Auntie Noorie, a middle-aged eunuch from the hijra transgender community of Chennai - the huge south Indian port-city - is in great demand. For the loneliest of India’s lonely hearts, there’s no better matchmaker. In a mid-life career shift, the 54-year-old former sex worker has reinvented herself as a specialist marriage-broker-cum-agony-aunt for the HIV-positive community. Twenty years ago, she became the third person to be diagnosed HIV-positive in India. In these two decades an epidemic of terrifying proportions has spread across the sub-continent, infecting more than five million Indians. With 500,000 new cases recorded a year, experts say that if India has not done so already, it will soon overtake South Africa as the country with the most HIV infections. And it will be in India, home to one-sixth of humanity, that the global fight against Aids will be won or lost.
Noorie nurses an HIV infant, whom she recently rescued from the filth of a local rubbish dump. As she does so, she welcomes a young couple into her Chennai office, the headquarters of the South India Positive Network, which she founded. Elizabeth, 27, contracted HIV from her first husband, a truck driver who died of Aids in January. “I felt lonely and I wanted help, so I went to Auntie,” she says. Noorie introduced her to K. Radhakrishnan, 32, a mechanical engineer whose own marriage plans fell apart in 1995 after he tested positive for HIV in Dubai. Immediately deported to India, he spent the next nine years keeping his condition a secret. In June, the two became the eighth couple to get married under Noorie’s auspices in a joyous ceremony held at her office. Elizabeth and Radhakrishnan, who are among the lucky few to have access to Indian-made anti-retroviral drugs, are now consulting a doctor about how to have an HIV-free baby.
”People come to me for counselling and tell me the saddest things,” says Noorie. “They have been thrown out of their families and are helpless, fearing death, depression and stigma. Marriage helps them avoid all that. They say, ‘Madam, help me!’ so I try to find them a partner.” No one could look happier than Elizabeth, dressed in a brilliantly embroidered red and gold sari, smiling ear to ear. “I am looking forward to starting my new life,” she says. “It was difficult when I learnt that I had the disease, and losing my husband was equally hard. But being HIV-positive does not mean we are not entitled to desires. We also have dreams and aspirations.” Radhakrishnan, now a social worker and president of the Kancheepuram District Network of Positive People, is just as defiant. “Don’t HIV people have a right to marriage? You tell me why HIV-positive people shouldn’t marry.”
A few miles away, 33 children, ranging from nameless infants to a 19-year-old rescued from the brothel into which her grandmother had sold her, occupy a deliberately unmarked house in Valasaravakam, a suburb of west Chennai. Eighteen are infected with the virus, while another five are thought to be but will need to be retested when they are 18 months old in case residual maternal antibodies are giving a false positive result. The rest of the children’s parents have died of Aids, but they do not themselves carry the infection. According to Dr P. Manorama, founder of the Community Health Education Society (CHES), 80 per cent of the 200 children she has looked after since 1994 have been abandoned by orphanages that want nothing to do with the victims of HIV/Aids.
”Most orphanages are catering for the adoption market and they subject their children for testing because no one wants a child with HIV,” says Manorama. “We found we were becoming a burial ground, a dumping ground.” Evicted twice in the past, she has not told the landlord or neighbours about the nature of her work, in a telling illustration of the stigma facing the most helpless of all HIV/Aids victims. Gradually, however, CHES has reopened links with the community. “We made contact with their families. Relatives came and visited, saw we were not wearing gloves and were handling the children naturally, and realised that communal living is possible.” The results have been remarkable, with 63 orphans now reintegrated into their extended families since the start of the programme and about 20 adopted or given to foster parents. “The others have died,” she says.
