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Role of Community Led Structural Interventions in working with Sub-populations vulnerable to HIV/AIDS
Adding a new dimension to Targeted Interventions
It is common understanding in the HIV discourse that certain sub-populations are relatively more vulnerable to HIV/AIDS and are more susceptible to infection and less able to handle its consequences. The proximate cause of this vulnerability may be unsafe sex (as in the case of sex workers and Men who have sex with men) or reuse of unsterilised needles. (Injecting Drug Users). But these are often the symptoms and not the cause.
Targeted interventions [TIs], a major component of India’s National AIDS Control Programme, seeks to address the proximate causes of this vulnerability.
The TIs, now numbering more than 882, [Full list of TIs] have contributed to creating awareness regarding the epidemic and in increasing access of such population to services. The TIs, as they are structured today, attempt to :
provide behaviour change communication (to motivate the beneficiaries to change to safer behaviours and to access services which helps protect against infection),
provide and promote such services (such as STI services and condoms)
create an enabling environment where the delivery of these interventions can be facilitated.
However these components have not been able to address the more immediate needs of the primary stakeholders. These needs are perceived by them to be more important to them than sexual health needs, which the targeted interventions deal with. Care and support of infected persons from among the target group is also emerging as an important unmet need.
Further, the TI approach does not take into account that the sub populations in question do not have the desire or power to make decisions that would lead to the utilisation of such services, for if that would have been the case, the interventions would have achieved what they sought to i.e. halt and reverse the spread of infections in these populations and from them to their contacts. These aspects point out the gap in current HIV programming and challenge the fundamental assumptions underlying the design of TI s.
Core causes of vulnerability
The underlying causes that make such sub populations vulnerable result from a complex interplay of social, economic, cultural and other systemic factors. The sub-populations have become vulnerable not by choice, but due to the situation to which the society has assigned them. Some of the contributing factors that are result of the lives that these groups lead could be summarised into the following:
1. Low expectations from future: People invest in the future, such as forgoing present consumption and pleasure for education or health promoting activities, when they are convinced that they are likely to reap a richer harvest later. But if a person does not believe that he/she will be able to enjoy such rewards in the future, he/she cannot be persuaded to take precautions in the present so as to avoid a danger that may come up in the future.
Most of the vulnerable populations be they sex workers, truckers or IDUs are not assured of a secure future due to the environment in which they exist. Their life situation is such that there is no reasonable assurance that they would even be alive in the future. The trucker, driving on the unsafe highways, is apprehensive that he may meet with an accident. A sex worker who earns her livelihood from the streets is always under threat from the unlawful elements that rule that environment. Hence it is difficult to persuade them to take precautions against HIV/AIDS, they do not see it as their immediate priority as the consequences of the disease are not immediately obvious. Therefore one of the necessary conditions for the TIs to succeed is to assure the person with high-risk behaviour that he/she has the possibility of a good future which he has to invest in. To do this the programmatic has to go beyond sexual health needs and respond to the more immediate needs of security and livelihood.
2. Social identity and power: an individual's sense of identity is derived from the space he/she occupies and the transactions that he/she carries out with other individuals / entities / institutions in the society. Building on this understanding, a sex worker occupies a space in this society which lies in the grey area between legality and illegality. This 'space' makes it difficult for her to realise her rights such as access to public health care, social security measures and right to legal aid. It thus becomes unreasonable to expect the vulnerable groups to even believe that they can change their own behaviours when their right to exist as citizens is not recognised. Altering this self-concept would involve empowering sex workers and making it possible for them to claim their right to exist with in their society and ensuring that they receive their entitlements. This process would seek to not only involve the vulnerable groups but also build advocacy networks with the policy makers and implementers of the society.
3. Power to take decisions regarding own actions: Quite often a vulnerable person does not perceive him/herself to be in a position to take decisions regarding his/her own actions. This is because the social identity of a person determines her power both in her perception as well as that of others. Power is also determined by the structure and practices in the spaces they occupy. How a street worker can function is determined not so much by her knowledge and attitudes but by the powerbrokers that influence and control sex work and the context in which s/he operates. The truckers ability to adopt safe practices is contingent on the truck operators’ and good owners’ perception of how it is important to get the goods to the destination at the minimum cost and fastest time and the transport authorities decision that truckers cannot operate during day time in certain sectors. Even among the same sub- population economic status (or its correlates such as education, house to live or beauty to attract clients) leads to stratification among members of the same sub-population. In a situation where there are too many sex workers competing for a few clients, a sex worker who is in a disadvantaged position may be forced to weigh the possibility of not earning an income versus the possibility of getting infected due to unprotected sex. Factors like these that finally determine behaviors and qualify them according to risk to HIV have to examined and must inform any strategy that is designed to counter high risk behaviour.
