Roll Back Malaria Campaign—How its Ineffectiveness is Increasing Malaria Throughout Sub-Saharan Africa- Kamila Przytula

The Roll Back Malaria Campaign was initiated in 1998 by the World Health Organization, in collaboration with UNICEF, UNDP, and the World Bank to help fight the preventable and curable disease in such regions as Africa, Haiti, the Indian subcontinent, and Central America. Its vision as stated on the official website is to have accomplished the UN’s Millennium Development Goals by 2015, which include the elimination of Malaria as a major cause of death and a hindrance to social and economic development (1.) That is a confident and detailed goal for a campaign to achieve, especially worldwide. Unfortunately regardless of how optimistic the campaign’s goals may be on the issue of Malaria, it is not succeeding in halving Malaria deaths due to the following factors. First, supporting nations and organizations are unwilling to increase the budget set up for fighting Malaria with the proper drug-treatment because artimisin-based treatment is 10-15 times more expensive than chloroquine. (2) Refusal to adopt the new drug treatment universally is leading to the development of resistant strains, which are harder and much more expensive to treat. Third, is the campaign’s inability to distribute proper bed nets to all those living within high-risk areas. It has been proven that if 80% of a village uses bed nets, a protective barrier is created repelling the mosquitoes and protecting even those without bed nets. However, if only a few individuals use the bed nets in the community then the infected mosquitoes will just move next door. (3)
Introducing the issue
Malaria is a parasitic infection that is spread primarily through mosquito bites, but can also spread through two other ways, a transfusion, or the sharing of a needle with an infected person. It is endemic in tropical climate regions, such as Africa. There are four different parasites that cause malaria, the Plasmodium falciparum being the most dangerous (4); the African region is affected by the most fatal out of the four parasites causing Malaria to be a tougher epidemic to deal with (5). Once the parasite enters the blood stream it goes into the liver, multiplies exponentially and goes back into the blood stream, where it disrupts the flow of blood into major organs by clogging blood vessels and rupturing red blood cells (6). Fever is the major symptom associated with Malaria, and if untreated Malaria can cause permanent damage to the spleen, brain, and/or lead to death (7). Over 1 million people die yearly due to Malaria, regardless of the fact that it is considered a preventable and curable disease; most of these fatalities are young children living in Sub-Saharan Africa (8). Many well-accredited organizations have stated that the 2 major tools for malaria control are artimisin-based drugs and bed nets that have been sprayed with insecticides (9). Even the World Health Organization, the main founder of this campaign, states that artimisin-based drugs and not chloriquine treatment is the most effective (10). This shift in drug of choice for Malaria treatment was said to be approved by the US, who provides 1/3 of the budget for fighting Malaria, but then data in 2003 showed that most of the money was still being spent on chloroquine drugs instead of artimisin (11).
Failure to Increase Financial Support
The Roll Back Malaria Campaign claims its mission is to “…enable sustained delivery and use of the most effective prevention and treatment for those affected most by Malaria (12).” It has been reiterated several times by different sources that only through an increase in the budget will this campaign be able to become successful. Regardless of all the data presented to the health community, there is still insufficient funding for proper Malaria treatment. Private investors feel as though putting money into further Malaria research would be unrewarding in the long run. Also, many contributors to the campaign lack the will to promote an increase in the budget because “…eradicating the disease over such a large land mass [such as Africa] involves very high costs, and subsequent maintenance” that the world community is uncomfortable with accepting (13). According to the Red Cross, the international community needs to increase funding for intervention programs to significantly impact the fight against HIV/AIDS, Malaria, and other diseases in high-risk areas (14). Reiterating the need for more funds does not seem to be resulting in any action; recent data shows that $1 billion a year would pay for artimisin treatment for 60% of those who need it. But in the year 2000, the budget for the campaign was a mere $100 million, of which only a small percentage of it was used to buy the necessary drugs (15). An increased budget would also provide the opportunity to expand scientific research in the hopes of finding a vaccine for Malaria, but major vaccine producing companies, such as Merck, do not see a market for malaria. If a vaccine were to be developed, it would have to be distributed to countries at high risk at a low cost, if any; therefore private investors along with pharmaceutical companies are unwilling to participate (16).
The necessary changes that need to occur in the financial sector of the Roll Back Malaria Campaign could be easily understood using the social marketing theory. Social marketing theory depends on the 4 p’s: product, price, place, and promotion. This theory refers to how a campaign must take into consideration the benefits of adopting the best technology or treatment, and the overall cost, not just financial, of adopting this new treatment (17). The cost of increasing the budget for malaria would put a small dent in the pocket of major contributors such as the US, but its impact would save the lives of thousands.
One of the UN Millennium Development Goals is to “halt and begin to reverse [the] incidence of malaria and other major diseases by 2015 (18).” With high resistance developing throughout the Sub-Saharan African region this will be a more complex task to accomplish than initially expected. The emergence of drug resistance strains is also influenced by patients’ inability to adhere to the treatment suggested because of the campaign’s failure to consider the low levels of self-efficacy found among these poverty-stricken regions (19). Within the last 15 years, mortality due to Malaria has been rising primarily because of the development of drug resistance and the inability to speed up the rollout of new, more effective drugs because of the immense costs (20). Further studies show that from “…1999-2003, the number of deaths worldwide from Malaria was higher than in 1998, when the campaign was launched (21).” The parasite’s ability to develop a resistance to the drugs used in treatment hinders the campaign’s success, and maintains fatalities at a steady rate of one child every 30 seconds (22).
Self Efficacy & Treatment
Patients’ inability to stick to the treatment necessary to cure Malaria is aiding the spread of resistance throughout the region. A lot of the medical cases are located in devastating poverty-stricken regions where the nearest clinic might be located several walking hours away. Therefore, if a person has to choose between working, or finding food for the family, and walking to a clinic for a check-up or treatment, he/she will choose what benefits the family overall. The concept of self-efficacy has to be included in how the treatments are carried out by the Roll Back Malaria Campaign. The majority of Africans are struggling to feed themselves; they do not believe that they have the ability “…to take an action [and stick with it] and overcome the obstacles to taking this action;” The action referring to the ability to stick to the medical treatment necessary to recuperate from Malaria (23). Many individuals are less likely to even seek treatment if they know they are not going to be able to follow through with it. Others might begin treatment but due to other priorities they may stop seeking continuous medical attention. The idea of prioritizing one’s tasks and goals is part of the community mobilization theory, which needs to be incorporated in the Roll Back Malaria Campaign. The major concept of this theory is to understand and define the community that the campaign wants to target, and take into consideration whether or not Malaria is a top issue for this given community (24). The campaign needs to be more understanding of those living in these high-risk areas as they may have a hard time accessing a clinic and its facilities. They are living from day to day, trying to keep themselves and their family members alive with the limited resources they have. But it is “…necessary to improve public awareness of the importance of seeking appropriate treatment and complying with [the] recommended regimen” so the issue of Malaria becomes a prioritized issue that all have to deal with (25).
Failure in Bed Net Distribution
Along with the use of drugs to eradicate the Malaria epidemic, the distribution and use of insecticide-sprayed bed nets is the 2nd most important tool needed (26). The theory of diffusion of innovations incorporates the idea of introducing a new technology, such as insecticide-sprayed bed nets and seeing how effectively it is adopted by the community (27). The two main parts of this theory relating to the proper distribution of bed nets in the Roll Back Malaria Campaign are the adoption and implementation initiatives (28). The adoption portion is getting the community to incorporate the bed nets as part of the necessary preventative action. The implementation portion refers to getting the community using these bed nets continuously. Bed nets are very effective in reducing and preventing childhood mortality from Malaria. However, they are only effective if they are available to high-risk communities. Only 1 in 7 children sleep under a bed net in Africa, and out of this percentage only 2% use a net that has been sprayed with insecticides (29). A village elder living in the Sub-Saharan region said that “our people are poor, very few could afford to buy a mosquito net for 50 shillings [equivalent to 75 cents]. But she says that now they are all very happy since their village has received free bed nets for all (30). The only way to get bed nets to all the people that need them is to give them out for free. This type of distribution needs to happen worldwide. Many times, for a health change to be properly instilled, there must be a change in the community as a whole (31). Therefore providing bed nets for everyone, free of charge, would be the best way for people to implement using them at all times. A study has shown the benefit of having the majoring of a community using bed nets: “…insecticide-filled nets when used by 80% or more of a village, create a barrier that kills or drives off mosquitoes in the area, and protects even those few without nets (32).” But currently, the method in which most bed nets are distributed is not appropriate in order to achieve the campaign’s desired goal, along with the UN Millennium Development Goals, by 2015 (33).
Finding Success in the Future of the Campaign
The Roll Back Malaria Campaign, since its establishment in 1998, has only led to an increase in Malaria-related deaths throughout Sub-Saharan Africa (34). In order for the campaign to be effective it has to properly adapt to many factors that play a major role in its success such as individual self-efficacy, community mobilization, need for an increased budget, proper treatment with artimisin drugs, and effective distribution of insecticide-bathed bed nets. In 2002, 4 years after the start of the campaign, Malaria was still one of the major causes of death in children living in developing countries (35). Such statistics further support the lack of any drastic changes occurring in the worldwide fight against Malaria. In order for the high-set goals to be met by 2015, a deep renovation has to be made in the campaign and further international economic involvement is crucial. Without the necessary international investment in Malaria programs such as this one, Malaria will remain one of the leading causes of death in Africa and other high-risk countries.

