HIV/AIDS in India: What women know about it and what is the impact in rural areas Saseendran Pallikadavath R William Stones Opportunities and Choices Programme Centre for AIDS Research HIV/AIDS in India: What women know about it and what is the impact in rural areas HIV/AIDS in India What women know about it and what is the impact in rural areas

“In 2021, undoubtedly, there will still be an AIDS epidemic..The next 20 years can be different, but only if we act now” (Robert and Jeffrey, N Engl J Med, 2001) Structure of presentation An overview of HIV/AIDS in India Women’s knowledge about HIV Impact of AIDS in rural areas Research needs Conclusion

Our research Secondary data 1.Pallikdavath S and Stones RW, Women’s reproductive health security and HIV/AIDS in India, EPW, Vol 38, Pallikdavath S and Stones RW, Dissemination of AIDS knowledge through Indian Family Planning programme: prospects and limitations, AIDS, Vol. 17, Pallikdavath S, Snneh A, McWhirter and Stones RW, Rural women’s knowledge of AIDS in the higher prevalence states, Health Promotion International (under review) 4.Pallikdavath S, Jaychandran and Stones RW, Women’s reproductive health, socio-cultural context and AIDS knowledge in northern India, Journal of Health Management (under review) 5.Pallikdavath S, Sreedharan C and Stones RW, Sources of AIDS knowledge in India, AIDS care (submitted) Primary data 6.Pallikadavath S, Garda L Apte, Freedman J, and Stones RW, HIV/AIDS in Rural India: context and health care needs, Journal of Biosocial Sciences (under review) Women’s reproductive health in the context of HIV:

An overview of HIV/AIDS in India

HIV in India First HIV case in 1986,Tamil Nadu HIV cases in 2002: million (15-49) 2002 estimate based on 384 sentinel sites : 166 STD :200 Antenatal (proxy for general) :13 IDU :3 MSM :2 CSW :0.8% prevalence :10% global burden Projections: 30 million HIV by 2010: Dr Soloman (March , talk in California) 12 million HIV by 2015 according to UN (Economist, April 15, 2004) 9 million HIV by 2010 according to NACO (Economist, April 15, 2004)

AIDS cases in India: 68,809 as on March 31, 2004 (others estimate: 600,000)

MTCT 21% 35% More men Proportion of women increased

HIV prevalence (%) among antenatal attendees, Northern region-India, million married women Million 23.4 Million

HIV prevalence (%) among antenatal attendees, Southern region-India,

HIV prevalence (%) among antenatal attendees, North-eastern region-India,

An increase of HIV prevalence in low prevalence states (Northern) A decline of HIV in high prevalence states (Southern and some NE States). North-South differentials can mask the reality Significant variations exists across states Low HIV prevalence in some states can neglect localised epidemics Implications

Even a decline in new HIV cases in future would lead to a large number of AIDS cases due to the momentum created in the past Provision of continued care to AIDS patients would remain a major task: [ART started in April, 2004 as “3 by 5 initiative” by WHO/UNAIDS. India plans to treat 100,000 PLWA with possibility of further increase]

Women’s knowledge about HIV

Rural women’s knowledge about AIDS 2001 Behavioural surveillance survey (BSS) (National) Survey conduced by the National AIDS Control Organisation 84,182 men and women years

Increase in HIV Decrease in HIV

Women’s knowledge about AIDS in low and high prevalence states Uttar Pradesh and Madhya Pradesh: LOW Maharashtra and Tamil Nadu: HIGH National Family Health Survey; a sample survey of 90,303 ever married women in the age group years

Women’s knowledge about HIV in Uttar Pradesh and Madhya Pradesh, % Heard of HIV Uttar Pradesh: 20.2India: 40.3 Madhya Pradesh: 22.7[106 million married women in the age no % Aware that HIV can be avoidedAIDS knowledge] Uttar Pradesh: 59.2 Madhya Pradesh: 56.4 % Having correct knowledge Uttar Pradesh: 45.7 Madhya Pradesh: 47.5 Only 5% married women have correct knowledge in UP