4. Social power structure prevents access to services: In the political economy of decision making resources are allocated according to the bargaining power of beneficiaries. Therefore in any transaction, if a person has some influence or goods to offer, he/she also influences decisions taken to benefit them. in the case of vulnerable populations, since they are often the most marginalized, they can not influence the decisions taken and are not involved in decision-making. Their interests will not be attended to. For instance while the red light areas or other living areas of sex worker lies beyond the limits of the city or in the margins, it is highly unlikely that an Anganwadi, which would have provided pre-school education, immunization and nutrition to their children, would be located there. Nor would it have a health outpost. Even if a sex worker or an IDU reaches a health facility she is likely to discriminated against due to the stigma of drug use and sex work. Such exclusion, both physical and social, leads to denial of services and hence vulnerability. It also leads to alienation from the concerns of the society as she does not perceive herself to be part of the society which has rejected her. Hence if the society needs the co-operation of vulnerable populations in containing HIV/AIDS, then programme managers have to put in place strategies to deal with these structural obstacles.
Why it is necessary to address structural issues?
It thus becomes evident that if targeted interventions are an important strategy for achieving the goals of National AIDS Control Program, the above mentioned issues and a host of other related challenges represent roadblocks to achieving them. They are not easy to address. They have been created by deep-seated social norms shared by the decision makers and even by their victims. They have become part of the social and political structures. The strategy to deal with them begins by being aware of and acknowledging the structural constraints, recognising the value of removing them, articulating a stand that is conducive to the removal of these constraints and investing in strategies and activites to remove them.
The HIV/AIDS epidemic is driven by individual behaviour. Unless this changes the epidemic cannot be halted. But individual behaviours do not occur in a vacuum. There are individual knowledge and attitudes, social norms and values, legal and administrative systems and the demonstration effect of peer behaviour that influence the behaviour of an individual. For instance, if the sex worker herself feels that her life is not worth protecting from HIV on account of her assessment of her self worth, she may not adopt the safer behaviours that TIs try to inculcate. So long as the peers and the society retains an assumption that a trucker is a person who lives life dangerously, and does nothing to change the risks associated with the profession, the life style approach that the trucker acquires and adopts as his own will also translate into his sexual and recreational habits. The legal system that makes it impossible for IDUs to obtain syringes and needles legally will negate the impact education on adopting safer injecting practices.
TIs try to change the behaviour of individuals by providing knowledge, trying to change attitudes and by providing services without addressing any of the other group of causes. [The component of enabling environment is meant to deal with these issues. But it has remained an insignificant component of the TI s]. Behaviour Change Communication operating in vacuum and without building on the underlying causal analysis will not be able to lead to sustained and consistent behaviour change.
Who benefits from Targeted Interventions?
Populations seen as vulnerable to HIV today have been suffering discrimination and violations in this country since ages. Their conditions attracted attention and resources only when it became clear that HIV/AIDS can not be controlled without involving them. Hence the objective of TIs is not the welfare of the marginalised populations. It is a public health measure to protect the general population. That aim will not be achieved without the collaboration of the vulnerable populations and other agencies that influence the lives of these groups beyond health. .
To be willing collaborators the vulnerable populations must share the objective of the programme managers. No group will identify with objectives that are perceived to benefit a society in which they have no stakes. In return for their collaboration, the society will need to accept them and involve them as stakeholders in the campaign against HIV/AIDS. Therefore before attempting to change the behavior of the vulnerable sub-populations, society will need to change their attitude to the sub-populations. This goes against the grain of established beliefs; but is a non-negotiable if their collaboration is needed for the success of the AIDS control programme. And the logic of the National AIDS Control Programme states that unless the spread of the virus among the vulnerable populations is prevented the epidemic cannot be halted and reversed. Therefore structural interventions proposed to be addressed in the SAKSHAM programme is an essential element in the success of the National AIDS Control Program.
Vested interest VS social good
Given the extent of their disempowerment, sex workers are objects to be hunted down by vested interests, without opposition from the systems society has to protect the life and wealth of its citizens. An instance is the real estate lobby that is attracted by properties where sex workers live and carry out their work. Here the other interests who would benefit from eviction of sex workers assist them. They would manifest themselves as social workers out to save the society from the menace of sex work. All the persons who assist them based on altruist or corrupt reasons are also protected from the consequences of their actions owing to the vested interests being disguised as social work. If vulnerable communities were to live in the shadow of such threats it is highly unlikely that they would develop the needed stability to respond to the messages of Targeted Interventions. It is also possible that certain values may lead to unacceptable behavior e.g.: A police officer who believes that sex workers are harmful to society may beat up sex workers and feel he is doing the right thing. These dimensions are also part of the complex scenario to be addressed.
How can they be addressed?
Social disabilities created by deep-seated attitudes and years of practice and incorporated into the structure of the society cannot be wiped away easily. It will have to be a sustained operation undertaken with faith in the rationale of the strategy and with acceptance and participation of the beneficiaries. It will mean building the capacity and empowering the marginalized sub-populations and changing attitudes of policy makers and implementers. This would involve a paradigm shit of moving from structural and targeted interventions to Community led structural interventions.