References

1. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

2. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

3. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .
4. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

5. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

6. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

7. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
8. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

9. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

10. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

11. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
13. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

14. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .

15. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

16. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .


17. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

18. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

19. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

20. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


21. "African Red Cross & Red Crescent Health Initiative 2001." Red Cross Crescent-African Red Cross & Red Crescent Health Initiative. 13 Jan. 2001. International Federation of Red Cross and Red Crescent Societies. 23 Oct. 2007 .

22. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


23. Sachs, Jeffrey. "Helping the World's Poorest." 13 Aug. 2007. Harvard University. 8 Nov. 2007 .

24. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. 51-64.


25. Africa and the Millennium Development Goals: 2007 Update. United Nations. UN Department of Public Information, 2007. 1-4. 6 Nov. 2007 .


26. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


27. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

28. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .


29. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


30. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .


31. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.53.


32. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.69.


33. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


34. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .


35. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 58.


36. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 59.

37. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

38. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

39. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p. 69.

40. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .


41. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

42. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


43. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .

U.S. Policy of Immigration and Travel Inadmissibility for People Living with HIV/AIDS Fails Reinforces Stigmatization – Sounivone Phanthavong

Section 212(a)(1)(A)(i) of the U.S. Immigration and Nationality Act defines the criteria for “General Classes of Aliens Ineligible to Receive Visas and Ineligible for Admission” to include anyone who “is determined to have a communicable disease of public health significance” (24). As of 1987, HIV/AIDS has been included on the list of communicable diseases classified to be of public health significance. The inclusion of HIV/AIDS occurred with the attachment of the “Helms Amendment”, proposed by Senator Jesse Helms (R-NC), to an extensive appropriations bill (26) supported by the Reagan Administration. The primary focus of the Helms Amendment was to ban the use of federal funds for any AIDS/HIV education and prevention materials that would “promote or encourage, directly or indirectly, homosexual activities”; the recommendation to add HIV/AIDS to the exclusion list and mandatory HIV testing of immigrants was enclosed in this amendment (2).

The Public Health Service (PHS) of the Department of Health and Human Services (DHHS) maintains the list of communicable diseases; with the passing of Immigration Act of 1990, sole authority for the list of communicable diseases was vested to the Secretary of Health and Human Services. Due to the original inclusion of HIV/AIDS by a mandate of Congress, it was argued that only a Congressional law could remove it. Thus, despite the recommendation of the HHS Secretary, Dr. Louis Sullivan, and the Centers for Disease Control to remove HIV/AIDS and all other infectious diseases, except for tuberculosis, from the exclusion list in February 1990, HIV/AIDS remained on the PHS list. Nested within the 1993 bill to expand appropriations of the National Institutes of Health, the immigration and travel inadmissibility policy was voted into legislation resulting in the permanent inclusion of HIV/AIDS HIV on the list of communicable diseases (7, 26). This legislation limited the applications of HIV-infected non-citizens seeking immigrant travel visas, refugee status, legalization, and adjustment of status.

HIV-positive individuals desiring to immigrate to the U.S. or those living in the U.S. attempting to change their legal immigration status may only apply to do so for reasons of family unity or humanitarian grounds (seeking asylum) (20, 24). HIV-positive foreign nationals seeking short-term travel (30 days or less) into the U.S. must apply for a waiver to establish that the danger to the public health and possibility of transmission would be minimal, as well as, provide proof that they would not become a public charge of any federal assistance program. Those applying for a temporary visa can meet these criteria with a statement from a qualified physician about their current asymptomatic HIV/AIDS status also noting that they have been properly counseled about modes of transmission as well as providing proof of private insurance (24). The legislation originally enacted in 1987, and further upheld in 1993, severely restricts the travel and immigration of people living with HIV/AIDS (PLWHA) into the U.S. and affects the legal immigration status of non-citizens with HIV/AIDS living in the U.S. This legislation has been intended to promote the best interest of the public, but actually poses a public health risk creating barriers to testing and care for those who fear the punitive effects on their immigration status. Furthermore, identifying HIV/AIDS as “a communicable disease of public health significance” from which the public must be protected simply reinforces the stigmatization of people living with HIV/AIDS.

U.S. Policy Regarding the Legalization Status of PLWHA Results in Delays in HIV Testing among Immigrants
Immigrants who have reason to believe that they may be HIV positive will view this policy as a deterrent to testing. Aware of the possible repercussions on their legal immigration status, non-citizens will be less inclined to get tested. These non-citizens may also be undocumented immigrants who have entered the U.S. illegally. Undocumented immigrants who may be concerned that their illegal status would be discovered and reported when they seek medical care will likely opt to forego HIV testing (13, 18).

According to the Health Belief Model (HBM), individuals employ a cost-benefit calculation accounting for perceived costs, perceived benefits, perceived susceptibility and perceived severity before choosing to undertake a health behavior (9), such as HIV testing. The punitive consequences that could affect non-citizen populations are perceived costs that may outweigh the perceived benefits of HIV testing. Undocumented immigrants’ fear of deportation/removal becomes a personal barrier to action. The possible denial of permanent residency for those seeking a change in legal immigration status also becomes a perceived cost. While the individual’s perceived susceptibility to HIV infection might be high as well as awareness of the perceived severity, in the cost-benefit analysis the HBM suggests, fear of removal and denial of permanent residency status will usually be more consequential than knowing one’s HIV status (6, 18).

