. A specific example from Mumbai is the AIDS Workplace
Awareness campaign which is mandatory and which targets the drivers
at the regional transport authority, where the drivers get their
licenses renewed annual.
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