After UNAIDS revised the estimated number of people living with HIV in India downwards from 5.7 million to 2.5 million in 2007, it appeared that the burden of the disease in the Indian society was not as important as other issues, such as basic sanitation and food security.1 However, India is still the country with the most HIV infections in the world, with prevalence in some states as high as 1.13%. Recently the Indian government launched a five year US$2.5 billion response to the epidemic, where 70% of the budget was earmarked for prevention strategies and 20% allocated for care and treatment.2
To increase the efficiency of such an initiative, it is very important to understand how much the population knows about HIV, how much stigma there is, and how much HIV preventive actions (in the form of abstinence, faithfulness, and condom use) are being practiced. Investigating the correlation of HIV knowledge, HIV stigma, and sexual behaviour with socioeconomic variables such as gender, age, marital status, place of residence, religion, education, and wealth can potentially shed some light into which segments of the population are more susceptible to infection and, therefore, where preventive resources should be more heavily allocated. The recent release of India’s National Family Health Survey warrants such an examination.3
HIV knowledge in the Indian population is very poor. Seventeen percent of males and 40% of females say that they have never heard of HIV/AIDS. These numbers are much higher when compared to responses from populations of sub-Saharan African countries. Those who said they knew of AIDS were not necessarily very knowledge: when asked if a healthy looking person could have AIDS, 27% of males and 38% of females did not know the answer. These statistics raise some concerns as to how inadequately prepared the population is in the advent of an outbreak. Another point of concern is the reported levels of stigma in the population. Thirty six percent of males and 37% of females would not buy vegetables from an HIV-infected person. This variable is the most commonly used proxy to measure stigma in these surveys.
Who is at risk?
Giving the complete ignorance about the disease’s existence in great parts of the Indian population, understanding their sexual behaviour is paramount. Careless and abundant sex could introduce unnecessary risks to a great part of the population. It is well known that most HIV preventive campaigns (ABC campaigns) have three major goals:
- Resources are invested in order to increase abstinence in society by promoting delays in sexual initiation;
- Faithfulness is advocated; and
- Condom distribution and education programmes are implemented in order to increase condom use during intercourse.
Data suggests that the population in general is abstaining and being faithful; however, condom use is not widespread – only 8.7% of males and 6.9% of females report having used a condom in their last sexual intercourse.
The low levels of reported condom use could be in part because couples in long-term relationships elect not to use condoms during sex. Given the fact that the overwhelming majority of couples claims to being faithful (assuming honest responses), more focus should be given to sexually active single individuals.
Using data on never married males from NFHS-3 and controlling for many socioeconomic characteristics, I find that wealth and place of residence are the only variables significantly associated with condom use. The top quintile of wealthiest males is 33%more likely to use condoms then the bottom quintile. In general, there is an increasing relationship between wealth and the likelihood of using condoms in India. Also, males living in urban areas are 8% more likely to use condoms compared to males living in rural areas.
Whenever all males are included in this analysis, the variables capturing education, age, and marital status also become significant predictors of the likelihood of condom use. More educated males are more likely to use condoms than less educated males. Not surprising is the fact that currently married males are less likely to use condoms than never-married males. Age has a bell shaped relationship with condom use as the likelihood of condom use increases between 15 and 35 and decreases between 40 and 55.
Amongst females, there is no relationship between socioeconomic characteristics and the likelihood of condom use. This differs from similar studies for countries in sub-Saharan Africa.4,5 These results suggest that a combination of two events is possibly happening: First, it appears that females have very little power in the decision to use condoms; and second, single wealthier males are randomising their choice of sexual partners. That is, the female socioeconomic characteristic is not an important factor in the decision of males to have sex with them.
The relationship between HIV knowledge and socioeconomic correlates is qualitatively similar for both males and females, with larger quantitative differences in the model with just females. That is, higher levels of education and wealth increase the likelihood of knowing about the existence of HIV. The richest female quintile is 28% more likely to know about HIV than the poorest female quintile. For males, this probability is 14%. Also, more educated females are 39% more likely to have heard of HIV compared to the less educated. For males this same probability is 20%. Wealth is also positively associated with knowing that a healthy looking person can have AIDS. The richest males and females, compared to the poorest counterparts, are 13% and 14% more likely to know this fact.
HIV stigma is negatively correlated with wealth and education for both males and females in India, after controlling for all other socioeconomic characteristics. Educated persons are 27% less likely not to buy vegetables from an HIV infected person. Wealthier males are 19% less likely to do so, while wealthier females are 15% less likely.
Even though a great part of the Indian population is faithful and abstains from sex, there are still large segments of the population at risk of contracting HIV. Because condom use is very low and knowledge about the disease is very poor, especially with respect to females and poorer and uneducated single males, preventive policies should be targeted at these groups by increasing condom distribution and awareness, increasing substantially HIV/AIDS basic education, and promoting women’s empowerment particularly with respect to sexual choices.
2 Claeson, M and Alexander, A (2008): “Tackling HIV in India: Evidence-Based Priority Setting And Programming,” Health Affairs, 27(4), 1091-1102.
4 Corno, L and De Walque, D (2007): “The Determinants of HIV Infection and Related Sexual Behaviors: Evidence from Lesotho,” World Bank Policy Research Working Paper 4421.
5 De Walque, D (2006): “Who Gets AIDS and How? The Determinants of HIV Infection and Sexual Behaviors in Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania,” World Bank Policy Research Working Paper 3844.