A report for the US Central Intelligence Agency by the National Intelligence Council, a think tank, forecasts that 25 million people could become infected in India over the next five years. HIV has already spread to the general population in several states. The National Aids Control Organisation (NACO), a government agency, has identified six “high-prevalence” states, where infection rates among high-risk groups exceed five per cent and one per cent among pregnant women. Of these, four are contiguous southern states - Tamil Nadu, Maharashtra, Karnataka and Andhra Pradesh - where the epidemic has been driven by sex workers such as those in Mumbai, where 44 per cent of female prostitutes carry HIV. In Manipur and Nagaland, by the north-east border with Burma, it has principally spread through drug use.
”India is at a tipping point in this epidemic and it’s time to mount the largest prevention programme the world has ever seen,” says Ashok Alexander, director of the Bill Melinda Gates Foundation’s Avahan project, which is the single largest donor to India’s fight against Aids. The Gates Foundation’s annual $40m budget compares with $32m lent by the World Bank to NACO, $20m provided by the Global Fund To Fight Aids, Tuberculosis and Malaria, and a meagre $7m from the Indian government itself. “Unfortunately, the tipping point has already happened in a number of places where the prevalence rate is above 2 per cent. In about 24 districts you can see a clear corridor where the transmission is happening.”
Dr S.Y. Quraishi, a former television executive drafted in to run NACO, is leading India’s battle against HIV/Aids. He says the more that people such as Noorie and Manorama can help reduce the stigma of HIV by showing that infected people can live normal, long and happy lives, the better India’s chances of controlling the spread of the disease. The stigma of HIV/Aids, at every level of society, is a serious barrier to effective prevention and treatment. It breeds fear among the infected, and keeps HIV/Aids undercover where it can spread unchecked. “It requires guts to come forward and get tested,” he said at a recent conference in New Delhi. “If you turn out to be positive, you are ostracised. As a result, there’s gross underreporting. For every one person that comes forward, four do not. Stigma drives people underground and if they’re not treated properly, they take revenge and go into the street and infect other people.”
Compared to some countries in southern Africa, where HIV rates run as high as 20-30 per cent, India, with an estimated rate of 0.91 per cent of the adult population, might seem on top of the epidemic. But any complacency is misplaced for two reasons: first, the sheer size of the population, at more than 1.03 billion, means that for every percentage point added to the adult infection rate another 5m people are thrown on to the resources of an already overburdened health system; and second, there is no reason to believe that the several dozen localised Indian HIV epidemics in various parts of the country will not mesh and contribute to a terrifying steepening of the infection curve, exactly as happened in South Africa in 1991 when its rate of about one per cent skyrocketed into the 20s in the space of a decade.
HIV/Aids statistics are fraught with difficulty the world over, but they are especially controversial in India. Data are patchy and politicised. Some states such as Bihar, the poorest in the country, offer none at all. Because an estimated 80 per cent of HIV/Aids carriers never get tested and few of those who do then report the result, India is forced to derive its official rate by extrapolating the results at just 670 sentinel sites across the vast subcontinent. These estimates need to be interpreted with caution. The data for new infections estimated for a single year, for example, are a far-from-perfect guide to the trend of an epidemic, as a test itself may come many years after an infection occurred. An increase in diagnoses might mean that HIV testing has become more easily available than in preceding years, or that the stigma associated with HIV has declined, encouraging more to get tested.
Richard Feachem, executive director of the Global Fund To Fight Aids, Tuberculosis and Malaria, has fuelled another statistical argument. Feachem enraged the Indian government by stating earlier this year that India had probably already surpassed South Africa in having the largest number of HIV/Aids sufferers. Referring to UNAids’ latest official figures, he said that although South Africa had 5.3m people with the infection against India’s 5.1m, the massive range of the estimate in the latter - 2.2m-7.6m cases among adults and children compared with 4.5m-6.2m in South Africa - left “many unknowns about the state of the pandemic”. He also admonished the Indian government for “not doing enough” to curtail the pandemic’s growth. NACO, which denies that India has overtaken South Africa, said Feachem’s comments were “loose” and “unproductive”.