As the policy results in delays in HIV testing, it poses a public health risk in terms of both primary and secondary HIV prevention. It is important for PLWHA to be informed of their infection status and delays in testing may also critically delay prevention efforts. Without proper counseling and education regarding modes of transmission, PLWHA may continue to transmit the disease to others. If those infected are not aware of their HIV status, they will not take the necessary precautions to try to prevent further transmission (19, 22). Primary prevention of HIV transmission is particularly important in immigrant populations, where lack of informed knowledge can be a serious barrier to action (19). Secondary prevention is aimed at early detection and treatment to slow disease progression; delays in HIV testing reduce opportunity for interventions of secondary prevention efforts (6, 10).

Limits Accessibility to Health Care and Social Services
By limiting the options of non-citizens infected with HIV/AIDS to become permanent residents, this policy also restricts their access to health care. Members of immigrant populations, both legal and undocumented, are often among the most marginalized populations in society. They often face many obstacles due to their lack of legal status, including lack of medical insurance and limited access to health care. Due to welfare reform, undocumented immigrants are ineligible for most federal assistance programs and legal immigrants face a number of restrictions to obtaining federal assistance (11, 17). Inability to change their legal immigration status also affects the ability to access employment that may provide benefits such as private insurance. Without insurance, publicly assisted or private, the cost of HIV treatment is substantial and becomes a financial barrier to treatment for these populations of non-citizens (3, 10).

Concerned with their legal status, HIV positive immigrants often delay seeking medical care or treatment until their disease is advanced and they are co-infected with other opportunistic infections (8, 18). Without access to insurance and advanced disease presentation, immigrant PLWHA may require hospitalizations that can place a large burden on the health care system and public resources. The policy would thereby create one of the effects it was intended to counteract, by providing no other option for these immigrants but to become public charges (7). A delay in accessing medical care and lack of access to appropriate treatment leads to poorer health outcomes among HIV positive immigrants. However, early initiation of treatment, such as antiretroviral therapy, can improve CD4 counts hopefully slowing the progression to AIDS disease and allowing for better control of overall health status (6). Concerns regarding legal immigration status may also interfere with the comfort level of these HIV positive patients to share information with their health care providers. Fear of reporting affects the rapport that is otherwise expected with the understanding of doctor-patient confidentiality (8, 21). If patients are not forthright with their medical care providers, their treatment and health outcomes could be severely compromised.

Confluent with the limited access to health care, immigrants will be less likely to take advantage of counseling and social support services. These services are intended to help individuals manage their illness and provide informed knowledge about their health, possible treatment and available support services. When PLWHA are fearful of disclosing their HIV/AIDS status to medical care providers, social workers, community outreach workers, peer groups and in some cases, their families, they lose opportunities to fully benefit from treatments and services (19, 22). When fears regarding immigration status are compounded with health concerns, social support becomes vital for the individual to cope with the demands of their illness.

Further evidence of the plight of immigrant populations to be adequately informed about available support is their lack of use of the AIDS Drug Assistance Programs (ADAP). Established by the federal government and regulated by each state, ADAP aims to assist the uninsured and underinsured, such as those of the immigrant population. ADAP removes the financial barriers to treatment by providing HIV-related drugs at no cost. However, the numbers of immigrants accessing these programs is relatively low compared to the proportion of immigrants composing the population of uninsured/underinsured (15, 19). Many undocumented individuals may not realize that they can qualify for services such as ADAP.
Reinforces Stigmatization of PLWHA

According to Brinlow et al of DHHS, “HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS” (4). The HIV-related stigma is not only experienced by immigrants but by all individuals perceived to have HIV/AIDS. A policy that treats HIV/AIDS status as a reason for exclusion only further reinforces negative public perception of PLWHA as a group of infectious individuals who should be shunned and from whom the public requires protection.

The reinforcement of this stigmatization can be examined with Labeling/Stigma Theory. According to the precepts of Labeling/Stigma Theory, individuals are likely to internalize the negative public perception, which may cause guilt, make individuals feel forced to hide their HIV status or drive them to adopt unhealthy behavior that may be considered associated with the stigma (4, 27). As such, stigma affects all aspects of the lives of HIV-positive individuals and thus, all phases of the management of their illness. Stigma may deter individuals from seeking testing, even if results are negative, they may fear the opinions of others for getting tested at all (6, 22). Due to fear of discrimination, PLWHA may choose to limit the disclosure of their HIV status, which may affect their access to treatment or social services and support (18). As medications must often be taken on a regimented schedule, concern about HIV status being discovered may interfere with adherence to treatment. With regard to the travel ban restrictions, PLWHA attempting travel to the U.S. who choose not to apply for a waiver may disrupt their treatment by choosing not to travel with their HIV/AIDS medications that will make them more likely to be questioned and barred entry (1).

The instatement of the policy in 1987 was reflective of the general public fear and lack of knowledge in regards to HIV/AIDS in the 1980s. Proponents of the immigration ban have argued that U.S. admission of HIV positive individuals will become public charges placing an excessive burden on public resources, as HIV/AIDS is a chronic disease (7). This idea further reinforces the stigma of HIV/AIDS, as no other chronic disease is included on Public Health Service list of criteria for immigration and travel inadmissibility.

Time to Move Beyond Inadmissibility
Since its introduction in 1987, the U.S. immigration/travel inadmissibility policy, later codified into legislation, has been a source of controversy. It was established for the protection of the public health; its advocates noted that it would inadvisable to fuel an epidemic by allowing HIV infected persons to enter the country and that it would be detrimental to the health of all U.S. citizens (7, 14). Upon evaluation of this policy with reference to the Health Belief Model, Labeling/Stigma Theory and social science literature, it is evident that rather than promoting the health of the public, the policy poses a public health risk to HIV positive members of the immigrant population by affecting their access to testing and care. Moreover, it fails to promote the health of the public at large, as it is also impedes prevention efforts and reinforces stigmatization of HIV/AIDS.

On World AIDS Day 2006, the White House produced a fact sheet entitled “The President is Dedicated to Ending Discrimination Against People Living with HIV/AIDS”. This fact sheet included a statement proposing a categorical waiver for HIV-positive people seeking to enter the United States on short-term visas; no further action followed the issuance of this statement (2). As of September 2007, H.R. 3337: HIV Nondiscrimination in Travel and Immigration Act of 2007 was introduced by Rep. Barbara Lee (D-CA): “To remove from the Immigration and Nationality Act a provision rendering individuals having HIV inadmissible to the United States, and for other purposes” (12). This bill is in the first step of the legislation process and has been referred to the Subcommittee on Immigration, Citizenship, Refugees, Border Security, and International Law (12, 14). Passing this bill would reverse the immigration/travel ban first initiated in 1987 and move beyond an inadmissibility policy that failed in its own aims to protect the public’s health by reducing HIV/AIDS transmission. The HIV Nondiscrimination in Travel and Immigration Act would affect the lives of PLWHA and the public health at large, succeeding where its counterpart legislation did not; it will promote public health by removing structural barriers to access and care and take a significant step towards eliminating stigmatization of HIV/AIDS.