Madhya Pradesh Uttar Pradesh Variables Aware of HIV Knowledge that HIV can be avoided Correct knowledge about HIV transmission Aware of HIV Aware that HIV can be avoided Correct knowledge HIV transmission Age group Y Y Y Y × Y Education Y Y × Y Y × Work Y Y × Y × × Religion Y × × Y Y × Caste Y × Y Y × × Standard of living Index Y Y Y Y × × Place of residence Y × × Y × Y Watch TV once a week Y Y Y Y Y × FP worker visited × × Y × × × Discussed FP with partner Y Y × Y Y × Everuse of F P Y Y × Y Y Y Media __ Y × - Y Y Vulnerable women groups in North Older Poor Less educated Not having access to TV Non-users of FP Lack of integration of FP with HIV

Women’s knowledge about HIV in rural Maharashtra and Tamil Nadu, % Heard of HIV Maharashtra: 40.1 Tamil Nadu: 84.0 % Aware that HIV can be avoided Maharashtra: 55.4 Tamil Nadu: 85.5 % Having correct knowledge Maharashtra: 59.3 Tamil Nadu: % married women in rural TN have correct knowledge 24% married women in rural MHA have correct knowledge

Vulnerable women groups in the South Less educated Not working Not having access to TV Not visited by a FP worker Never users of FP No access to modern electronic media

Where do women obtain AIDS knowledge from? National Family Health Survey; a sample survey of 90,303 ever married women in the age group years

Source of AIDS knowledge % women heard of AIDS from: Measure of effectivenessMeasure of independent effect Average number of sources Radio Television Newspaper Pamphlet/magazine Clinic/health worker Church/Mosque School/teacher Community meeting Friends/relatives Work place Cinema Exhibition Adult education programme Political leaders All Number of women19,803**19,803 Proportion heard of AIDS from only one source, from among women who had heard of AIDS from that particular source along with other sources. E.g. 950 women heard from radio alone, From among 9073 who heard from radio Along with all other Source 950/9073*100=10.4% Proportion heard of AIDS from only one source in relation to all women who had heard of AIDS Eg. 950 had heard of AIDS from Radio alone and 19,903 were aware Of AIDS IE=950/1903*100=4.8%

Source of AIDS knowledge% women heard of AIDS from: Measure of effectiveness Measure of independent effect Average number of sources Radio Television News paper Pamphlet/magazine Clinic/health worker Church/Mosque School/teacher Community meeting Friends/relatives Work place Cinema Exhibition Adult education programme Political leaders All Number of women16,615**16,615 Electronic media alone may not achieve 100% awareness ‘Media underclass’ needs special efforts High-effective media needs special focus: community level, and inter-personal communication Targeting married women audience: appropriate time culturally compatible contents

Impact of AIDS in rural areas

Impact of AIDS in rural areas: Field work in Dec Interviews with HIV + men and women and focus group interviews with general population in 4 villages in Pune, Maharashtra

Truck drivers Small business trips to urban areas “I think I got the disease from sex workers to whom I used to visit during my trips to Bangalore. At that time I used to have sex with whomever was available. I was working as a truck driver. For about one to one and half years I used to go there and used to have sex about three or four times a month” [40 year old HIV positive man] How rural women get HIV?

“ I got the infection from my husband ……. He used to go ‘out’ and that is how he got it….In the last days when he was dying he made me sit by him and told me that he went out with other women and that is why he got this infection. He told me that he was sorry…” [23 year old HIV positive widow]

“ people do not invite me….family members do not treat me well. They do not let me touch anything, mix with them, do not let me cook for my son. I was admitted for TB. After I came home they asked me to stay separate… Neighbours when come to know about my HIV, asked my family members to keep me separate. They do not come to my house. My relatives do not come to my house. They do not touch me. …” [28 year old HIV positive widow]”

Impact in rural areas: TYPICAL PATTERN HUSBAND GET THE INFECTION FIRST USES FAMILY RESOURCES FOR TREATENT WIFE BECOMES HIV + WIDOW (WITH CHILDREN) DRIVEN OUT OF HUSBAND’S HOUSE TAKE SHELTER AT NATAL HOME BECOME A DESTITUTE

Research needs and conclusion

How to keep the low prevalence levels in northern India? Cost-effective IEC to reach hard-to- reach women population Cost-effective prevention: innovative projects Integrating HIV knowledge with FP

How to mitigate the impact of HIV on rural women? Economic projects/schemes targeting rural women Legal assistance to rural women Social projects to mitigate stigma Prioritising ART and health care to widowed and poor women with children

Conclusion While basic knowledge about AIDS needs to be imparted to women, there is an urgent need to provide health care including ART to women living with AIDS. Social and economic interventions focusing on women are required to mitigate the impact of AIDS in rural areas.

Thanks.