For many years, it was clear that India’s conservative society was in denial. That has started to change. Prime Minister Manmohan Singh discussed the crisis with George W. Bush in Washington last month. In a message to the 7th International Congress on Aids in Asia and the Pacific held in Kobe in July, he wrote that the epidemic was “no longer just a public heath issue”, but had become a serious socio-economic problem that could “severely hurt” India’s growth and development. But the shift in attitude has further to go, according to Ashok Alexander of the Gates Foundation. “The government is well beyond being in a state of denial and is now in a state of acknowledging there is a problem. It is in a state of alert. We need to be beyond this. We need to be on a war footing and we’re not there yet.”
The fight against HIV/Aids has clear geo-strategic implications for India. Robert Blake, the deputy-chief of mission at the US embassy in New Delhi, who has made the fight against Aids the defining feature of his time in India, warns that there is “perhaps no greater threat to India’s ambition to become a world power than the country’s rapidly growing HIV infection rates”. It is obvious, too, that Goldman Sachs’s endlessly quoted prediction - that India, now the 10th largest economy in the world, will overtake Japan, Germany, the UK, France, Italy and others to become the third largest by 2050 - will have no chance of becoming true if adult prevalence rates rise to a fraction of those in southern Africa. Yet the business community has been slow to wake up to the challenge.
Indian companies are still some way from facing the extreme difficulties of companies in parts of southern Africa that are obliged to employ two workers for every vacancy, in the knowledge that one of them is statistically likely to fall ill with HIV. But Neel Chatterjee, the Mumbai-based regional head of corporate affairs at Standard Chartered bank - which lost 10 per cent of its African workforce to Aids in 1999 - speaks from experience when he warns: “Unless we act now, what we faced in Africa in 1999 we will face in Asia - in China and India.” Quraishi of NACO puts it even more bluntly: “It’s not a matter of corporate and social responsibility, it’s a matter of corporate survival.”
As former US president Bill Clinton said during a recent trip to New Delhi to launch his foundation’s programme to train 150,000 HIV/Aids medics, a rampant epidemic will sap an economic revival that has lifted living standards to unprecedented levels. “You have come too far and worked too hard for your future to have any other course, but if you do not act now millions will die who do not need to die,” Clinton said. “You have a huge at-risk population in big cities and rural areas... I am quite hopeful about where you are now, but I want to be serious here and say that this is not something that you can take casually. There is no time to waste and every day you delay you put the country’s economic future at risk.”
HIV/Aids is not only a looming economic nightmare, but also a growing national security issue. Military personnel during peacetime are up to five times more likely to contract sexually transmitted infections, including HIV, than the civilian population. In time of conflict, when soldiers are away from their families for many months at a time, this can be significantly higher. Lieutenant-General Bhopinder Singh of the Assam Rifles, India’s oldest paramilitary force, recently sounded the alarm about HIV infections among Indian troops when he revealed that more soldiers were being killed by HIV/Aids than by enemy fire in India’s insurgency-hit north-east. Singh, who assumed command in May 2004, said that 32 servicemen had since died of Aids-related complications, while a further 118 were HIV-positive.
If India is to be spared a human catastrophe of unprecedented proportions, experts say it urgently needs to ramp up the amount of money being allocated to HIV prevention. The Gates Foundation estimates that a fully funded prevention and care programme could cost more than $1bn a year, compared with the $146m that is being provided by the Indian government, international organisations and NGOs. India is spending 29 cents per capita in Aids-related funding, compared with 55 cents in Thailand, $1.85 in Uganda and $5.70 in Cambodia. The bad news is that there’s not enough money, but the worse news is that it is not all being spent. Last year, bureaucratic hold-ups meant that the World Bank, which channels its funds to NACO rather than directly to NGOs, spent barely half its annualised Indian Aids budget. It says disbursement rates will accelerate as its programme matures.
