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Aids: On India's Roads, Cargo and a Deadly Passenger

Contributed by Anonymous on Tuesday, December 06 @ 20:42:13 CST

HealthBy AMY WALDMAN, The New York Times

Published: December 6, 2005
NELAMANGALA, India - Hot water: 10 rupees. Cold water: 8 rupees. Toilet: 5 rupees.

Sex: no price specified on the bathhouse wall, but, as the condom painted there suggests, safe.

Sangeetha Hamam, a bathhouse, sits on the national highway near this gritty truck stop about nine miles north of Bangalore. Its mistress is Ranjeetha, a 28-year-old eunuch who lives as a woman. Her lipstick and black dress provide a touch of glamour in the small dark shack.

Her clients are not only truckers, but also Bangalore college students and other city residents. They know to look for sex at highway establishments geared toward truckers. Her customers - as many as 100 on Sundays for her and five other eunuchs - come for a "massage" and the anal sex that follows, but also for the anonymity the location confers.

Ranjeetha knows men will pay more for unprotected sex, but she calculates that the extra money is not worth the risk to her livelihood and life. She knows they can go elsewhere; there are some 45 bathhouses doubling as brothels near this truck stop. She also knows several eunuchs who have died of AIDS.

India has at least 5.1 million people living with H.I.V., the second highest number after South Africa. It is, by all accounts, at a critical stage: it can either prevent the further spread of infection, or watch a more generalized epidemic take hold. Global experts worry that India is both underspending on AIDS and undercounting its H.I.V. cases.

Its national highways are a conduit for the virus, passed by prostitutes and the truckers, migrants and locals who pay them, and brought home to unsuspecting wives in towns or villages. In its largest infrastructure project since independence, India is in the process of widening and upgrading those highways into a true interstate system. The effort will allow the roads to carry more traffic and freight than ever before. But some things are better left uncarried.

The national highways between New Delhi, Calcutta, Chennai, formerly Madras, and Mumbai run through at least six districts where H.I.V. prevalence is above 2.5 percent. Earlier this year, a New York Times reporter and a photographer drove the route, which has been nicknamed the Golden Quadrilateral.

To drive it is to peel back a nation's secret, or not so secret, sex life, and the potent mix of desire, denial and stigma that is helping spread the disease.

India's entry into the global economy over the past 15 years may also be furthering the spread of AIDS. With rising incomes, men have more money for sex; poor women see selling sex as their only access to the new prosperity. Cities are drawing more migrants and prostitutes, and Western influences are liberalizing Indian sexual mores. In response, cultural protectionists are refusing to allow even the national conversation about AIDS to reflect this changing reality.

The notion of a sexually chaste India is a "complete myth," said Ashok Alexander, the director of Avahan, the India AIDS Initiative of the Bill and Melinda Gates Foundation. Its preservation hurts prevention: "You say it's not a big problem, only 'those people' are doing that."

Driving the highway also shows the complications in reaching the various constituencies along it. India's AIDS epidemic is as variegated as the country itself, with a multiplicity of high-risk groups. Intravenous drug users concentrate in northeastern states. Devadasis - poor, lower-caste women consecrated to gods as young girls and then consigned to prostitution - live in the south.

Many of the groups are deeply fragmented and in perpetual motion, making them difficult for educators to reach: the man who owns a single truck; the woman who works at night out of a thatched hut; the lone migrant who shuttles back and forth between his village and urban work.

But a number of AIDS prevention groups have come to see working along the highway as the best hope for targeted interventions.

Avahan is pouring much of its $200 million into efforts along the highway. Another group, Project Concern International, sent young men to walk the Golden Quadrilateral - 3,625 miles long - over the course of a year to raise awareness about AIDS.

They met truckers, villagers, road workers and migrants, and in some places were cheered as heroes. In others, they were chased out for daring to discuss condoms and H.I.V., accused of spreading promiscuity and disease.

Sometimes, construction on the highway blocked the workers' way. But the deeper obstacles were culture, politics and history. The puritanical values of British colonialists repressed sexual expression in this country - essentially criminalizing homosexuality - and stigmatized it in many Indians' eyes as well. Some of the socially conservative Hindu nationalists who governed until 2004 tried to pretend no one was having sex, at least outside marriage.

In truth, sex work has flourished in independent India. Red-light districts operate openly in cities like Mumbai, formerly Bombay, and in its new suburbs and industrial areas. Hundreds of girls and women parade the streets at night near "pharmacies" where quacks peddle fake AIDS remedies.





And advocates battling the spread of AIDS say they have learned that men having sex with men, then with their wives, is surprisingly common, but veiled by stigma.

Ranjeetha, the bathhouse mistress, believes the real danger is not open eunuchs like her, but the men in denial, who work in offices by day and dress in saris at night. "People who lead double lives don't use condoms," she said.

Awareness and Denial

At least 1,000 trucks a day pass through Nelamangala's trans-shipment point, often waiting hours or days for a new load. In the interim, drivers and their helpers patronize bathhouses like Sangeetha, although many of the sex establishments do not paint condoms on the outside, and use none inside.

