AIDS in India: police powers and public health. (Lancet article)

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AIDS in India: police powers and public health

Volume 367, Issue 9513 , 11 March 2006-17 March 2006,

Pages 805-806. doi:10.1016/S0140-6736(06)68319-0

Patralekha Chatterjee

Clashing priorities between India's police force,

which wants to crack down on illegal sexual behaviour,

and health workers, who promote safe sex to high-risk

groups, are threatening to undermine the country's

fight against AIDS. Patralekha Chatterjee reports from

Lucknow and Delhi.

20 years after the first case of HIV was reported in

India, the number of people infected with the virus

has topped 5 million. The government has ramped up its

response to the spiralling numbers of new infections,

but its failure to resolve the clash between

public-health priorities and police powers is

threatening to derail the country's fight against

HIV/AIDS.

At the heart of the crisis are systems of law and

enforcement that remain insensitive to the

requirements of the unfolding epidemic and the dangers

posed by cultural taboos that impede discussions about

sexual health (more than 80% of HIV cases in India are

attributed to sexual transmission). Recent incidents

in Lucknow, a North Indian town famed for its

magnificent gardens and historic monuments, brought to

the fore the crippling contradictions in India's

approach to AIDS.

In early January, the Lucknow police arrested four men

for allegedly running an online gay club; the move

sparked protests from national and international human

rights groups. “Criminalisation of people most at

risk of HIV infection may increase stigma and

discrimination, ultimately fuelling the AIDS

epidemicâ€, warns UNAIDS India Coordinator Denis

Broun.

Section 377 of the Indian Penal Code is used to

justify arrests and harassment of outreach workers and

peer educators working with men who have sex with men

(MSM). The law criminalising homosexual sex (dubbed an

unnatural offence) dates back to 1860 and could land

the offender with up to 10 years imprisonment.

India's National AIDS Control Organisation (NACO)

recognises the need to reach out to sexual minorities

and its latest annual report lists 31 interventions by

various State AIDS Control Societies specifically

targeting the gay community. But NACO is powerless to

stop police targeting individuals in high risk groups.

Weeks after the police crackdown on homosexual men,

the aftershocks still reverberate on the streets of

Lucknow. “6 months ago, on an average weekday

evening, I would meet at least six or seven

‘kothis’ (feminised males) at these hang-out

joints. Today, that number has halvedâ€, says an

outreach worker with Bharosa Trust, a local

organisation working with this community.

Since the January crackdown, Bharosa has stopped

holding its regular workshops where peer educators

promote safe sex in public parks. Tragically, those

worst-affected by this loss have been the

semi-literate daily wage-earners who most need the

information and the free condoms. Uttar Pradesh, of

which Lucknow is the capital, does not have a single

state-funded public-health intervention targeting the

gay community nor has HIV-prevalence been mapped

through the state's annual surveillance survey.

Police harassment of gay men reflects a wider problem.

In India, as in many other cultures, men who have sex

with men is a term that includes men who may not

identify themselves as gay or homosexual and who may

also have sex with women. This community forms a

bridge for transmission of the infection to the

general population.

In July, 2001, four staff members of Naz Foundation

International (NFI) and Bharosa Trust, were jailed for

47 days after the police raided their offices. The two

organisations work among the MSM community in Lucknow

raising awareness about AIDS. “I was arrested for

promoting homosexuality. The leaflets we use for our

outreach work were dubbed obscene. The police claimed

that the replica of a penis used to demonstrate the

proper use of condoms was actually a sex toy!â€,

recalls Arif Jafar, Regional Director of NFI Lucknow.

And yet, such tools are crucial to combating the

spread of HIV among the most vulnerable sections of

Indian society, the semi-literate or illiterate, who

have no access to the internet or even basic health

services. “The educational material to persuade them

to practise safe sex at all times has to be visually

explicitâ€, argues Shivananda Khan, CEO of the

London-based NFI. Sadly, it is left to the discretion

of the police to judge whether such tools are

pornographic or not.

The paradoxes are not confined to the Indian attitude

towards MSM. Outreach workers dealing with intravenous

drug users, for example, are equally vulnerable.

Needle sharing is the main form of high-risk behaviour

related to injecting drug use. To counter these

problems, needle-exchange programmes have been

introduced in some parts of the country. But such

initiatives run the risk of being misinterpreted by

law-enforcement agencies.

The proposed Immoral Traffic (Prevention) Amendment

Bill presents another difficulty for AIDS control

efforts. Ignoring protests by sex workers and HIV/AIDS

service organisations, amendments to the bill,

expected to be introduced in a forthcoming session of

the Parliament, seek to penalise clients of sex

workers rather than the sex workers themselves. But

activist groups, such as India's Lawyers' Collective,

have argued that “penalisation of clients will be

deleterious to health and safety interventions

including existing government and donor programmes to

promote condoms for preventing HIV/AIDS. Clients

wanting to avoid arrests will be driven into remote,

hidden settings where sex workers will find it

difficult to negotiate protection.â€

Already, attempts by outreach workers to contact

clients to promote safer sexual practices are

constrained by their invisibility. The new provision

will obstruct AIDS education and prevention in sex

work even further, claim critics. “Though the

amendments are being touted as pro sex workers, in

reality, they expose them to greater harassment and

intrusion by the policeâ€, asserts the Lawyers'

Collective.

The ambivalence of Indian officials towards HIV/AIDS

was highlighted by Human Rights Watch in a 2002

report. “In its official policies and statements,

the Indian government has recognised the importance of

reaching out to women in prostitution and men who have

sex with men as a central element of its HIV/AIDS

response … But in practice, one branch of the

government—the public-health service—relies on the

non-governmental sector to provide condoms and

information to persons at high risk, while another

branch of government—the law enforcement

establishment—abuses those who provide these

servicesâ€, observed the New York-based international

human rights watchdog.

Activists and lawyers' groups are now campaigning for

legal reform to repeal the Section 377 law. Indian

NGOs concede that it may not happen soon, but they

remain hopeful of future reform. And there are some

positive signs of change as India gears up for the

third phase of the National AIDS Control Programme

(NACP III, 2006–2011). Arif Jafar says that NFI is

discussing with NACO the idea of an “executive

order†to law enforcement agencies forcing them to

allow active promotion of condoms to MSM communities.

The local government in Delhi, India's capital city,

is taking the lead in confronting the diverse

attitudes of health officials and other bureaucrats.

“We are doing several things. We provide letters to

the NGOs who we work with so that outreach workers

involved with harm reduction programmes and promoting

needle exchange or those distributing condoms to

groups with high-risk behaviour are not harassed. One

also has to be tactical—instead of using a

photograph to demonstrate the correct way of slipping

on a condom, we use a line diagramâ€, says Delhi

paediatrician Jai Pal Kapoor, who works with the Delhi

State AIDS Control Society (DSACS).

One of the biggest challenges, adds Kapoor, is

“sensitising bureaucrats from other ministries and

departments, including the police, about the issues

underlining HIV and AIDSâ€.

DSACS has begun training for officials in other

ministries. One of its key achievements is a project

that has helped dispel myths about HIV/AIDS among

Delhi's police force. Supported by the UN Development

Programme, the project has trained 12 000 out of the

total 60 000 police volunteers in Delhi. This pilot

initiative has sparked interest in other state

governments and currently over 4000 police personnel

in Kanpur district in adjoining Uttar Pradesh are

being educated about HIV/AIDS, sexually transmitted

infections, condom use, and gender issues.

The Lancet: Volume 367, Issue 9513 , 11 March 2006-17 March 2006,

Pages 805-806

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