NACO has just launched a national HIV/Aids advertising campaign, with a coy cricketing tag line - “Save your wicket from the unwanted googlies of life” - but awareness levels are appallingly low, particularly among the 740m living in rural areas. Most NGOs have adopted a strategy of focusing resources on “core transmitters”, the very highest risk groups - sex workers, men who have sex with men, migrant labourers and drug users. But even those efforts are reaching only a small fraction of their targets. Peter Piot, executive director of UNAids, in his speech at the Kobe conference, said such prevention programmes by the end of 2003 had reached only one in five Asian sex workers, one in every 20 injecting drug users and one in 50 men who have sex with men. Ashok Alexander says prevention programmes need to reach 70 per cent of a high risk group to be effective.
Gujarat Ambuja Cement, a building materials company based in the west of India, supplies much of the cement for India’s construction boom and it is one of the largest employers of truck drivers in Asia. Depending on the season, it hires as many as 40,000 of the 300,000-400,000 freelance truck drivers and co-pilots, known as “cleaners”, that transport goods across 7,000km of national highway. As in Africa, infection rates are high in this group. India’s trucker community accounts for 6-8 per cent of the total number of HIV/Aids carriers in the country. Among long-distance truck drivers - who can carry the virus furthest and buy cheap sex from roadside prostitutes up to five times a week - rates are running at 8-12 per cent.
”After a journey of 180 miles, truckers will have sex whether we like it or not,” says V.K. Jain, a former head of police in the state of Uttar Pradesh and now the director of the company’s charitable arm, the Ambuja Cement Foundation. “There’s no point in teaching them morality and there’s no point in telling them to abstain, the only thing we can do is to make them aware they will get HIV unless they use a condom. But we face two problems: first, most truck drivers think that HIV will never happen to them; and, second, they can easily afford to pay more not to use condoms.”
The trucker sub-culture is resistant to change. Roadside prostitutes advertise their availability by hanging a red cloth from a tree and will either have sex with the driver and the cleaner there and then, for Rs10-Rs100 (13p-£1.30), or in the cabin of the moving truck. By the time they have finished, the truck may have travelled six miles down the road and an oncoming truck is then flagged down to take the woman back to her base. En route, the men in the second truck generally also pay to have sex with her. This toing-and-froing ensures that if the woman is carrying HIV, it travels hundreds of miles in either direction. It is estimated that 10 per cent of cleaners and drivers also have sex with each other.
”At first, we went to the ladies and showed them how to use a condom by putting it on their thumbs and then when they went and had sex, you know what they did? They put the condom on their thumbs!” exclaims Jain. “Can you beat it? There’s so much to do and what odds we are fighting. Now we are using artificial penises and telling them that the thumbs were just for illustrative purposes.” Female condoms have made little progress, he says, because at about Rs120 each they cost too much for prostitutes to buy or for the Ambuja Cement Foundation and other NGOs to give away.
Truck drivers are the most visible part of India’s high-risk migratory workforce, but more than 250 million people - one in four workers - are estimated to be living highly precarious, unhygienic and vulnerable existences as mobile workers. Isolated from their families for months on end, they inevitably engage in casual sex that leaves them vulnerable to sexually transmitted diseases and HIV/Aids. Unaware of the risk, disinclined to use condoms and oblivious to their status as virus carriers, tens of thousands of migrants pass on the infection to their wives and other sexual partners back home in the villages. Near the southern Rajasthan tourist town of Udaipur, famous for its luxurious Lake Palace hotel, lies the village of Chapra, a warren of mud huts and concrete shelters. For most of the year the men of Chapra, and those of the many other tribal villages like it, migrate to find miserably paid contract work in towns such as Surat in the neighbouring state of Gujarat, Mumbai in Maharashtra and even as far afield as Bangalore, nearly 1,100 miles away in HIV/Aids-ridden Karnataka. For 11 months of the year they will be away from their wives and families. But during July, the rainiest of the four monsoon months, men such as Pappu, a contract stone-grinder, return home to help their wives sow the crop.