Key components of community led structural interventions would include:
a. Nurturing leadership among the sub-populations: Experience with many interventions that have adopted rights based approach have shown that with appropriate handholding, leadership will emerge from the sub-population itself. To many it provides a fillip to their desire to prove their worth to themselves. Surviving for years in a hostile environment have built them into hardy and aggressive personalities. . Development of skills and creation of spaces that allow these groups to express themselves, use their lives experiences to fuel discussions and debates. This would also allow them to lead themselves and their communities by acumen that they have developed by dealing with complex environments to drive change in their lives and work environments, eventually reduce vulnerabilities to HIV and other human rights violations. There are many instances where such leadership has emerged from primary stakeholders and gone on to lead community based organizations among sex workers and IDUs. Truckers have trade unions, which can provide such leadership. The nature of intervention will depend on an assessment as to what skills are needed for successful leadership. Using techniques of adult learning such as coaching and mentoring, appropriate skills can be developed in collaboration with the communities.
b. Team building: If vulnerable populations are to command any influence they have to be united and build themselves into a team, which can bargain collectively. But given the hostile and secretive environment in which they operate, divisive forces outweigh the unifying ones. Therefore it is necessary for the group to engage in activities that build co-operation and a group dynamism. It is also necessary for the leadership to learn to resolve conflicts that are bound to emerge.
c. Savings and credit: While unity and capacity buildings adds to social empowerment it is also necessary to assure the community of degree of economic security as an insurance against unforeseen demands. Community financing initiatives including savings and credit movements have been found to be empowering to the community. Raising funds from their own resources and managing it themselves including who to lend to and on what terms, gives them power over part of their destiny, certain degree of economic independence and a community feeling that each person is involved in offering protection to every other member of the community.
d. Managing the external environment: Given the low social power of the marginalized sub-populations, many agents have influence over their conduct. If they are hostile the structural interventions will be thwarted. Therefore it is important for the programme to engage the power holders in the social environment of the sub-populations to generate support for the structural interventions. This will be difficult as many of the power holders have a vested interest in the low social position of the sub-populations. But the overwhelming importance of empowering them to achieve the objective of the society must be made to take precedence over the interests of the vested groups. Media support, political advocacy, activism by the sub-populations and the organizations supporting them and working on the attitudes of the power holders are some of the techniques that may be tried.
e. Building capacities: Many of the members of the marginalized populations have an overwhelming desire to learn new skills such as literacy and crafts. These may be positioned not only as pathways to alternate livelihood but also as something that enhances their self worth. In time it can also become a means to supplement their income. For IDUs, many of whom are highly talented, it can be an occupational therapy for rehabilitation. Legal awareness can help all the marginalized groups to understand and in time fight for their rights.
f. Policy support: It will not be possible to engage the marginalized populations without a policy decision that accepts their rights. Many of them exist on the margins of legality. It may be politically difficult to make changes that make their activities legal (though many countries have accepted the fact of sex work and drug use and have found that legalizing them helps to manage their adverse impact better than proscribing them). But if their co-operation is needed to prevent the spread of HIV/AIDS, it cannot be achieved when agents of the society hound them. Therefore a consensus has to be arrived at between the law enforcers and programme managers of HIV/AIDS as to how the rights of such populations may be protected. The representatives of the sub-populations will also have to be involved in the dialogue as to what the parameters of their functioning will be. While this is difficult it has been achieved in many interventions in the country.
The needs of marginalized populations may not receive much attention from decision makers. But if the AIDS Control Programme is to succeed the structural constraints to preventing the spread of infection in these groups must be addressed. Therefore it is as much a need of the society as that of the vulnerable populations.
