SEXUAL BEHAVIOUR AND AIDS IN INDIA: STATE-OF-THE-ART MONI NAG With no vaccine in sight for immunisation against the AIDS-transmitting virus, HIV, the only feasible method of controlling the spread of the disease seems to be through behavioural prevention. There is an urgent need for an awareness to be created among the people regarding those aspects of sexual behaviour which are particularly risky with regard to HIV transmission. Topics such as premarital sex, extra marital sex, female sex workers, homosexuality, hijras and male sex workers are covered by the paper. High risk sexual behaviour involving the above aspects are not as uncommon in India as generally assumed, according to evidence. Dr. Moni Nag is Adjunct Professor of Anthropology, Columbia University, New York and Senior Consultant, Johns Hopkins University's School of Hygiene and Public Health, Baltimore, U.S.A. Introduction Even the scientist seems to have underestimated the faith of the man of the street in the scientific method, his respect for the results of scientific research, and his confidence that his own life and the whole of the social organisation will ultimately benefit from the accumulation of scientifically established data. Kinsey, A.C. et al. in Sexual Behaviour of Human Male (1948) Although HIV (human immunodeficiency virus), the virus responsible for AIDS (acquired immune deficiency syndrome) can be transmitted through blood/blood products and from pregnant/lactating mother to her child, the principal mode of transmission in India is through sexual relations — primarily, heterosexual inter­ course. So far no vaccine for immunisation against HIV or cure for AIDS is available; nor is there a hope for any such in the foreseeable future. Hence the spread of AIDS can only be controlled through behavioural prevention. Since sex is a basic need for both pleasure and reproduction for most people, an effective way of preventing AIDS is to have a better understanding of what aspects of sexual behaviour are particularly risky for HIV transmission in India and to make people aware of them. But in order to achieve that we need to know much more than what we know at present about the existing patterns of sexual behaviour in diverse population groups of India. Sex is usually not a matter of overt discussion in India, but the threat of AIDS as a killer disease has made it a legitimate topic of allusion in Indian mass media. Much of the underlying assumptions behind the allusions are based on myths and stereotypes which may be far removed from real facts. India can boast of Vatsyay- ana who wrote the extraordinarily analytic treatise on sex and love, Kama Sutra, more than 1,500 years ago, but it, as well as other ancient Indian writings on sex, hardly gives us any glimpse of the patterns of actual sexual behaviour of common people. Even in contemporary India only a small section of people seems to be familiar with Kama Sutra, mostly through its English version first published in 1883 by Burton and Arbuthnot (1993), and is perhaps interested mainly in the visual representation of various techniques of sexual intercourse vividly described in it: 504 Moni Nag The ambivalence and inhibitions regarding sex in the minds of educated Indians are illustrated by the fact that Kama Sutra was kept in Delhi University library at least up to the late 1980s in a locked backstage room and even a faculty member had to take special permission to borrow it (Ganguli, 1988). The limited amount of studies done on sexual behaviour in contemporary India has concentrated on the diagnosis and treatment of sexual illness or pathology from psychiatric, psychological or physiological perspectives or from a combination of these. This is true for many other countries also (Mundigo, 1992), but the AIDS pandemic has generated national surveys in a few countries such as England, France and USA, aimed at understanding patterns of sexual behaviour. Much of these studies is exploratory and has an applied objective. In India, no national survey has been conducted as yet, but the National AIDS Control Organisation (NACO) of the Government of India (India NACO, 1993a: 44-48) and a few NGOs (Pachauri, 1992) have initiated some studies on sexual behaviour in a number of urban and rural areas. Situation in India The numbers of full-blown AIDS and HIV seropositive cases in India officially reported so far are small compared to many other countries. Since May 1986 when the first AIDS case was reported (infected through blood transfusion in the USA), 440 cases of AIDS (336 males and 108 females) among Indians in India upto 30 September 1993 (India NACO, 1993b). The number of reported cases represents only a small proportion of the actual AIDS morbidity because, among other reasons, diagnosing AIDS presents insurmountable difficulties in India. As a proportion of India's total population of about 890 million, this figure is insignificant compared to some countries in Africa and the West, for