REFERENCES
1. Adam BD, Maticka-Tyndale E, Cohen JJ. Adherence Practices among People Living with HIV. AIDS Care 2003; 15:263-74.
2. Bernard EJ. US Promises ‘Streamlined’ Process for HIV-positive Tourist Visas. Aidsmap 2006: http://www.aidsmap.com/en/news/5FAF6B5F-A486-4E50-A0A6-7C3AFD0530F5.asp.
3. Borjas GJ. Welfare Reform, Labor Supply, and Health Insurance in the Immigrant Population. Journal of Health Economics 2003; 22:933-958.
4. Brinlow DL, Cook JS, Seaton R, eds. Stigma and HIV/AIDS: A Review of the Literature. U.S. Department of Health and Human Services 2003; http://hab.hrsa.gov/publications/stigma/front.htm.
5. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report: HIV Infection and AIDS in the United States and Dependent Areas, 2005.
6. Chesney M, Smith A. Critical Delays in HIV Testing and Care. The American Behavioral Scientist 1999; 42:1162-1174.
7. Clymer A. House, Like Senate, Votes to Ban H.I.V. Immigrants. New York Times, 1993 March 12.
8. Cunningham CO, Sohler NL, Wong MD, Relf M, Cunningham WE, Darinoni ML, Bradford J, Pounds MB, Cabral HD. Utilization of Health Care Services in Hard-to-Reach Marginalized HIV-Infected Individuals. AIDS Patient Care and STDs 2007; 21:177-186.
9. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
10. Foley EE. HIV/AIDS and African immigrant women in Philadelphia: Structural and Cultural Barriers to Care. AIDS Care 2005; 17:1030-1043.
11. Gardner DB. Immigration and Health Care Reform: Shared Struggles. Nursing Economics 2007; 25:235-237.
12. GovTrack. Legislation, 110th Congress. http://www.govtrack.us/congress/bill.xpd?bill=h110-3337
13. Howe M. Aliens Testing Positive for AIDS Are Said to Be Giving Up on Legalization. New York Times, 1989 August 18.
14. Immigration Equality. HIV Issues. New York: Immigration Equality. http://www.immigrationequality.org
15. Kaiser Family Foundation. National ADAP Monitoring Project Annual Report. Washington, DC: Henry J. Kaiser Family Foundation 2007.
16. Kim, Rebecca Y. Welfare Reform and “Ineligibles”: Issue of Constitutionality and Recent Court Rulings. Social Work 2001; 46:315-323.
17. Kullgren, JT. Restrictions on Undocumented Immigrants’ Access to Health Services: The Public Health Implications of Welfare Reform. American Journal of Public Health, 2003; 93:1630-1633.
18. Levy V, Prentiss D, Balmas G, Chen S, Israelski D, Katzenstein D, Page-Shafer K. Factors in Delayed HIV Presentation of Immigrants in Northern California: Implications for Voluntary Counseling and Testing Programs. Journal of Immigrant Health 2007; 9:49-54.
19. Morin SF, Carrillo H, Steward WT, Maiorana A, Trautwein M, Gomez CA. Policy Perspectives on Public Health for Mexican Migrants in California. Journal of Acquired Immune Deficiency Syndrome 2004; 37:S252-S259.
20. Neilson V. HIV-Based Persecution in Asylum and Immigration Decisions. American Bar Association 2004; 31:8-9.
21. Okie, Susan. Immigrants and Health Care – At the Intersection of Two Broken Systems. New England Journal of Medicine 2007; 357:525-529.
22. Shedlin MG, Drucker E, Decena CU, Hoffman S, Bhattacharya G, Beckford S, Barreras R. Immigration and HIV/AIDS in the New York Metropolitan Area. Journal of Urban Health 2006; 83:43-58.
24. U.S. Citizenship and Immigration Services. Immigration and Nationality Act. Washington, D.C: U.S. Citizenship and Immigration Services. http://www.uscis.gov/
25. Vanable PA, Carey MP, Blair DC, Little W. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behavior 2006; 10:473-82.
26. White N. The Tragic Plight of HIV-Infected Haitian Refugees at
Guantanamo Bay. Liverpool Law Review 2007; 28:249-269.
27. Wikipedia. Labeling Theory. Wikipedia, The Free Encyclopedia. http://en.wikipedia.org/wiki/Labeling_theory.

The Failure of PEPFAR and its ABC Campaign - Erin Lee

The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity… is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” HIV, also known as the human immunodeficiency virus, has played a major role in preventing thousands of people from obtaining this definition of health. In response to this growing crisis, the United States of America proposed an initiative to fight HIV/AIDS in some of the world’s most vulnerable countries. Known widely as the President’s Emergency Plan for AIDS Relief (PEPFAR), this initiative was created in 2003 with the goal of preventing 7 million new infections, treating 2 million people living with AIDS related illnesses, and providing care and support for 10 millions person affected by AIDS. One of the largest sources of international funding for HIV/AIDS, PEPFAR requires its beneficiaries to use one-third of the fund to promote its ABC (Abstinence, Be Faithful, Condom Use) campaign (8). However, the ABC campaign is an inefficient public health initiative because it does not incorporate the theories behind social and behavioral sciences in its implementation of programs to tackle HIV/AIDS in developing countries.

PEPFAR and Cultural Anthropology

Cultural anthropology is defined as an approach that strives to “understand and explain health behavior as part of a pattern of living that integrates action with meanings, symbols, and values, as these are connected to a larger social structure” (1). In order to create an effective public health intervention, one needs to incorporate the community and its perception of the health condition. In other words, the “behavior cannot be separated from its larger context” (1). For example, before implementing a child vaccination program, one needs to understand the local practices and their views toward vaccinating their children.

One reason why the ABC campaign is ineffective in its approach to tackle HIV/AIDS is because it fails to incorporate the ideas behind cultural anthropology. PEPFAR uses the principles behind “A” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that “Abstinence” can reduce the HIV transmission rates in many of these developing countries. However, this idea of abstinence is culturally ignorant because it does not acknowledge that sex may be used for different reasons (i.e. other than sexual pleasure) around the world. “Many sexual relationships include transactional or commercial sex, in order to pay for post-secondary schooling, to gain financial independence from family obligations, or to provide adequate resources for those contained in IDP camps” (2). Sex in these situations is used as a tool for survival and as a result abstinence is not an option.

In addition to being culturally ignorant, the promotion of abstinence assumes that other cultures also have a negative view towards premarital sex. As a result, this contributes to the stigmatization and demoralization of people who become infected with HIV. “Promoted evangelically, even in the context of generalized epidemics… the A/B-only message suggests that HIV negative people can prevent infection by moral fortitude” (7). This view not only stigmatizes HIV patients, but also reduces the general population’s self-efficacy to reduce HIV transmission. For example, if one cannot live a life of abstinence, one might assume that HIV infection is inevitable. Thus, this might discourage someone to have the self-efficacy to practice safe sex. By mandating its beneficiaries to promote abstinence, PEPFAR is essentially forcing U.S. based Christian ideals that premarital sex should be avoided.

The way sex is used is different depending on the culture and attitudes of its people. It is difficult to use abstinence as a preventive measure when sex is used as a tool for survival. As a result, PEPFAR and its promotion of abstinence fail to acknowledge the cultural issues surrounding HIV transmission. One way to remedy this problem is to do an anthropological study to determine the values and perception of sex found in these different countries, instead of forcing them to use abstinence as a form of prevention.

