Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

National AIDS Control Organization Prevention Programs: Failure In India Due To Westernized Ideas In Intervention – Vyshali Murthy

It is estimated that 5.7 million people are living with HIV/AIDS in India today (1). In India, it is reported that two-thirds of these cases are concentrated in six of India’s 28 states. The prevalence is on average 4-5 times higher in these regions than in any of the other states (2). The highest concentration of cases reside in Manipur and Nagaland, where the epidemic is driven mostly by intravenous drug users (IDUs) and in Maharashtra, Tamil Nadu, Karnataka, and Andhra Pradesh, where the primary mode of transmission is through unprotected, heterosexual intercourse (3).

Heterosexual intercourse is the predominant mode of transmission, it contributes to 85% of infections in the country; women account for 38% (2). Female sex workers (FSWs) play a significant role in the widespread of HIV/AIDS in India. Because such a large percentage of the accounted cases of HIV infection is through unprotected sex, many of the programs and prevention efforts have been geared towards FSWs. However, not enough efforts have been made towards the general female population. Women continually face harsh judgments, discrimination, and condemnation within Indian society. Therefore, creating a comprehensive prevention program and overcoming cultural barriers with the purpose of educating and increasing sexual awareness to prevent HIV/AIDS continues to be problematic (4).

With condom usage as the main intervention in preventing the spread of HIV/AIDS, the National AIDS Control Organization (NACO) is focused on targeting areas that are most vulnerable, highly populated, and most susceptible to HIV/AIDS exposure. A primary target in prevention is aggressive promotion and distribution of condoms especially among high-risk groups. NACO’s interventions stem from Westernized views of prevention such as the use of slogans; ideas like the A.B.C. approach (Abstain, be faithful in marriage, and when appropriate use condoms), or strategically placed condom machines placed in colleges and along truck routes (5). In an effort to promote and increase condom usage, most local government agencies believe that an integrated approach that factors in education, ideally would be the best method of prevention.

The Diffusion of Innovation (DOI) approach is based by which a behavior or technology, in this instance, condom usage, is adopted into a population and spreads through the culture. DOI takes into account the individual and the environmental factors that influences behavioral change. It examines how populations adopt the new form of technology or behavior over time. The principles considered in this approach are development and research of the innovation, dissemination and adoption, acceptance, then maintenance through self-efficacy.

In India, promotion of condom usage to prevent and decrease the spread of HIV/AIDS has been implemented by national policy. While there has been success in decreasing the spread of HIV/AIDS in various areas of the country, other populations continue to struggle with this epidemic. NACO’s concepts in targeting HIV/AIDS prevention are flawed because the intervention uses Western constructs and views (5). So, in NACO’s attempt to use the DOI approach, they have failed to be successful. The aim in changing behavior through this approach is ineffective since it fails to address cultural stigmas associated in Indian cultures, the role of Indian woman and their limitations, and educational and socioeconomic status.

1. Failure to consider conservative cultural stereotypes and stigmas in condom intervention program.

Social stigma and discrimination occurs worldwide and each country experiences major complications in implementing HIV prevention programs. NACO’s initial stress on condom usage to control the spread of HIV was framed in the context of “Use condoms, stop AIDS” and the ABC approach (5, 14). While these first messages emphasized using condoms as the means of controlling the spread of HIV/AIDS, it was not well-suited in India because it did not address or incorporate cultural stigmas attached to such a sensitive issue (5, 13). Because these messages were widely accepted and successful in increasing condom usage overseas, like in the United States, it was assumed that these ideas could be universally applied. Secondly, these messages addressed sexual behavior through a Western viewpoint, where it is commonly accepted to freely possess a condom. In India, the very possession of condoms can trigger harassment from the police and can deter the outreach efforts used to prevent the spread of HIV/AIDS throughout the country, especially in concentrated regions where HIV is prevalent (6).

NACO’s approach was a failure in this instance because of the lack of research into India’s highly conservative culture in examining what is appropriate and what is not. Adoption of using condoms through blatant public campaigns may have caused resistance, not acceptance, thus counteracting the premise of the initial intervention. While the intent of NACO’s placement of condom machines in public areas were to promote self efficacy within the individual, such a public display dismisses cultural values that is an essential aspect if implementation and adoption if change is to be considered, especially in a conservative society.

2. Failure to understand women’s role in Indian society due to limitations in family infrastructure.

Sexual ignorance and purity of women are cultural norms and it blocks access to prevention information and limits self-efficacy. Due to lack of awareness, many women in India generally have little ability to discuss or negotiate the use of condoms with their partners (8). Therefore, the stigma surrounding the acceptance of condom use has its obstacles. Promotion of condoms has been shown to have negative connotation among women even if they can exert their own autonomy. Condom usage is usually seen as going against strong family values and family planning; a responsibility each woman must uphold due to external pressures (3, 10).

Domestic violence among women in India influences the extent to which they seek assistance in obtaining HIV treatment (3). In the chance the woman or wife acquires the disease, the social consequences against disclosure of their HIV status could be devastating. Some women feel that because there is a threat of violence, if by exposing their illness, further violence would ensue in the home. As a result, this leads to a lack of reporting, neglect, and the possibility to receive medical treatment is compromised (10). In a survey conducted in six Indian states with the highest HIV prevalence, 40% of women reported being physically assaulted at some point in their life (11). NACO supported community-based programs that provide condoms to women are scarce. This, then limits the decision and option to adopt behavioral change and also lessens the awareness that the technology of ‘protection’ exists.

