Combating the spread of HIV among Indian migrants

SV Mishra¹, KS Jethwani²,  
¹ Decimal Foundation, Mumbai, Maharashtra, India; Atlas Corps, Washington, DC; Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
² Department of Dermatology, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School; Center for Connected Health, Partners Health Care, Boston, MA, USA

Correspondence Address:
Dr. K S Jethwani
Department of Dermatology, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School; Center for Connected Health, Partners Health Care, Boston, MA, USA

Full Text

Approximately 2.1 million people live with HIV in India. [1] However, unlike other middle and low-income countries, HIV affects more men than women in India. This is most likely due to the concentration of this infection in predominantly male high-risk groups, such as truck drivers and migrant workers. [2] Migrant workers constitute the bridge between urban and rural areas, and spread this infection across disparate regions of the country. This necessitates a unified, national strategy to target effective interventions to help contain the spread of HIV within this group.

The findings of Rizwan et al. add to a growing body of literature that characterizes the facilitators of high-risk sexual behavior among migrants. [3] These facilitators can be grouped into three broad categories: Lack of awareness and/or stigma associated with the risks of high-risk sexual behavior, factors that hinder the use of protective measures, and non-migrant factors that promote high-risk behaviors in migrants.

Efforts have been made to counter the lack of awareness of the perils of high-risk behavior through mass media campaigns as well as targeted efforts at educating and intervening with these groups. [4] In the Rizwan et al. study, only 18% migrants reported having non-spousal encounters, in contrast to over 60% reported in the literature for Indian migrants. This is most likely due to the prevalent cultural stigma associated with public disclosures of non-spousal sexual encounters. Targeting interventions specifically to high-risk individuals is harder in the presence of such stigma, and renders interventions less effective. [5]

Rizwan et al. have explored factors that hindered the use of protective measures, specifically adherence to condoms. They found a threefold decrease in condom usage among migrants who consumed alcohol. Further, 50% men who consumed alcohol and indulged in non-spousal sexual encounters reported having at least one STI symptom. These findings are in-line with several other studies from India as well as globally. [6],[7],[8] These findings suggest that HIV prevention strategies could benefit from taking alcohol abuse into account when educating migrants about condom use, and even integrate de-addiction and coping strategies to enhance the effectiveness of HIV prevention programmes. [9],[10]

Several other factors, besides migrant-related issues, are worth exploring in this paradigm. Many studies involving migrants in developing countries have pointed to female sex workers' (FSW) behaviors in promoting alcohol consumption and condom non-use, noting that only about 50% FSW's area actually able to engage in negotiations about condom use. [11] Poverty, gender inequality, lack of empowerment [11],[12],[13] and low social status diminishes an individual's ability to act on positive intentions to use condoms with clients. Preventive strategies today focus on empowering FSW's to insist on condom use with their clients. However, with Rizwan's findings, it is clear that discouraging alcohol consumption with clients could also have a big impact. Further, FSW's own alcohol consumption also leads to condom non-use and is worthy of further exploration. [14]

Rapid urbanization has resulted in a unique sub-culture of migrants, who have developed their own norms and realities. Non-spousal sexual encounters are a big reality of this culture, and are unfortunately leading to the spread of disease among themselves and their loved ones. Intervening and changing this behavior requires an astute understanding and acceptance of this sub-culture. Strategies that help migrants prevent disease without completely reinventing their culture and lifestyle will likely be more successful than those that simply expect them to abstain from such behavior.

Abstinence, in the context of the larger Indian 'culture' has been recently presented as a valid HIV prevention strategy in India, despite the lack of scientific evidence for it. [15] Rather than abstinence, effectively countering the spread of this epidemic needs a concerted effort on all three fronts: Education/awareness building and addressing cultural stigma, promotion of preventive strategies during high-risk activities (condom use) and finally addressing the problem holistically, by targeting migrants, FSW's and all relevant parties with equal impetus. With a comprehensive national strategy grounded in evidence-based practices, developing nations can very effectively counter this menace.

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