PEPFAR and Self-Efficacy

Self-efficacy is defined as a “person’s belief in his or her ability to take action” (1). It is considered as “one of the keys to change” and is needed for an individual to adopt a new behavior (1). For example, it is very difficult for an individual with the intention to quit smoking to actually change behavior if he/she lacks the self-efficacy to overcome his/her addiction to tobacco. The low level of confidence in his/her ability to fight the addiction hinders one’s ability to change the negative behavior. As a result, intention alone is insufficient to alter behavior if one lacks self-efficacy.

The ABC campaign is limited in its effectiveness in developing countries because of its failure to take into account the concept of self-efficacy. PEPFAR uses the principles behind the “B” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that if an individual has the intention to “Be Faithful” and is married, one has the ability to prevent the transmission of HIV. Ironically, by “promoting marriage as a prevention measure, this campaign negates one of the highest risk groups in Africa: monogamous, married women” (2). Despite their intention and commitment to marriage/being faithful, many of these women are vulnerable to HIV because of their sexually active husbands. Married men in many of these developing countries participate in extramarital sexual activity, which makes them susceptible to HIV transmission (4). Women in these countries lack the self-efficacy to protect themselves from their HIV infected husbands because they do not have the right to refuse their husbands sex (5). For these women, the ABC approach does not protect them from HIV infection because of the ineffective prevention strategy of unilateral monogamy.

As the feminization of HIV/AIDS increases, public health interventions need to address the issues faced by women in order to decrease the number of HIV/AIDS cases in developing countries. If PEPFAR wants to prevent 7 million new infections, it needs to incorporate the concepts of self-efficacy in its ABC campaign. The preventive measure to “Be Faithful” is not enough to protect these women because of their unequal relationships with their husbands. “The presumption that marriage is somehow protective is misleading and potentially dangerous for young women” (2). Since marital sex has become a major risk factor for HIV among women, prevention programs need to make extramarital sex safer (6). For example, one way the ABC approach can be more effective is to incorporate a campaign within the “Be Faithful” campaign to promote gender equality. This could be accomplished through the media with the goal of changing society’s perception of the male/female relationship. Ultimately, if PEPFAR wants the ABC approach to be a sustainable preventive measure, it needs to give women the confidence and self-efficacy to take action.

PEPFAR and the Theory of Planned Behavior

Another reason why the ABC approach does not work in developing countries is because it fails to incorporate the ideas behind perceived behavioral control/power. According to the Theory of Planned Behavior, “behavioral intention alone is not a sufficient predictor of behavior” and as a result one needs to consider the concept of perceived behavioral control/power, which “refers to the degree to which someone believes they have control over whether they can take action and the strength of that belief” (1). This theory emphasizes the point that intention alone is not enough to alter one’s behavior if one does not believe he/she has the power or control to take the necessary actions to change his/her behavior. For example, one’s intent to have safe sex and/or decrease sexual partners is insufficient when one does not believe he/she has the power or control to overcome the external issues preventing him/her from changing one’s behavior.

This idea that intention must be coupled with an individual’s perceived behavioral control/power in order to successfully change behavior can be seen in the failed attempts to reduce HIV transmission rates in internally displaced person (IDP) camps. The unstable and fragile political situations found in most developing countries have contributed to the 1.6 million people living in IDPs (3). Reducing HIV/AIDS cases in these camps has proven to be difficult because of the lack of power/control individuals have in preventing HIV transmission due to its limited resources. “The HIV/AIDS prevalence rates in IDPs… may be attributed to insufficient condom provision and inadequate sexual education in an area where control over sexual exposure to HIV is limited” (2). Lack of resources in IDPs highlight the ineffectiveness of the “C” found in the ABC approach, which is the promotion of condom use. Even if an individual has the intent to use condoms and practice safe sex, it is difficult to expect a change in behavior when the individual does not have the power/control to access the necessary condoms.

By putting the emphasis on individual behaviors, the ABC campaign does not acknowledge the underlying factors that make people living in IDPs vulnerable to HIV/AIDS. Condom use to decrease HIV transmission is impractical when these camps do not have the resources to provide its community members condoms. If PEPFAR wants its beneficiaries to incorporate the ABC approach, it needs to make sure that these countries are providing its’ camps with the necessary resources. For example, one way to remedy this situation is to provide one condom for every dollar PEPFAR donates to its beneficiaries and monitor the distribution of these condoms in the IDPs. This provides people living in IDPs with the intent to practice safe sex also have the power/control to access the condoms needed to perform the behavior. Otherwise, the principles behind the “C” of the ABC approach are not enough to change behavior because it does not provide the power/control to overcome the external obstacles of living in IDPs.

Conclusion

Despite PEPFAR’s goal to reduce HIV/AIDS in developing countries, the “ABC strategies dismiss the real social, political, and economic causes of the epidemic, and end up blaming infected people, because it is implied that they failed to adopt and practice the ABCs” (2). Many of these programs fail because they do not incorporate the important concepts behind cultural anthropology, self-efficacy, and perceived behavioral control/power. The ideas behind abstinence fail to recognize that the definition of sex is different in different cultures and as a result is culturally ignorant. The ideas behind being faithful fail to recognize that marriage does not protect women in relationships of unequal power. The ideas behind condom use fail to recognize that condoms are not always available especially in areas of limited resources. These examples only highlight the multifaceted and complex nature of HIV/AIDS. As a result, in order to tackle this growing epidemic, PEPFAR needs to develop a new campaign that incorporates all these complex issues by referring to the many different levels of social and behavioral sciences.

REFERENCES

1. Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

2. Murphy E. Was the “ABC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda’s Decline in HIV? PLoS Medicine 2006; 3:1443-1447.

3. Lowicki-Zucca M. AIDS, Conflict and the Media in Africa: Risks in Reporting Bad Data Badly. Emerg Themes Epidemiology 2005; 2:12.

4. Ntozi JP. Has the HIV/AIDS Epidemic Changed Sexual Behavior of High Risk Groups in Uganda? Afr Health Science 2003; 3:107-116.

5. Gage AJ. Factors Associated with Self-reported HIV Testing Among Men in Uganda. AIDS Care 2005; 17:153-165.

6. Hirsch JS. The Inevitability of Infidelity: Sexual Reputation, Social Geographies, and Martial HIV Risk in Rural Mexico. Am J Public Health 2007; 97:986-996.

7. Health Global Access Project. Health GAP Report – Between the Lines (GAO Report on PEPFAR Prevention Programs: U.S. Abstinence/Being Faithful-Only Programs Produce Stigma and Death). New York, NY: Health Global Access Project. Nttp://www.healthgap.org.

8. Office of the United States Global AIDS Coordinator (2004) Appendix 2: The Emergency Plan for AIDS Relief: Fiscal year 2004 Prevention Expenditures and Program Classification Criteria. Washington (D.C.): US Department of State.

Pressure to Eliminate an Age-old Practice: Discussion of failures in Egypt’s attempts to ban Female Genital Mutilation – Sarah Munson

Introduction

Although mortality has long been a risk associated with the age-old practice of female circumcision, the recent deaths of two young Egyptian girls due to complications of the procedure have been heavily publicized in the international media creating a renewed pressure for the government to intervene. Worldwide efforts to eliminate these practices are failing; there are an estimated 100-140 million girls and women who have undergone some form of circumcision, with an additional 3 million girls expected this year. The prevalence remains high in Egypt as well as 27 other countries around the world, mainly in Africa, Asia, and the Middle East (1). Adding to the problem, the international community vastly underestimates the complexity of socio-cultural factors surrounding and perpetuating this tradition.

