Tribal communities & HIV Fabian Tögel, MD, MPH Aktionsgemeinschaft Partner Indiens, e.V. Munich, Germany November 11 th, 2006

“Half of the world’s indigenous people live in India” (89 million, equivalent to the current population of the State of Bihar or the Philippines) Tribal identity differs from caste identity in terms of: language, social organization, religious affiliation, economic patterns, geographic location and self- identification “Primitive Tribes”: - low literacy - pre-agricultural technology - stagnant/diminishing population

8.1% of the population (89 million) Protected under constitutional schedules: 5 th (areas in Central India with >50% tribal population) and 6 th (in the Northeast) Tribal sub-plans under Integrated Tribal Development Agency (ITDA) Article 46 (promotion of interests, protection from exploitation), Article 47 (improve standard of living, promote public health) National Health Policy, 2002 (equitable access to health services) with reference to tribals

Social Assessment of HIV/AIDS among Tribal People in India A report submitted to the National AIDS Control Programme Phase 3 (NACP-III) Planning Team, New Delhi (May 2006) Data collection from one district each in Andhra Pradesh, Chhattisgarh, Maharashtra, Manipur, and West Bengal Review of social dimensions of other project preparation studies Consultations with tribal stakeholders and other participating agencies

Key findings of Social Assessment Low awareness and knowledge of HIV/AIDS and STIs Wide variation in sexual and marital practices Very low access to modern health facilities (especially women face social, physical and economic barriers to seeking healthcare) High use of traditional healers or unqualified practitioners High vulnerability among youth and those who come in contact with non-tribal populations (eg. migrants, women engaging in sex work)

Contact with high-risk groups (HRGs) Women: Truckers, contractors, tourists, defence personnel Men: CSW during migration Acting as HRGs: CSW, MSM or IDU (in Northeast) Other ways of acquiring HIV: Pre- and extramarital unprotected sex, unsafe injection and tattooing practices

NACP-3 Tribal Strategy & Action Plan : Classification of districts based on prevalence Level A: High prevalence district Level B: Concentrated epidemic Level C: Vulnerable population Level D: Low prevalence, low/unknown vulnerability Accordingly, the district will see varying numbers of services including ICT, PPTCT, STI/OI care, ART, presence of link workers.

Implementation of Tribal Action Plan Mapping of vulnerable populations in collaboration with the Integrated Tribal Development Authorities (IDTAs) Translation of IEC material by Tribal Research Institutes for behavior change communication, condom promotion; referral to ICTC and ART services Compensation for travel and related expenses Targeted interventions for migrant workers Involvement of CBOs/NGOs

Challenges Mainstreaming: Collaboration with the Ministry of Tribal Affairs, Ministry of Social Justice & Empowerment, Ministry of Human Resource Development (Education) Integration into National Rural Health Mission (NRHM), Reproductive & Child Health Phase 2 (RCH-2), Revised National TB Control Programm (RNTCP)

NGO initiatives to prevent HIV among tribals in Jhabua district, Madhya Pradesh District profile: Borders with Rajasthan, Gujarat, Maharashtra Population: 1.4 million (2001 Census) Tribal population: > 85% (1.2 million belonging to Bhil tribe) Below poverty line: 47% Literacy: 37% (4% among women; lowest literacy in the country in the 1991 Census) Lowest Human Development Index of all 45 districts in the State (2002) Out-migration: 65% on average during last decade Low HIV/AIDS awareness (WHARF survey during July 2004 workshop)

Current scenario of Madhya Pradesh (since inception 2001), MPSACS Jhabua district with the VCT centers at Jhabua, Alirajpur and Jeevan Jyoti Hospital/Meghnagar LEGEND No of HIV-positive cases > < 10

Jhabua district HIV prevention program Germany WHARF Mumbai/Boston Jeevan Jyoti Health Service Society, Jhabua (operating a 100-bed mission hospital) Coordination of 582 Self-help groups in 180 villages across the district; IEC activities including linkage with voluntary counseling & testing centres Services in 3 voluntary counseling & testing centres across the district (Jhabua, Alirajpur, Meghnagar) FundingTechnical support Coordination with district administration; higher secondary and college HIV education programme Project Manager CounselorsPatients Medical supervisor Government institutions: Community Health Centres; ART Centres in Indore/ Ahmedabad Clients Referral

Voluntary Counseling and Testing at Three Centres in Jhabua district:

Characteristics of 68 clients tested in the period of August through October 2006: Clients largely from tribal communityMore than 2/3 of clients were women Almost half of clients were illiterate40% of clients had TB, 45% had an STI

Scaling up the programme Since prevalence (1.88%) still low: Increase service uptake through direct referral from village self-help groups, TB and antenatal care programs, other NGOs Collaborate with medical officers on STI care Establish two additional VCT centres at Pelawad (Northeast corner of the district) and Pitol (truckers stop at the border with Gujarat) Extension into other districts with NGO presence: Ratlam, Neemuch, Mandsaur (prevalence 3%!) Establish linkage with ART Centres at Indore and Ahmedabad

Recommendations Rally for local support, community involvement Public-private partnership: direct Government support under NACP-3 Support from abroad (financial, experts) Large scale-funding to conduct behavioralstudies, targeted interventions, condom promotion Engage stakeholders in discussion on circumcision and stigma reduction Formalize linkages with RNTCP, NRHM, RCH-2

Thank you!