ANNEXURE: 1
STATUS OF TARGETED INTERVENTIONS IN INDIA- 2003
TARGETED INTERVENTIONS : Dec., 2003
Sr. No. State Total TI Projects CSW Truckers MSM IDUs Migrant Workers Street Children Prison Others
1 A & N Island 4 1 0 0 0 1 0 1 1
2 Ahmedabad 21 1 0 1 0 3 1 0 15
3 A.P 117 25 24 3 0 23 6 25 11
4 Arunachal 7 0 4 0 2 1 0 0 1
5 Assam 29 7 8 0 1 7 2 0 4
6 Bihar 17 2 14 1 0 0 0 0 0
7 Chandigarh 12 0 2 0 0 8 1 1 0
8 Chattisgarh 10 2 7 0 0 1 0 0 0
9 Chennai 20 5 1 2 3 4 1 0 4
10 D. & N. Haveli 1 0 0 0 0 1 0 0 0
11 Diu & Daman 0 0 0 0 0 0 0 0 0
12 Delhi 29 2 3 2 1 17 4 - -
13 Goa 10 1 1 1 0 5 0 0 2
14 Gujarat 87 10 12 3 0 45 2 9 6
15 Haryana 0 0 0 0 0 0 0 0 0
16 Himachal Pradesh 12 0 6 0 0 5 0 0 1
17 J & K 2 0 2 0 0 0 0 0 0
18 Karnataka 29 10 11 1 0 6 1 0 0
19 Kerala 56 45 1 3 1 3 0 1 2
20 Lakshadweep 0 0 0 0 0 0 0 0 0
21 MP 8 4 4 0 0 0 0 0 0
22 Maharashtra 24 9 11 0 0 4 0 0 0
23 Mumbai (MC) 16 5 4 3 1 3 0 0 0
24 Avert 22 4 1 1 0 16 0 0 0
25 Manipur 42 5 2 1 31 3 0 0 0
26 Meghalaya 2 0 2 0 0 0 0 0 0
27 Mizoram 24 5 2 0 13 2 1 1 0
28 Nagaland 22 1 1 0 17 0 2 1 0
29 Orissa 21 1 6 0 0 11 1 1 1
30 Pondicherry 5 1 1 1 0 2 0 0 0
31 Punjab 11 3 6 0 0 2 0 0 0
32 Rajasthan 9 3 2 0 0 2 2 0 0
33 Sikkim 4 0 1 0 0 2 0 1 0
34 Tamil Nadu 82 23 17 2 0 35 0 3 2
APAC 38 10 9 0 0 14 0 0 5
35 Tripura 19 3 5 0 1 8 1 0 1
36 Uttar Pradesh 35 6 14 0 0 6 0 9 0
37 West Bengal 35 15 6 0 3 9 1 1 0
Total 882 209 190 25 74 249 26 54 56
ANNEXURE: 2
Community led Structural Interventions - suggestions on what needs to be done
Interventions with sex workers
1. Policy advocacy: This is the toughest but most essential part of working with sex workers. In the law of the land sex work is illegal. But sex work is also inevitable. HIV cannot be controlled unless this reality is accepted. Decision makers have to face this and resolve the dilemma. The project can stimulate and modulate debate on the topic.
2. Empowerment of sex workers: Unless the sex workers feel that their lives are worth saving they are unlikely to be convinced of the need to invest in changing to safe behaviours. In consultation with sociologists and psychologists and through participation of the community, the project has to devise strategies that work on the self-concept and self-image of sex workers.
3. Create a desire to live for the future: Sex workers, especially street based sex workers face an uncertain future. They have nothing to look forward to. Caring for their children, ensuring proper education for their children, creating a provident fund that will help them put together an amount to hedge for the future, teaching them a profession which they can practice when they can no longer do sex work, helping the community groups create a housing scheme for them are possible strategies that the project could follow.
4. Create a group feeling: Studies of military personnel have shown that in extremely depressing situations, what helps individuals survive is their concern for the group. Hence supporting the creation of a group is useful to building self-esteem. A well-knit group also enhances the ability to negotiate with decision-makers.
5. Targeted provision of services: While sex workers are among the most marginalized groups they are often kept out of welfare services such as Anganwadis or health centres. The project could ensure access to these services, if necessary by part financing provision, such as obtaining a building to house these services.
6. Savings and Credit groups: Street based sex workers do not have a steady source of income. Some of their expenses are bunched and could be catastrophic. In order to give them a degree of financial protection it is useful to facilitate the creation of community savings and credit groups. It helps to foster the creation of group feeling and can be the precursor to the provident fund and housing schemes discussed earlier.
7. Leadership development: Outsiders who work with sex workers can be effective only in the beginning. Later leadership has to emerge from the community. The project has to facilitate leadership development process, handholding in the beginning and gradual withdrawal by handing over the reins to community leaders.
Community led structural Interventions with truckers
Truckers do not face the same degree of disempowerment as sex workers. For them the lifestyle that could foster high-risk behaviour is the result of their working conditions. Hence structural interventions with truckers have to intervene to make their lives less risky. This could involve:
Advocacy for
1. Ensuring compliance to rules regarding the number of hours a trucker can drive: Often truck drivers are under pressure to reach the goods to destination within an unrealistic timeframe. This leads to taking unacceptable risks on the roads. The truckers unions need to be persuaded to take an uncompromising stand on this, in view of the danger it poses to truckers.
2. Acceptable accommodation en route: Decent accommodation, with facilities for rest and recreation has to become part of the highway scene in the country. These services can be franchised, funded out of road tax or special cess.
3. Highway assistance teams: Including trained para – medicals for evacuation from accident sites,
Facilitation of
1. Linking up between trade unions in different locations: This makes it possible for truckers to access support structures wherever they travel. This instils a feeling of security among truckers and could minimise harassment by police and transport department
2. Persuading trade unions or employer associations to provide services: In the current model of TI with truckers the services to reduce vulnerabilities are provided by NGOs. These have been very effective. But in the interest of sustainability and ownership it is necessary to move the services into existing structures. The trade unions or employee associations could be persuaded to provide HIV and STI related services at the accommodation centres in the highways at hours convenient to truckers.