For Delvi, one of Chapra’s young and lonely housewives, Pappu’s homecoming has not been a happy one. I find her crying in her yard, clutching the fragments of a photograph of Pappu, to whom she has been married seven years, with a woman in Bangalore. Illiterate and clueless about HIV/Aids, Delvi, 25, says she has no intention of asking Pappu to use a condom, despite the best efforts of a local NGO. She is afraid of him and, in any case, she is trying to have a child. Within days of returning from Bangalore, Pappu beat her up then left for the fleshpots of Udaipur, saying he had worked all year and deserved to enjoy himself. Her mother-in-law, who shares their hut along with Pappu’s brother, tells her that she must accept her fate because Pappu “is a man and can do anything he wants”.
Migrant labourers such as Pappu might be the flotsam of the global economy, but for sex workers in India’s big cities they are prized and cherished customers. Among the male prostitutes of Tamil Nadu, the southern state where the first Indian case of HIV was diagnosed in 1986, competition over panthis, as their clients are known, is particularly ferocious. In Tondiarpet, one of the oldest parts of Chennai, a dozen male sex workers discuss their financial problems at a drop-in-centre and clinic funded by the Gates Foundation. Most sell sex for between Rs20-Rs100 and need about Rs300 to live each day. Most have to find an average of five panthis a day to survive. When trade is thin, prices drop to Rs20 and few insist on condoms.
The majority are kothis, men who aspire to look feminine but who have yet to attain the prized status of nirvanas through the quasi-religious ceremony of castration. Panthis pay more for sex with nirvanas than with pre-operation kothis, who in turn outearn and look down on “double-deckers”, the least feminine and highest-risk male sex workers, who both penetrate and are penetrated. “Kothis and double-deckers will fight over sesa panthis, handsome men who are good in both personality and performance, and sometimes they will pay the panthi so he stays with them,” says Simpson Cornelius, a project officer with the Tamil Nadu Aids Initiative, who estimates that 10-12 per cent of the 9,500 male prostitutes he works with have HIV. The NGO, which will receive $12.8m over five years from the Gates Foundation, offers training in skills such as hair-dressing and camera work to sex workers looking for other ways to earn a living.
R. Gopinathan, a slender 22-year-old kothi, started sex work at the age of nine and now has a regular panthi, a married 35-year-old who happened to be his teacher at school. Gopi, as he is known, never uses a condom with this man “because he is a regular partner” and because condoms “shatter trust”. He is weighing up his sesa panthi’s offer to sponsor the operation that will make him a nirvana. Gopi has a part-time job distributing condoms and advising other sex workers to go for medical check-ups, and because he wants to stop sex work and earn his living by other means, he is reluctant. “For a person who wants to make their life out of sex work it makes sense because you make more,” Gopi says. “I have a well-paid job now so I have no urgent need for the operation.”
For others in the group, life is considerably harder. Jansi, a 28-year-old with bright pink nail polish, is scraping together the Rs10,000 needed for castration by a quack-doctor. However, she may opt for a cheaper castration that costs about Rs3,500 and is crudely administered by a fellow hijra. She is averaging six customers a day and makes extra money by tagging along with one of the bawdy eunuch gangs that turn up at births and weddings, ceremonies to which hijras are believed to bring good luck. Jansi tested negative two months ago and says she always insists on a condom. In this respect, she is unusual. The only contraceptives many kothis use are the cheap pills containing a hormone that increases the size of their breasts.
In 10-15 years, India will be a very different country to the one it is today. If everything goes to NACO’s plan and the multitude of localised HIV/Aids epidemics are contained and eliminated, India will have every chance of fulfilling the bullish predictions of the investment banks and of assuming its rightful place as the world’s third largest economy, behind the US and China. If not, all bets will be off. India’s precarious public finances and under-resourced public health system are in no state to cope with the colossal financial burden of a sub-continental Aids pandemic similar to that now afflicting parts of Africa. India is at a crossroads in its fight against Aids, and the path it takes now will be decisive for nothing less than the future of the world.
Jo Johnson is the FT’s South Asia correspondent.