The Western approach of ABC, once promoted by NACO, which has since been reversed, paired with the convenience of condom machines may have perpetuated the spread of HIV/AIDS giving husbands an excuse to have extramarital affairs. Since a significantly higher number of abusive men seek out extramarital affairs and sexual encounters usually with FSWs, the impact this had on the spread of infection among women is severely damaged the implementation of any intervention (12). Fear of violence, constantly, exposes the wife to high-risk sexual practice by her husband because she is limited in her own capacity. For the majority of Indians, until understanding that promoting safe sex practices, especially among men who have extramarital relationships, and looking at efforts to decrease the social stigmas associated with HIV/AIDS are evaluated, interventions and preventions may not succeed.

The failure here is that NACO’s marketing focused on the female population that is somewhat inaccessible or is unable to assert autonomy. In this instance, NACO’s intervention strategy, again, counteracts the original premise of decreasing the spread of HIV/AIDS within the community because of the lack of cultural understanding. At the state level, there is has been a failure on the part of the Indian government in that it has neglected to protect women against violence. Currently, domestic violence laws against women do not exist.

3. Failure to address environmental reasons for poor literacy rates, autonomy, and socioeconomic status, especially among female populations.

Education level strongly influences awareness of disease. In India, however, logistical issues like language barriers can make it difficult to address, even the basic understanding that the severity of HIV/AIDS is rampant and precautions need to be applied aggressively (5, 14). Educating people about HIV/AIDS and how it can be prevented is complicated in India, considering the number of major languages and hundreds of different dialects spoken within the population. As a result, while some HIV/AIDS prevention and education can be done at the national level with the assistance of NACO and non-governmental organizations, many of the efforts, by necessity need to be carried out at the state and local levels.

In large part, difficulties in behavior change reside in woman’s autonomy, which very few are able to exert. There are many social stigmas that are attached to Indian women. Because they tend to have a lower socioeconomic status, they are dependent on their husbands and family; thus, are consequently unable to assert much independence. If a woman is infected and reveals her HIV status, she faces social and familial abandonment and rejection, threats or violence inside the household, and blame (15).

Education on the consistent use of condoms has been stressed, in the hopes that this knowledge empowers and helps aid in the autonomy of FSWs, abandoned or widowed wives, yet many demonstrate low literacy rates and thus lack the basic knowledge in prevention, condom usage, and awareness (8, 11). Furthermore, NACO’s attempt to promote educational campaigns, through mass media and government-sponsored advertisements, have played an integral part in bringing awareness to rural areas and individuals with low literacy rates (7). While, exposure to television and other media did increased awareness, especially in condom usage the limitations with media use is that it simply conveys basic general knowledge and does not address specific information (8).

Many of the educational programs that NACO and local government agencies and organizations created targeted large populations or social networks. While the fundamental basis of the programs and prevention methods were culturally sensitive, very few addressed the problem at an individual level. It seems as though NACO and the government agencies had utilized the DOI approach successfully in its intervention, the failure here, however is the implementation and advancement of self-efficacy on the individual level.

HIV/AIDS in India is characterized as an ‘epidemic’ which certainly is true as most individuals tend to just fall underneath this umbrella. While education about prevention and condom usage has been stressed, an individual may have the intent to change but may not have the ability to exert the autonomy to do so. The technology to change the behavior is available, unfortunately, the resistance to change caused by environmental or social circumstances and barriers remains.


In an increasing need for a more effective HIV/AIDS intervention programs, NACOs performance to promote condom usage is a failure. In its attempt to provide condom machines, education, and protection, the intervention did not incorporate the environmental barriers and conservative cultural society into the development of the intervention. NACOs lack of research into its target demographic ignored and dismissed many cultural barriers, beliefs, and values that Indian society regards as highly sacred. Therefore, the thought of maintenance of a technology, which DOI strives for, could not have been achieved. While the ideas taken from Western society are valid and work, they are not applicable in a society that is limited and conservative. The intervention applied in this instance did not address the cultural stereotypes and stigmas, considered a huge barrier in the prevention of HIV/AIDS, it failed to understand the limitations placed on Indian women, and lastly, disregarded poor literacy rates and socioeconomic status, especially among women.

With an estimated projection of 25 million HIV cases forecasted for 2010 (2) and with the number of infectivity exceeding South Africa, the time for stabilization and prevention is urgent. Like most developing countries, each face barriers to create programs that are effective and promotes the reduction of transmission. Because of the strict, conservative Indian culture the barriers to overcome stigmas need to be combated and the walls need to come down. NACOs use of the DOI approach has great potential, however, in order for implementation and adoption to occur research into cultural beliefs, regional demands, and specific needs of the high-risk populations must be addressed. Strategies need to be implemented that look into long-term effectiveness and prevention for maintenance to be achieved in an intervention. While investing in education programs, media, condom usage, and STD management are steps in the right direction; they only result in the management of current needs. Long-term goals need to be addressed by breaking social constructs and increasing awareness, not only by prevention but also by removing social discrimination and giving women equal status in the community.

The role of women in India is of major concern. Empowerment in both social and economic development along with men, as equals, can help mobilize prevention within the country in all fronts. This disease, characterized, as ‘someone else’s problem’ is at the forefront and leads a worldwide concern that if HIV is not contained, could cause social and economic devastation in the second most populated country in the world. The efforts and priorities of NACO is to build on what is effective in the short-term, but should look to expand and enhance access to treatment, education, and drug therapy and break the social stigmas that promote equality, integrity, and respect of the culture in India in the long-term.


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