There are a number of terms used to describe this practice, including female circumcision, female genital cutting, female genital operations, female genital torture, or female genital mutilation. The chosen term will effectively elicit different responses. While advocates of these practices use circumcision, for the purpose of this paper, female genital mutilation (FGM) will be used. The background, including cultural beliefs and previous efforts to limit the practice, is important for understanding why an effective intervention is imperative. Three of the most recent intervention programs will be critically considered in light of tradition, politics, and social science theory. These include the 2007 government issued ban, an intervention program developed by the National Council on Childhood and Motherhood, and the UNICEF supported local non-governmental organization, Better Life Association for Comprehensive Development (BLACD). Social Cognitive Theory reveals how these approaches to reducing the prevalence of FGM, all different in scale and design will fall short.

Background: Statistics, Definitions, and Health Consequences

Female Genital Mutilation (FGM) is defined by the World Health Organization, UNICEF, and the United Nations Population Fund (UNFPA) as “the partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non-therapeutic reasons” (7). Ninety-six percent of women in Egypt have endured some form of FGM, while 90% of girls were between five and 14 years old when they underwent FGM. The procedures are more recently performed by health care professionals, but are also still practiced by midwives without anesthetic or by barbers using scissors, razors, or knives. There are no known health benefits, yet many feel that “it is an integral part of their cultural and ethnic identity” and that it is necessary for purity, beauty, and chastity (6).

There are four types of FGM divided into Type I, II, III, and IV as defined by the World Health Organization in collaboration with UNICEF and UNFPA:

Type I – excision of the prepuce, with or without excision of part or the entire clitoris.

Type II – excision of the clitoris with partial or total excision of the labia minora.

Type III – excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening, also called infibulation.

Type IV – pricking, piercing, or incising the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissues surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above (1).

Infibulation, seen in Type III, is the most severe form of FGM and accounts for an estimated 15% of all procedures. Comprising nearly 80% of all procedures is the excision of the clitoris and the labia minora, seen in Type II (7).

It is not surprising that these procedures result in an appalling array of health complications. Often FGM is performed without anesthesia, causing overwhelming pain and clinical shock. Infections are common due to unregulated conditions under which FGM may be performed; HIV/AIDS has become a greater concern, but more commonly blood poisoning known as septicemia and bacterial diseases such as tetanus occur (1).

In the long-term cysts, abscesses, keloids (thick, raised scars), damage to the urethra, painful intercourse (dyspareunia), and difficulties with childbirth can occur. The physical health complications are generally coupled with a variety of psychological and psychosomatic disorders. These have been difficult to measure as women commonly suppress these symptoms and deny psychological effects. These may include impaired cognition, recurring nightmares, panic attacks, prolonged stress, and long-term trauma. This psychological detriment can create farther-reaching problems like inhibiting the ability for women to obtain an education. The battle to reduce FGM begins with empowering and educating women; the WHO emphasizes these effects of FGM on a girl’s education in building a stronger argument against FGM (7,1).

The Egyptian Department of Health Services conducted a survey in 2005 to collect data quantifying the far-reaching effects of tradition. There were 19,474 Egyptian women included in the study; revealed from this population was 96% prevalence of FGM among ever-married women between ages 15 and 49. The data also show varied prevalence due to place of residence, level of education, and financial status. Women of higher education and in the highest wealth quintile have a reduced prevalence: 92% and 87%, respectively. Women with greater wealth and higher education have a more objective view of FGM and its risks, as wealth relieves some of the financial and social pressures that typically bind young women to these practices. Ninety-nine percent of women in rural Lower Egypt have been circumcised. This rural and less wealthy population shows an increased amount of support for FGM; it is more important for the family to receive the greatest bridewealth possible for their daughters’ marriage. Women supporting the continuation of FGM comprise 2/3 of the surveyed population and there is very little recognition among women of the potential health consequences. In addition, 60% of ever-married women feel that FGM is a requirement of religion (8).

Despite the use of religion as justification for FGM, the practice predates both Christianity and Islam. Evidence from Egyptian mummies show that forms of female circumcision existed some 5000 years ago (1). The cultural roots of this practice reach so deep that it seems nearly impossible to change. Studies by the New Women Research Center in Cairo, Egypt have shown that women claim two main reasons for FGM. First, circumcision reduces a woman’s sexual desire, ensuring the preservation of her virginity before marriage. Second, circumcision accelerates the achievement of femininity; this can also be seen as a rite of passage into womanhood (2). In addition to the aforementioned, many other factors sustain the tradition. These include coming of age and reason for celebration, ensuring the prospects of a husband, enhancing male pleasure during sex, promoting cleanliness and beauty, and for religious purification (6).

Tradition, Intervention, and Social Science Theory

With an understanding of the practices of Female Genital Mutilation and the associated health concerns, this section will focus on the current happenings in Egypt. Social Cognitive Theory will be applied to three interventions to show how each lacks key elements for success. First will be the recent June 28, 2007 government issued ban. Second will be the National Council of Childhood and Motherhood, a government agency working to reduce the prevalence of FGM. Finally, the intervention techniques of the Better Life Association for Comprehensive Development (BLACD) a non-governmental organization in Minya, Upper Egypt will be discussed.

In a New York Times international podcast, Michael Slackman, Cairo Bureau Chief and New York Times correspondent, referred to the “confluence of events” shaping Egypt’s recent stand on FGM as “the perfect storm” (9). This refers to an unprecedented merging of powers in Egypt following the international broadcast of the deaths of two young girls in the summer of 2007. On June 28, the Minister of Health and Population issued a decree criminalizing FGM. Coinciding with this decree was a statement released by the highest religious authority of Egypt, Al-Ashar Supreme Council of Islamic Research, saying FGM had no place in Islamic law. Additionally, Ali Gomaa, Egypt’s grand mufti declared FGM “haram,” or prohibited by Islam.

Representing the common opinion of Egypt’s leadership, television advertisements and billboards have become commonplace; the broadcasts air on state television channels and billboards have been placed in urban and rural communities alike (9). Susan Mubarak, wife of President Hosni Mubarak, has become very vocal on the issue and in support of the National Council of Childhood and Motherhood. This combination of international pressure, government influence, non-government organizations, religious leaders, local activists, and the media has resulted in Egypt’s strongest fight against FGM.

Although the government is able to shut down clinics and discourage the practice, the ban has not yet passed legislation; without formal legislation FGM cannot be punishable by law. Even if legislation is enacted many are skeptical that punishments will be enforced. Similarly, the use of media fails to account for geographic regions where television may not be available. In addition to these apparent gaps, there are many other reasons this ban will be ineffective. Primarily, the government issued ban does not account for the power of social norms, environment, and self-efficacy as embodied by Social Cognitive Theory and Social Expectations Theory.

A variety of theories have been developed in the field of social and behavioral sciences to explain individual behavior. Albert Bandura’s Social Cognitive Theory combines a series of individual characteristics with a series of environmental factors that both influence behavior. The individual characteristics include self-efficacy, behavioral capability, perceived expectations, self-control, and emotional coping. Equally important, the environmental factors include vicarious learning, reinforcement, and conscious operating (12). Each of these factors must be addressed to change behavior. To effectively implement a program to reduce FGM, it is helpful to focus on the how the individual consciously operates in their immediate environment and whether these individuals have the perceived self-efficacy and behavioral capability necessary in achieving the goal of the intervention.

