How Denial of MCP Drives the Indian Pandemic

"Sexual behaviour is private to an individual and influencing the sexual attitude (behaviour change) of an individual is the toughest challenge in HIV preventive interventions anywhere..."

Published in the November 2009 edition of Exchange, a publication on HIV/AIDS, sexuality, and gender from the Royal Tropical Institute (KIT) in collaboration with Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS), this 2-page article examines the role of multiple and concurrent sexual partnerships (MCP) in increasing the risk of HIV and other sexually transmitted infections (STIs). Its author, Vinayakan Ellath Kavinkare, is motivated by the observation that "HIV prevention interventions do not address the vulnerability of men or women in the general community who have multiple sexual relationships - because social mores frown upon such unions, preventing such populations from opening up and seeking relevant services."

As Kavinkare explains, at least a few theoretical models of the ways in which MCP drive the HIV epidemic in India have been developed, but there is less agreement on how to derive evidence-based experiences or experiments and also on how to assess the relationship between MCP and HIV infection. Part of the problem is that a conservative society means that even consensual and concurrent multiple sexual behaviours are taboo. "Such relationships are kept secret, making it difficult to analyse their impact on HIV incidence and prevalence."

What does seem to be clear is that MCP carry much greater risk of HIV transmission than the same number of sequential, non-overlapping multiple partnerships - particularly in India, with its high prevalence of sex work, STIs, and (in some communities) polygamy. Other risk factors include gender inequality, low levels of condom use, and high prevalence of poverty (which tends to push many women into sex work, which is illegal in India; thus, "call girls" and other non-brothel sex workers are not reached with information on how to avoid HIV infection or live positively if infected).

In India, HIV and AIDS data are generated through sentinel surveillance, which involves voluntary counselling and testing centres (VCT), prevention of mother-to-child transmission (PMTCT) centres, STI clinics, and intervention sites for sex workers, intravenous drug users, men who have sex with men (MSM), and truckers. HIV data are also generated through behaviour surveillance survey (BSS), normally undertaken every 5 years, which tracks changing behaviour patterns among different categories of populations. According to the BSS, the other (sentinel) surveillance methods do not track the HIV prevalence that occurs through MCP, nor does it shed light on the impact of the MCP on HIV prevalence in India. In Kavinkare's estimation, "Research agencies and the governments in high HIV prevalence countries should explore the possibility of developing methodologies and indicators to track and analyse the personal sexual behaviour pattern of the respondents who are covered under HIV and AIDS surveillance....This will greatly help organisations involved in HIV and AIDS to plan appropriate and innovative behaviour change communication strategies."