David Miller is an expert in psychosocial management of hiv/aids. He has worked in developing countries since 1986 and is currently the Country Programme Adviser of unaids in India. He talks to Vibha Varshney
Why is it so difficult to control HIV/AIDS after all we know?
The disease is linked with immorality and promiscuity. People don't want to accept these issues or discuss perceptions of them. As many people have never heard about hiv, they do not know how to avoid it. There is a lack of adequate testing facilities and counseling and therefore the probability of contracting hiv does not even come to mind. So, in a sense, hiv/aids is also an epidemic of non-communication. Even though the Indian government's behavioural surveillance survey has shown that over 70 per cent Indians know about the disease, a large number of these people do not understand its link to sexual behaviour or drug injection. We have to sincerely redouble effort to ensure that people make the intellectual link between hiv and behaviours that might put them at risk.
Are some groups more vulnerable to the disease?
Studies in India have shown that 90 per cent of the women who contract the infection are getting it by doing exactly what their families expect them to do, namely to avoid pre-marital sex and to be faithful to their spouse; in other words they acquire hiv from their husbands. Women are also vulnerable because they are economically dependent on men and are unable to negotiate safe sex. The level of awareness amongst women is also low as many cannot read or write. Even after they become infec-ted, it is more difficult for women to get treatment. Poverty is also one of the major factors leading to the spread of the virus, as it increases vulnerability. So do natural disasters such as floods, droughts and earthquakes.
Has society's perception regarding HIV changed in the last two decades?
It has changed extraordinarily. Senior political leaders have started talking about it at the highest level, including the United Nations Security Council and General Assembly, and the World Economic Forum. This shows the degree of commitment of political leaders around the world to control the problem. Such a commitment was unthinkable even five years ago. Even the common person's acceptance has increased.
How do we control the disease in India?
It is important to tell people how the disease is transmitted and even more important to know how it is not. We have to understand that people don't want to get infected or infect others. People have the right to know about the disease, especially as it does not have a cure and can ultimately damage the economy. It is necessary that we don't increase fear and stigma through our education but increase acceptance and understanding. Local leaders and the panchayats should take the message across. We have to increase the access to condoms and drugs.
There is also a need to create partnerships between the government, non-governmental organisations and the corporate sector. The corporate sector is very important; they are specialised in advertising. They should use this talent to tell people about the disease. The corporate sector should also create programmes where workers and their families can learn about the disease. They can also set up systems for voluntary testing and referral.
We have to realize that people with hiv are part of the solution and not the problem. They, too, can tell people about their experiences and help in developing strategic approaches for control of the disease.
Are there some India-specific problems?
Most developing countries face roughly similar problems - how to educate society, how to develop government structures to distribute health, how to reduce stigma, how to increase welfare measures. There are cultural and social practices, which conspire against open discussion in developing countries. In most Asian countries, it is hard for political leaders to come forward and discuss the disease as this means that they have to talk about sexuality issues, condom use and other means of protection. Sometimes the leaders might feel that these are things that the people might not be ready to listen to. To an extent, India is ahead of other countries as enormous talent is available in research and training. But the system is still ailing. When it comes to issues of delivery of testing, counseling or availability of drugs, we fail.
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