Bandura emphasizes the idea of vicarious learning; actions can be predicted by examining what is observed within the environment. The environments where this procedure is most common greatly impact the decision to practice FGM. Egypt persists as a strongly patriarchal society; however, families, peers, and entire communities insist that this practice continue to maintain social order. Men in Kafr Al Manshi Abou Hamar were outraged at the government ordered closing of a clinic that had routinely offered circumcisions after a 13 year-old girl bleed to death. One man protested, “even if the state doesn’t like it, we will circumcise the girls!” As men control the majority of decisions made regarding their families, especially their daughters, they drastically hinder the eradication of FGM (9).

The opinions of older women also influence a girl’s perception of FGM. Her ability to oppose circumcision cannot exist in an environment where the people she trusts the most require this of her, as “people tend to describe FGM as a form of violence that is performed by women on women” (2). Girls have very few alternatives if their family feels strongly that FGM is required. They may mean being cut by force or sent away from the home without resources to provide for themselves. These harsh alternatives represent the extent to which Egyptians believe FGM is necessary to assimilate girls into society. Fears of sexual liberation and rebellion have the potential to brand both the girls and the families with shame. The lavish ceremonies that generally accompany FGM, where families are honored and girls receive gifts, are outward proof of adherence to tradition. In any case, the girl’s wishes are often irrelevant (6). The greater challenge “rests in persuading people that their grandparents, parents, and they themselves have harmed their daughters” (9). The social pressures that exist are significant and have proven difficult to change.

The National Committee on Childhood and Motherhood has attempted to address these societal pressures. This governmental agency works to close the gaps left by the government ban geographically, socially, and legislatively. They work in 120 villages around the country to locally promote women’s rights. In February of 2000, the President officially recognized the National Council of Childhood and Motherhood as a governmental agency in a decree. Their initiatives include monitoring and evaluating the existing policies towards women, researching women’s issues and collecting data, proposing public policies for development and empowerment of women, drafting laws related to women, and training women to raise awareness and promote their rights. The NCCM operates with reasonable efficacy and adequate resources provided by the government (11).

Mosheira Khattab, head of the NCCM has declared their position with regard to FGM. They aimed to have the government ban replaced by law in November of 2007 and are currently still working for a prompt enactment of legislation. The NCCM has opened a hotline to anyone interested in obtaining information and aim to keep the information unbiased and allow people to make rational decisions based on the obvious harms and risks. The hotline represents an intervention based on the Theory of Reasoned Action, which incorporates three major factors in behavioral change: attitude, subjective norms, and behavioral intention. Unfortunately, the NCCM neglects the influence of environmental factors; they think that if they can simply change people’s attitudes, the behavior will follow. Social Cognitive Theory demonstrates that “attitudes and subjective norms are not sufficient determinants of intentions and that intentions are not a sufficient impetus for action” (10).

Social Expectations Theory is similar to Social Cognitive Theory but it only takes into account two very important aspects of behavior: intention and social norms. Social norms are defined as “customary codes of behavior in a group or culture, together with the beliefs about what those codes mean” (12). The customary codes of behavior that exist in Egypt are strict ways of defining identity and roles in society. If the NCCM incorporated a way to deal with social norms into their interventions they may be able to change the social environment, making it more acceptable to oppose FGM. Basing change on the rationale of informed individuals has logical implications but will fail in application. Egypt is a country where individual level change can only happen if the social environment is accepting.

Established in 1995 in Minya, Upper Egypt, the Better Life Association for Comprehensive Development (BLACD) has followed a “Rights Based Approach” to improving the quality of life among the poor and deprived people in Egypt. They currently work in five areas of development: democracy and human rights, education, housing, economic empowerment, and health. Their first experience in fighting FGM was in 2004 when they began holding community meetings, collecting data on local opinions, training doctors, midwives, teachers, and girls to promote women’s rights. The meetings have featured religious leaders and trained doctors offering opinions negating the medical, social, and religious justification for the practice. BLACD receives funding and sponsoring for many of the meetings and training sessions from UNICEF (13).

Much of the research initiated by BLACD follows the appropriate steps; before developing programs of action, extensive time and effort has been spent in assessing the obstacles and evaluating the most effective intervention. However, one program developed by BLACD in 2006 utilizes individuals who have already chosen to stand against FGM to promote their views. “Positive deviants” as they are referred to, “undertake awareness-raising activities within their community to educate people on the harms of FGM and persuade them to abandon the practice” (5). This program, like that of the NCCM, fails to account for social environmental factors.

As mentioned before, Social Cognitive Theory stresses the influence of the environment on individual behavior. The “positive deviants” target young girls who are rarely the ones who choose to undergo FGM. Mothers, fathers, sisters, brothers, extended family members, and peers all contribute to the environment surrounding the individual. To be effective, the program must deal with this social environment, targeting families in addition to young girls for the possibility of change.

Although advocates of FGM emphasize the importance of tradition and culture, the practice goes beyond this, embodying an entire national identity. According to Adia Seif El Sawali, “it has to do with the perception of one’s role in the world, with a complete self-image” (2). It is this very concept that creates tension within the international community, mainly ‘the West,’ and pushes for a change in these harmful practices. Egyptian identity has become increasingly important to preserve, and FGM is a way to resist cultural imperialism.

The girls who are coming forward as positive deviants and promoting change risk being sent away from their families, socially ostracized, or killed. An example comes from the New York Times article, ‘Voices Rise in Egypt to Shield Girls from an Old Tradition.’ Fatma Ibrahim, a 24-year-old woman, claims she is still haunted by her experience with circumcision. She was 11 and her parents told her she was at the doctor for routine blood tests. The doctor put her to sleep and when she woke, she was unable to walk. She hopes to spare other women the trauma she has had to endure by volunteering as a positive deviant, but says, “my parents at home don’t know that I work in FGM, and if they find out, they’ll kill me” (9).

The fact that this violent practice continues today is representative of Egyptian values. If interventions can address these core values they may be able to change the social environment such that girls can take comfort in making their own decisions. Influential international powers are appalled that this government has allowed such a prolonged and invasive violation of basic human rights, and the resulting pressure is important to fuel the eradication of FGM, but it is equally important that appropriate interventions, modeled after appropriate theories of behavior, be developed.

As discussion of the topics surrounding FGM, including women’s rights, female sexuality, and the short and long-term risks, has become more candid at the international and local level, the pressure for the government to better address these issues grows. This pressure peaked in 1994 making the United Nations International Conference on Population and Development “a turning point in the approach taken to address FGM” (2).

Female genital mutilation found its way into the conference alongside issues such as development aid, financial commitments, and other public policies through the Program of Action to aid children and women. As stated in section 4.17 of the program, “one of the aims should be to eliminate excess mortality of girls, wherever such a pattern exists.” Later in section 4.22, more specifically, “governments are urged to prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among non-governmental and community organizations and religious institutions to eliminate such patterns” (3).

Although the government and the UN recognized FGM in the resulting program, it was a heated topic of debate during the conference. In response to the discussion of such topics as abortion, FGM, and reproductive rights, citizens unassociated with the conference were aggressively vocal. They feared their government would act in accordance with international pressure rather than account for its citizens’ beliefs. However, “reform is often a top-down process in which national laws are developed to change rather than reflect local attitudes” (14). This has certainly become the case in banning FGM, where “governmentally enforced laws that touch on personal aspects of people’s lives in Egypt can invite hostility rather than respect for the law” (2). The local opinion was that these discussions were “attempts to violate our traditions, our culture, our norms, vis-à-vis a Western agenda that wants to negate us as a nation” (2).

