In India the HIV/AIDS epidemic is more than 15 years old. The national HIV prevalence rate has risen from 0.1 per cent in 1986, to 0.8 per cent in 2001 – an eight-fold increase in 15 years. Conservative estimates by the government say that perhaps as many as 4.5 million Indians are living with HIV/AIDS. In six states, more than one per cent of the population is HIV positive. Given India’s large population, each 0.1 per cent increase in the prevalence rate would increase the number of adults living with HIV/AIDS by over half a million people. As elsewhere in the world, it is poor and marginalized people, and especially women, who are most vulnerable. Oxfam’s work on HIV/AIDS is being implemented through local Indian NGOs partners. This leaflet looks in more detail at work with one partner in the State of Orissa.

Programme background
Koraput district in Orrisa is a centre for industries both large and small, and the hub of a highway network. Many young men migrate there from rural areas seeking jobs. The population is very mobile and there is a high demand for commercial sex. These conditions are risk factors for the spread of HIV/AIDS and other sexually-transmitted infections (STIs).

Oxfam’s partner organisation, South Orissa Voluntary Action (SOVA), has been working in and around Koraput since 1996. SOVA’s research showed that knowledge of HIV/AIDS and of STIs was low and that safe sex was not practised. Truck drivers were identified as a key high-risk group on which to focus. However, experience has shown the value of widening this focus. SOVA selected and trained committed truck drivers as “peer educators” on HIV/AIDS and STIs, with 72 drivers trained so far. It involved both the truck drivers’ union and the truck drivers’ employers’ association to take more responsibility for enabling drivers to seek information and support services, including condoms and treatment, with 800 drivers so far having been assisted. But SOVA realised that focusing on “high risk” groups failed to address the risks to larger population groups, notably the wives of men who may have multiple sex partners. It therefore decided to work to reduce high-risk behaviour across all groups in both rural communities and in towns. In order to reach these wider groups, and respond to the different ways in which people learn. It uses a wide range of methods, including stalls at weekly markets, and theatre. It had already worked to establish self-help groups (SHGs) in tribal villages, with the initial aim of helping villagers, mostly women, to save money collectively to purchase seeds or fertilisers or manage the government ration scheme. These SHGs have helped to empower women with greater individual and collective strength, and SOVA

realized that they could play a major role in increasing people’s knowledge about reproductive health and HIV/AIDS, and this is happening.

The SHG structure has enabled women to achieve greater autonomy in their sexual relations. For example, wives concerned that their husbands may have visited commercial sex workers are more able to negotiate safe sex. There is increased demand for condoms. Initially, SOVA distributed condoms free-ofcharge but now sells them, at a low price, through the peer educators and through small shops, youth clubs and other outlets. Commercial sex workers are much more likely now to refuse to have sex without condoms. There has been a reduction in HIV-related social stigma because of greater awareness that simply having an infected member in the family need not lead to other family members becoming infected.

Lessons learned
It is important to recognise the need to reduce high-risk behaviour through working with the extended community, rather than focus on so-called “high-risk” groups. Indeed, focusing just on “high-risk” groups may actually increase fear and stigma and push them underground. It is a challenge to maintain contact with truck drivers and the community approach is particularly useful in this regard. Integrating HIV/AIDS into general reproductive health-care programmes definitely increases the coverage and impact. Partner treatment of STIs is critical for prevention and reducing risk. This type of work requires a good understanding of the communities and their structures. Taking action to prevent HIV/AIDS infection requires a degree of autonomy in sexual relations, so it is important that programmes contribute to the empowerment of women. Peer education is a key strategy for sustainability and impact.

The epidemic is in its early stages in Orissa. One of the biggest challenges SOVA faces is sustaining interest in its work in areas where HIV/AIDS is not visible. On the other hand, many truckers have been infected already but treatment is hindered by lack of resources both in the district health authority and among non-governmental organisations.

The programme approach has to be inclusive. It has to cater to the needs of the infected and the affected and strengthen the capacity and skills of whole communities. People living with HIV/AIDS need programmes that address rights and legal issues, and also information and training for alternative livelihoods. Peer education is a key strategy for behaviour change. HIV/AIDS work needs to be integrated with reproductive health care.

But for this to happen, the programme providers also have to work inclusively. That means government doctors, health workers and other authorities, NGOs and traditional providers have to work more closely together and reinforce each other’s skills. This in turn also requires networking and advocacy with district legislators and other political stake-holders who can establish policies and resources from the top in order to create “friendly” services.