example, 30,190 AIDS cases in Uganda (population 22 million) and 2,13,641 cases in the USA (population 255 million) up to the end of 1991. The low number of AIDS cases in India also reflects the fact that HIV infection started relatively late and that relatively large number of AIDS cases are undiagnosed and unreported in the country. The number of AIDS cases reported so far, however, show wide geographical variation within the country. Out of 310 reported cases mentioned above, Maharashtra and Tamil Nadu accounted for 93 and 92 cases respectively. The remaining 125 cases were reported from 16 other states/union territories. According to the national surveillance network, out of 18,89,670 individuals (mostly belonging to vulnerable groups such as female sex workers (FSWs), intravenous drug users, blood donors, antenatal clinic attendants and STD clinic attendants) tested from October 1985 to March 1993, 13,254 (7.4 per 1,000) were found to be infected with HIV. The National AIDS Control Organisation (NACO) estimates the number of HIV seropositive cases in the total Indian population as about one million by the end of 1992. So far the preponderance of reported HIV cases is in Ma­ harashtra, Tamil Nadu and Manipur states. The major concentration of infection is in Bombay city which alone may contain 5 to 10 per cent of the country's infected individuals. The other cities known to have high concentration of infected individuals are Pune, Madras and Vellore. In consideration of proportion of population infected Sexual Behaviour and AIDS in India 505 with HIV, the northeastern states of Manipur, Nagaland and Mizoram rank high because of the relatively wider use of intravenous drugs in those states. Heterosexual promiscuity has been the principal mode of transmission of HIV in India so far except in the northeastern states. Multi-partner sexual relationship on the part of men and women accounted for 75 per cent of infection among 310 AIDS cases reported up to March 1993. Therapeutic blood transfusion accounted for 12 per cent and sharing unsterilised equipment by intravenous drug users for 7 per cent. In some selected groups of FSWs (female sex workers) 35 per cent or more were tested as HIV positive in 1992 and in some groups of males with multiple sexual relationship 16 per cent were so. The HIV prevalence rate in intravenous drug users is very high (54-74 per cent in Manipur and 50 per cent in Nagaland), but it is quite likely that some of them got the infection through sexual relationship. The HIV transmission rate through blood transfusion is quite high in India because until recently only a small proportion of blood used for the purpose was tested for HIV and also because a considerable proportion of blood for transfusion comes from professional blood donors among whom the prevalence of HIV is high. Among 15,297 blood donors in a few selected samples tested in 1992, 0.85 per 1,000 were HIV positive. In Madras and Bombay the proportion of blood donors infected was much higher — 23 per 1,000 in each city. Other possible modes of transmission of HIV are through male homosexual rela­ tionship, from infected mothers to their children during pregnancy, childbirth and lactation, and through injection needles and other sharp equipments contaminated with infected blood. No data is available regarding the extent of male homosexual relationship and the prevalence of HIV among male homosexuals in India. Tests conducted among 6,031 pregnant women in some selected populations in 1992 show that the HIV prevalence rate per 1000 pregnant women was 1.16. If this figure represented the average prevalence rate among all pregnant women in India, then an alarmingly large number of infants are being born currently in India with HIV infection because 20 to 40 per cent of the infants born of infected mothers are likely to carry the infection (Anderson and May, 1992: 69). According to one estimate, however, every year 20,000 out of 24 million deliveries in India are likely to occur in HIV positive women (Ramachandran, 1992). There is no data regarding HIV transmission in India through injection needles (other than those used by intrave­ nous drug users) and other sharp equipments. With increasing number of HIV- infected individuals around, the risk of such transmission is likely to increase mainly because in India such needles and equipment are often not sterilised properly. The risk of infection through sharp razors used for shaving by millions of street and saloon barbers, and through sharp instruments used for skin piercing are particularly high in India. Although the validity of the estimates of the actual AIDS and HIV prevalence in the total population extrapolated from the number of cases reported is questionable, the evidence regarding the rapid rate of increase in prevalence in various population groups and subgroups in recent years is quite clear and seems to justify the labelling of India as a dormant volcano for HIV and AIDS pandemic.