Since then it is clear that the government is unsure of how to appropriately confront FGM. In 1996, the Health Minister issued a decree prohibiting “all medical and non-medical practitioners from performing FGM in either public or private facilities, except for medical reasons certified by the head of a hospital’s obstetrics department […] [P]erpetrators are subject to the loss of their medical licenses and can be subjected to criminal punishments. In cases of death, perpetrators are also subject to charges of manslaughter under the Penal Code” (4). The decree was tried in the Court of Cassation, the highest appeals court in Egypt, and upheld as a government ban. Because of this medical exception, FGM has persisted in both medical and other facilities including barber shops and homes. Exacerbating this situation is the fact that doctors now have a new financial incentive to perform more surgeries at the expense of women (2). This has been the situation until the 2007 renewed government interest in eradicating FGM.

For the last decade, despite efforts by non-governmental agencies, little headway has been made in reducing FGM; this is painfully obvious with the 2005 survey showing 96% prevalence. The recent collaboration of the government with non-government organizations, religious leaders, and international organizations offer the potential for new agendas in achieving a significant decrease in FGM. This combination may be just right for addressing each individual and environmental factor for behavioral change called for in Social Cognitive Theory. Proving the importance of honoring basic human rights, promoting women’s rights, gaining male support, spreading information about health risks, and changing the social norms may, in combination, slowly eradicate FGM. Female genital mutilation has been practiced for over 5000 years and has acquired a complicated web of traditions that cannot be undone without careful analysis of both individual level and environmental level factors for effective interventions.

References

1.UNDP/UNFPA/WHO/World Bank Special Programme of Research,

Development, and Research Training in Human Reproduction. Progress in

Sexual and Reproductive Health Research: Female genital mutilation – new knowledge spurs optimism. 2006.

http://www.who.int/reproductive-health/hrp/progress/72.pdf

2. Sawala, Aida Seif El. The Political and Legal Struggle over Female Genital Mutilation in Egypt: Five Years Since the ICDP. Reproductive Health Matters 1999. 13: 128-136

3. Programme of Action of the UN ICPD. 1994. 4.17-4.22.

www.iisd.ca/Cairo/program/p04006.html

4. Office of the Senior Coordination for International Women’s Issues. Egypt: Report on Female Genital Mutilation (FGM) or Female Genital Cutting (FGC). 2001. http://www.state.gov/g/wi/rls/rep/crfgm/10096.htm

5. UNICEF: Fresh progress toward the elimination of female genital

mutilation/cutting in Egypt. http://www.unicef.org/egypt/FinalNewsletter.pdf

6. Althaus, Frances A. Female Circumcision: Rite of Passage of Violation of Rights? International Family Planning Perspectives 1997. 23: 130-133

7. World Health Organization Fact Sheet: Female Genital Mutilation

www.who.int/mediacentre/factsheets/fs241/en/print.html

8. 2005 Egypt DHS Survey of Female Circumcision. Link from New York Times website: http://graphics8.nytimes.com/packages/pdf/world/20girls.report.pdf

9. Slackman, Michael. Voices Rise in Egypt to Shield Girls from an Old Tradition. Article and Podcast, The New York Times September 20, 2007 front page, also website: http://www.nytimes.com/2007/09/20/world/africa/20girls.html?_r=1

10. Bagozzi, Richard. The Self Regulation of Attitudes, Intentions, and Behavior. Social Psychology Quarterly 1992. 55: 178-204

11. Official National Council for Women website:

http://www.ncwegypt.com/new-ncw/english/index.jsp

12. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett 2007

13. Website for Better Life Association for Comprehensive Development (BLACD) http://www.blacd.org/index.php?pagename=Projects&pageid=32

14. Peres, Sharon and Boyle, Elizabeth Heger. National Politics as International Process: The Case of Anti-Female-Genital-Cutting Laws 2000. Law and Society. 34: 703-737

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.

Conclusion:

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.

REFERENCES:

1. Becker, M.L., Ramesh, B.M., Washington, R.G., Halli, S., Blanchard, J.F., and Moses, S., 2007. Prevalence and determinants of HIV infection in South India: a heterogeneous, rural epidemic. AIDS. 21, p. 739.
2. UNAIDS. AIDS Epidemic Update, December 2006. Geneva, UNAIDS.
3. Bloom, S.S., and Griffiths, P.L., 2007. Female autonomy as a contributing factor to women's HIV-related knowledge and behaviour in three culturally contrasting States in India. J. biosoc. Sci . 39, p. 557.
4. Dandona, L., Sisodia, P., Kumar, S.P., Ramesh, Y.K., Kumar, A.A., Rao, M.C., Marseille, E., Someshwar, M., Marshall, N., and Kahn, J.G., 2005. HIV prevention programmes for Female sex workers in Andhra Pradesh, India: outputs, cost and efficiency. BMC Public Health. 5, p. 98.
5. Abel, R. Spreading HIV/AIDS Awareness in a Culturally Sensitive Way in India. http://www.avert.org/.
6. UNICEF in action. 2006 Update. http://www.unicef.org/india/hiv_aids_156.htm
7. Chandrasekaran, P., Dallabetta, G., Loo, V., Rao, S., Gayle, H., and Alexander, A., 2006. Containing HIV/AIDS in India: the unfinished agenda. Lancet Infec Dis. 6, p. 508.
8. Dandona, R., Dandona, L., Kumar, G.A., Gutierrez, J.P., McPherson, S., Samuels, F., Bertozzi, S.M., and ASCI FPP Study Team., 2005. HIV testing among Female Sex Workers in Andhra Pradesh, India. BMC Public Health. 5, p. 87.
9. Pallikadavath, S., Garda, L., Apte, H., Freedman, J., and Stones, R.W., 2005. HIV/AIDS in rural India: context and health care needs. J. biosoc. Sci. 37, p. 641.
10. Chandrasekaran, V., Krupp, K., George, R., and Madhivanan, P., 2007. Determinants of domestic violence among women attending an human immunodeficiency virus voluntary counseling and testing center in Bangalore, India. Indian J Med Sci. 5, p. 253.
11. Devine, A., Kermode, M., Chandra, P., and Herrman, H., 2007. A participatory intervention to improve the mental health of widows of injecting drug users in north-east India as a strategy for HIV prevention. BMC International Health and Human Rights. 7, p. 3.
12. Dandona, R., Dandona, L., Kumar, G.A., Gutierrez, J.P., McPherson, S., Samuels, F., Bertozzi, S.M., and ASCI FPP Study Team., 2006. Demography and sex work characteristics of Female Sex Workers in India. BMC Int Health Hum Rights. 6, p. 5.
13. Schensul, S.L., Mekki-Berrada, A., Nastasi, B.K., Singh, R., Burleson, J.A., and Bojko, M., 2006. Men's extramarital sex, marital relationships and sexual risk in urban poor communities in India. J Urban Health. 4, p. 614.
14. Overview of HIV and AIDS in India. http://www.avert.org/aidsindia.htm
15. Godbole, S., and Mehendale, S., 2005. HIV/AIDS epidemic in India: risk factors, risk behaviour & strategies for prevention & control. Indian J Med Res. 121, p. 356.