Adding a new dimension to Targeted Interventions
It is common understanding in the HIV discourse that certain sub-populations are relatively more vulnerable to HIV/AIDS and are more susceptible to infection and less able to handle its consequences. The proximate cause of this vulnerability may be unsafe sex (as in the case of sex workers and Men who have sex with men) or reuse of unsterilised needles. (Injecting Drug Users). But these are often the symptoms and not the cause.
Targeted interventions [TIs], a major component of India’s National AIDS Control Programme, seeks to address the proximate causes of this vulnerability.
The TIs, now numbering more than 882, [Full list of TIs] have contributed to creating awareness regarding the epidemic and in increasing access of such population to services. The TIs, as they are structured today, attempt to :
provide behaviour change communication (to motivate the beneficiaries to change to safer behaviours and to access services which helps protect against infection),
provide and promote such services (such as STI services and condoms)
create an enabling environment where the delivery of these interventions can be facilitated.
However these components have not been able to address the more immediate needs of the primary stakeholders. These needs are perceived by them to be more important to them than sexual health needs, which the targeted interventions deal with. Care and support of infected persons from among the target group is also emerging as an important unmet need.
Further, the TI approach does not take into account that the sub populations in question do not have the desire or power to make decisions that would lead to the utilisation of such services, for if that would have been the case, the interventions would have achieved what they sought to i.e. halt and reverse the spread of infections in these populations and from them to their contacts. These aspects point out the gap in current HIV programming and challenge the fundamental assumptions underlying the design of TI s.
Core causes of vulnerability
The underlying causes that make such sub populations vulnerable result from a complex interplay of social, economic, cultural and other systemic factors. The sub-populations have become vulnerable not by choice, but due to the situation to which the society has assigned them. Some of the contributing factors that are result of the lives that these groups lead could be summarised into the following:
1. Low expectations from future: People invest in the future, such as forgoing present consumption and pleasure for education or health promoting activities, when they are convinced that they are likely to reap a richer harvest later. But if a person does not believe that he/she will be able to enjoy such rewards in the future, he/she cannot be persuaded to take precautions in the present so as to avoid a danger that may come up in the future.
Most of the vulnerable populations be they sex workers, truckers or IDUs are not assured of a secure future due to the environment in which they exist. Their life situation is such that there is no reasonable assurance that they would even be alive in the future. The trucker, driving on the unsafe highways, is apprehensive that he may meet with an accident. A sex worker who earns her livelihood from the streets is always under threat from the unlawful elements that rule that environment. Hence it is difficult to persuade them to take precautions against HIV/AIDS, they do not see it as their immediate priority as the consequences of the disease are not immediately obvious. Therefore one of the necessary conditions for the TIs to succeed is to assure the person with high-risk behaviour that he/she has the possibility of a good future which he has to invest in. To do this the programmatic has to go beyond sexual health needs and respond to the more immediate needs of security and livelihood.
2. Social identity and power: an individual's sense of identity is derived from the space he/she occupies and the transactions that he/she carries out with other individuals / entities / institutions in the society. Building on this understanding, a sex worker occupies a space in this society which lies in the grey area between legality and illegality. This 'space' makes it difficult for her to realise her rights such as access to public health care, social security measures and right to legal aid. It thus becomes unreasonable to expect the vulnerable groups to even believe that they can change their own behaviours when their right to exist as citizens is not recognised. Altering this self-concept would involve empowering sex workers and making it possible for them to claim their right to exist with in their society and ensuring that they receive their entitlements. This process would seek to not only involve the vulnerable groups but also build advocacy networks with the policy makers and implementers of the society.
3. Power to take decisions regarding own actions: Quite often a vulnerable person does not perceive him/herself to be in a position to take decisions regarding his/her own actions. This is because the social identity of a person determines her power both in her perception as well as that of others. Power is also determined by the structure and practices in the spaces they occupy. How a street worker can function is determined not so much by her knowledge and attitudes but by the powerbrokers that influence and control sex work and the context in which s/he operates. The truckers ability to adopt safe practices is contingent on the truck operators’ and good owners’ perception of how it is important to get the goods to the destination at the minimum cost and fastest time and the transport authorities decision that truckers cannot operate during day time in certain sectors. Even among the same sub- population economic status (or its correlates such as education, house to live or beauty to attract clients) leads to stratification among members of the same sub-population. In a situation where there are too many sex workers competing for a few clients, a sex worker who is in a disadvantaged position may be forced to weigh the possibility of not earning an income versus the possibility of getting infected due to unprotected sex. Factors like these that finally determine behaviors and qualify them according to risk to HIV have to examined and must inform any strategy that is designed to counter high risk behaviour.
4. Social power structure prevents access to services: In the political economy of decision making resources are allocated according to the bargaining power of beneficiaries. Therefore in any transaction, if a person has some influence or goods to offer, he/she also influences decisions taken to benefit them. in the case of vulnerable populations, since they are often the most marginalized, they can not influence the decisions taken and are not involved in decision-making. Their interests will not be attended to. For instance while the red light areas or other living areas of sex worker lies beyond the limits of the city or in the margins, it is highly unlikely that an Anganwadi, which would have provided pre-school education, immunization and nutrition to their children, would be located there. Nor would it have a health outpost. Even if a sex worker or an IDU reaches a health facility she is likely to discriminated against due to the stigma of drug use and sex work. Such exclusion, both physical and social, leads to denial of services and hence vulnerability. It also leads to alienation from the concerns of the society as she does not perceive herself to be part of the society which has rejected her. Hence if the society needs the co-operation of vulnerable populations in containing HIV/AIDS, then programme managers have to put in place strategies to deal with these structural obstacles.
Why it is necessary to address structural issues?
It thus becomes evident that if targeted interventions are an important strategy for achieving the goals of National AIDS Control Program, the above mentioned issues and a host of other related challenges represent roadblocks to achieving them. They are not easy to address. They have been created by deep-seated social norms shared by the decision makers and even by their victims. They have become part of the social and political structures. The strategy to deal with them begins by being aware of and acknowledging the structural constraints, recognising the value of removing them, articulating a stand that is conducive to the removal of these constraints and investing in strategies and activites to remove them.
The HIV/AIDS epidemic is driven by individual behaviour. Unless this changes the epidemic cannot be halted. But individual behaviours do not occur in a vacuum. There are individual knowledge and attitudes, social norms and values, legal and administrative systems and the demonstration effect of peer behaviour that influence the behaviour of an individual. For instance, if the sex worker herself feels that her life is not worth protecting from HIV on account of her assessment of her self worth, she may not adopt the safer behaviours that TIs try to inculcate. So long as the peers and the society retains an assumption that a trucker is a person who lives life dangerously, and does nothing to change the risks associated with the profession, the life style approach that the trucker acquires and adopts as his own will also translate into his sexual and recreational habits. The legal system that makes it impossible for IDUs to obtain syringes and needles legally will negate the impact education on adopting safer injecting practices.
TIs try to change the behaviour of individuals by providing knowledge, trying to change attitudes and by providing services without addressing any of the other group of causes. [The component of enabling environment is meant to deal with these issues. But it has remained an insignificant component of the TI s]. Behaviour Change Communication operating in vacuum and without building on the underlying causal analysis will not be able to lead to sustained and consistent behaviour change.
Who benefits from Targeted Interventions?
Populations seen as vulnerable to HIV today have been suffering discrimination and violations in this country since ages. Their conditions attracted attention and resources only when it became clear that HIV/AIDS can not be controlled without involving them. Hence the objective of TIs is not the welfare of the marginalised populations. It is a public health measure to protect the general population. That aim will not be achieved without the collaboration of the vulnerable populations and other agencies that influence the lives of these groups beyond health. .
To be willing collaborators the vulnerable populations must share the objective of the programme managers. No group will identify with objectives that are perceived to benefit a society in which they have no stakes. In return for their collaboration, the society will need to accept them and involve them as stakeholders in the campaign against HIV/AIDS. Therefore before attempting to change the behavior of the vulnerable sub-populations, society will need to change their attitude to the sub-populations. This goes against the grain of established beliefs; but is a non-negotiable if their collaboration is needed for the success of the AIDS control programme. And the logic of the National AIDS Control Programme states that unless the spread of the virus among the vulnerable populations is prevented the epidemic cannot be halted and reversed. Therefore structural interventions proposed to be addressed in the SAKSHAM programme is an essential element in the success of the National AIDS Control Program.
Vested interest VS social good
Given the extent of their disempowerment, sex workers are objects to be hunted down by vested interests, without opposition from the systems society has to protect the life and wealth of its citizens. An instance is the real estate lobby that is attracted by properties where sex workers live and carry out their work. Here the other interests who would benefit from eviction of sex workers assist them. They would manifest themselves as social workers out to save the society from the menace of sex work. All the persons who assist them based on altruist or corrupt reasons are also protected from the consequences of their actions owing to the vested interests being disguised as social work. If vulnerable communities were to live in the shadow of such threats it is highly unlikely that they would develop the needed stability to respond to the messages of Targeted Interventions. It is also possible that certain values may lead to unacceptable behavior e.g.: A police officer who believes that sex workers are harmful to society may beat up sex workers and feel he is doing the right thing. These dimensions are also part of the complex scenario to be addressed.
How can they be addressed?
Social disabilities created by deep-seated attitudes and years of practice and incorporated into the structure of the society cannot be wiped away easily. It will have to be a sustained operation undertaken with faith in the rationale of the strategy and with acceptance and participation of the beneficiaries. It will mean building the capacity and empowering the marginalized sub-populations and changing attitudes of policy makers and implementers. This would involve a paradigm shit of moving from structural and targeted interventions to Community led structural interventions.
Key components of community led structural interventions would include:
a. Nurturing leadership among the sub-populations: Experience with many interventions that have adopted rights based approach have shown that with appropriate handholding, leadership will emerge from the sub-population itself. To many it provides a fillip to their desire to prove their worth to themselves. Surviving for years in a hostile environment have built them into hardy and aggressive personalities. . Development of skills and creation of spaces that allow these groups to express themselves, use their lives experiences to fuel discussions and debates. This would also allow them to lead themselves and their communities by acumen that they have developed by dealing with complex environments to drive change in their lives and work environments, eventually reduce vulnerabilities to HIV and other human rights violations. There are many instances where such leadership has emerged from primary stakeholders and gone on to lead community based organizations among sex workers and IDUs. Truckers have trade unions, which can provide such leadership. The nature of intervention will depend on an assessment as to what skills are needed for successful leadership. Using techniques of adult learning such as coaching and mentoring, appropriate skills can be developed in collaboration with the communities.
b. Team building: If vulnerable populations are to command any influence they have to be united and build themselves into a team, which can bargain collectively. But given the hostile and secretive environment in which they operate, divisive forces outweigh the unifying ones. Therefore it is necessary for the group to engage in activities that build co-operation and a group dynamism. It is also necessary for the leadership to learn to resolve conflicts that are bound to emerge.
c. Savings and credit: While unity and capacity buildings adds to social empowerment it is also necessary to assure the community of degree of economic security as an insurance against unforeseen demands. Community financing initiatives including savings and credit movements have been found to be empowering to the community. Raising funds from their own resources and managing it themselves including who to lend to and on what terms, gives them power over part of their destiny, certain degree of economic independence and a community feeling that each person is involved in offering protection to every other member of the community.
d. Managing the external environment: Given the low social power of the marginalized sub-populations, many agents have influence over their conduct. If they are hostile the structural interventions will be thwarted. Therefore it is important for the programme to engage the power holders in the social environment of the sub-populations to generate support for the structural interventions. This will be difficult as many of the power holders have a vested interest in the low social position of the sub-populations. But the overwhelming importance of empowering them to achieve the objective of the society must be made to take precedence over the interests of the vested groups. Media support, political advocacy, activism by the sub-populations and the organizations supporting them and working on the attitudes of the power holders are some of the techniques that may be tried.
e. Building capacities: Many of the members of the marginalized populations have an overwhelming desire to learn new skills such as literacy and crafts. These may be positioned not only as pathways to alternate livelihood but also as something that enhances their self worth. In time it can also become a means to supplement their income. For IDUs, many of whom are highly talented, it can be an occupational therapy for rehabilitation. Legal awareness can help all the marginalized groups to understand and in time fight for their rights.
f. Policy support: It will not be possible to engage the marginalized populations without a policy decision that accepts their rights. Many of them exist on the margins of legality. It may be politically difficult to make changes that make their activities legal (though many countries have accepted the fact of sex work and drug use and have found that legalizing them helps to manage their adverse impact better than proscribing them). But if their co-operation is needed to prevent the spread of HIV/AIDS, it cannot be achieved when agents of the society hound them. Therefore a consensus has to be arrived at between the law enforcers and programme managers of HIV/AIDS as to how the rights of such populations may be protected. The representatives of the sub-populations will also have to be involved in the dialogue as to what the parameters of their functioning will be. While this is difficult it has been achieved in many interventions in the country.
The needs of marginalized populations may not receive much attention from decision makers. But if the AIDS Control Programme is to succeed the structural constraints to preventing the spread of infection in these groups must be addressed. Therefore it is as much a need of the society as that of the vulnerable populations.
ANNEXURE: 1
STATUS OF TARGETED INTERVENTIONS IN INDIA- 2003
TARGETED INTERVENTIONS : Dec., 2003
Sr. No. State Total TI Projects CSW Truckers MSM IDUs Migrant Workers Street Children Prison Others
1 A & N Island 4 1 0 0 0 1 0 1 1
2 Ahmedabad 21 1 0 1 0 3 1 0 15
3 A.P 117 25 24 3 0 23 6 25 11
4 Arunachal 7 0 4 0 2 1 0 0 1
5 Assam 29 7 8 0 1 7 2 0 4
6 Bihar 17 2 14 1 0 0 0 0 0
7 Chandigarh 12 0 2 0 0 8 1 1 0
8 Chattisgarh 10 2 7 0 0 1 0 0 0
9 Chennai 20 5 1 2 3 4 1 0 4
10 D. & N. Haveli 1 0 0 0 0 1 0 0 0
11 Diu & Daman 0 0 0 0 0 0 0 0 0
12 Delhi 29 2 3 2 1 17 4 - -
13 Goa 10 1 1 1 0 5 0 0 2
14 Gujarat 87 10 12 3 0 45 2 9 6
15 Haryana 0 0 0 0 0 0 0 0 0
16 Himachal Pradesh 12 0 6 0 0 5 0 0 1
17 J & K 2 0 2 0 0 0 0 0 0
18 Karnataka 29 10 11 1 0 6 1 0 0
19 Kerala 56 45 1 3 1 3 0 1 2
20 Lakshadweep 0 0 0 0 0 0 0 0 0
21 MP 8 4 4 0 0 0 0 0 0
22 Maharashtra 24 9 11 0 0 4 0 0 0
23 Mumbai (MC) 16 5 4 3 1 3 0 0 0
24 Avert 22 4 1 1 0 16 0 0 0
25 Manipur 42 5 2 1 31 3 0 0 0
26 Meghalaya 2 0 2 0 0 0 0 0 0
27 Mizoram 24 5 2 0 13 2 1 1 0
28 Nagaland 22 1 1 0 17 0 2 1 0
29 Orissa 21 1 6 0 0 11 1 1 1
30 Pondicherry 5 1 1 1 0 2 0 0 0
31 Punjab 11 3 6 0 0 2 0 0 0
32 Rajasthan 9 3 2 0 0 2 2 0 0
33 Sikkim 4 0 1 0 0 2 0 1 0
34 Tamil Nadu 82 23 17 2 0 35 0 3 2
APAC 38 10 9 0 0 14 0 0 5
35 Tripura 19 3 5 0 1 8 1 0 1
36 Uttar Pradesh 35 6 14 0 0 6 0 9 0
37 West Bengal 35 15 6 0 3 9 1 1 0
Total 882 209 190 25 74 249 26 54 56
ANNEXURE: 2
Community led Structural Interventions - suggestions on what needs to be done
Interventions with sex workers
1. Policy advocacy: This is the toughest but most essential part of working with sex workers. In the law of the land sex work is illegal. But sex work is also inevitable. HIV cannot be controlled unless this reality is accepted. Decision makers have to face this and resolve the dilemma. The project can stimulate and modulate debate on the topic.
2. Empowerment of sex workers: Unless the sex workers feel that their lives are worth saving they are unlikely to be convinced of the need to invest in changing to safe behaviours. In consultation with sociologists and psychologists and through participation of the community, the project has to devise strategies that work on the self-concept and self-image of sex workers.
3. Create a desire to live for the future: Sex workers, especially street based sex workers face an uncertain future. They have nothing to look forward to. Caring for their children, ensuring proper education for their children, creating a provident fund that will help them put together an amount to hedge for the future, teaching them a profession which they can practice when they can no longer do sex work, helping the community groups create a housing scheme for them are possible strategies that the project could follow.
4. Create a group feeling: Studies of military personnel have shown that in extremely depressing situations, what helps individuals survive is their concern for the group. Hence supporting the creation of a group is useful to building self-esteem. A well-knit group also enhances the ability to negotiate with decision-makers.
5. Targeted provision of services: While sex workers are among the most marginalized groups they are often kept out of welfare services such as Anganwadis or health centres. The project could ensure access to these services, if necessary by part financing provision, such as obtaining a building to house these services.
6. Savings and Credit groups: Street based sex workers do not have a steady source of income. Some of their expenses are bunched and could be catastrophic. In order to give them a degree of financial protection it is useful to facilitate the creation of community savings and credit groups. It helps to foster the creation of group feeling and can be the precursor to the provident fund and housing schemes discussed earlier.
7. Leadership development: Outsiders who work with sex workers can be effective only in the beginning. Later leadership has to emerge from the community. The project has to facilitate leadership development process, handholding in the beginning and gradual withdrawal by handing over the reins to community leaders.
Community led structural Interventions with truckers
Truckers do not face the same degree of disempowerment as sex workers. For them the lifestyle that could foster high-risk behaviour is the result of their working conditions. Hence structural interventions with truckers have to intervene to make their lives less risky. This could involve:
Advocacy for
1. Ensuring compliance to rules regarding the number of hours a trucker can drive: Often truck drivers are under pressure to reach the goods to destination within an unrealistic timeframe. This leads to taking unacceptable risks on the roads. The truckers unions need to be persuaded to take an uncompromising stand on this, in view of the danger it poses to truckers.
2. Acceptable accommodation en route: Decent accommodation, with facilities for rest and recreation has to become part of the highway scene in the country. These services can be franchised, funded out of road tax or special cess.
3. Highway assistance teams: Including trained para – medicals for evacuation from accident sites,
Facilitation of
1. Linking up between trade unions in different locations: This makes it possible for truckers to access support structures wherever they travel. This instils a feeling of security among truckers and could minimise harassment by police and transport department
2. Persuading trade unions or employer associations to provide services: In the current model of TI with truckers the services to reduce vulnerabilities are provided by NGOs. These have been very effective. But in the interest of sustainability and ownership it is necessary to move the services into existing structures. The trade unions or employee associations could be persuaded to provide HIV and STI related services at the accommodation centres in the highways at hours convenient to truckers.