There are three million to four million trucks on India's roads, at least one million of them traveling long distances. If truckers cannot find sex at trans-shipment points, they can buy it on the roadside, where women signal potential clients with flashlights.

As many as 11 percent of truckers may be H.I.V. positive. In some parts of the country, like Tamil Nadu, the stigma around truckers has grown so strong that fathers forbid their daughters to marry them.

Yet no one has figured out a comprehensive system for education or testing. There are perhaps 3,000 to 4,000 regional transport companies, but most trucks are owner-driven or run by small companies.

The major stopping points, or trans-shipment yards, see so many truckers each day that even if truckers take an AIDS test, there is no way to follow up - an "amnesiac system" in one advocate's words.

In a dusty parking lot at this truck trans-shipment point, an AIDS educator wielded a black dildo and a condom, encircled by truckers who stifled mirth and curiosity.

"Why are you targeting us?" a trucker asked the educator.

Truckers asked if AIDS could be transmitted by mosquito bites. They made ribald jokes about their sex lives, and boasted about not using condoms.

One trucker interrupted to say he knew people who used condoms and still got AIDS.

"Check the expiration date," the educator said.

"We are illiterate, we can't read," the trucker replied.

In the country's north, some drivers say they have never heard of AIDS, although their facial expressions may suggest otherwise. In the south, where AIDS is much more common, denial is trickier. Truckers have heard of AIDS, and often know someone who died from it, and word is starting to travel along with the virus.

But awareness does not always translate to protection. Bhagwan Singh, 47, a trucker who was halting at the Gujarat-Rajasthan border, said he did not use condoms, because he had paid for sex only a few times.

"What happens if I just go once, twice, thrice?" he said. "Only if I'm a regular fellow I might contract such things."

Bringing H.I.V. Home

Once, twice, thrice or more often, whatever the truckers do on the road, or migrants do in cities, is coming home to oblivious wives. Here, the danger of a culture that is simultaneously licentious and conservative, of seasoned husbands and sheltered wives, becomes clear.

This has become especially apparent in India's southern states, which are prospering economically, but have been hit the hardest by AIDS, along with pockets of the isolated northeast.

The states the highway runs through in the south all have H.I.V. infection rates of 1 percent or higher.

In the government hospital in Guntur, a district with a 2.5 percent H.I.V. infection rate, Sambra Ja Lakshmi, 27, a mother of two, was being counseled.

Her husband, a 33-year-old trucker, had done "thousands of kilometers on the national highway," as she put it. Where he got H.I.V. is unknown, but he was so sick he could no longer move. She, a homemaker and mother who barely left her village about 15 miles off the highway, was H.I.V. positive, too.

The counselor, Sunita Murugudu, had heard it before, and knew she would hear it again.

Some 80 percent of truckers' wives who came in for voluntary testing and counseling tested positive, she said, usually because by the time they came in their husbands were on their deathbeds, and denial could no longer be sustained.

G. Karuna, 24, was another woman who fell prey to the peregrinations of her husband, a long-distance driver from a family of truckers. When they both sought treatment for tuberculosis or opportunistic infections at hospitals, they hid his occupation, since many private hospitals now turn truckers away.

After her husband died, his family blamed her, a cruel vengeance some in-laws inflict on the widows. They have made treatment and prevention that much harder.

She was forced to sleep on the path outside; the family refused to share even a loaf of bread that she had touched. Soon their whole village had ostracized her.

Ms. Karuna cried as she told her story, but that story also conveyed an uncommon strength. She had left her husband's family and her village to start a new life on her own. She became an activist with the Social Educational and Economic Development Society, an advocacy group in Guntur, trying to save other truckers' wives.

She showed women pictures of her handsome husband before he sickened, and after.

She told the wives to know what their husbands were doing outside the home, to negotiate the use of condoms with them, to get treated for sexually transmitted diseases. Her husband's relatives still teased her: "Why are you working so hard? You also will die."

Morality and Stigma

In the town of Nippani, outside Lafayette Hospital, a sign warned against unprotected sex, showing a blue demon on a horse slaying a healthy man.

But those who fell prey to that demon were not welcomed, explained a doctor, Sunil Sase. AIDS carried a stigma like leprosy, he said, "so we are not exactly treating the AIDS cases." They were sent to another hospital 50 miles away.

A group working to raise AIDS awareness among prostitutes had been chased from Nippani after being accused of promoting sex. Most of the devadasis and prostitutes, who had been working in the town on the highway for 50 years, had been chased out in a morality crusade. Now they were scattered along the road, impossible to reach with education or condoms.

A mob had pulled one prostitute, Reshma Sheikh, and her 7-year-old son out of her house to try to force them from town. "We have a right to live and work there, we never hurt the sentiments of the people around," she said. She had stayed, only because she had nowhere else to go.

The main group leading the crusade was the Shiv Sena, a Hindu nationalist political party. Sunil Sadashir Dalavi, 32, the local leader, boasted about their success. But he said the women were not the only cause for the spread of AIDS.

"Educated boys don't get jobs, they have extra time, they don't know what to do," he said. "They can't marry till they get a job, they have very strong desires, so they go to these women."

Once the men were married they would not do "these things," he insisted, despite government surveys showing otherwise. The answer to controlling sex was controlling the culture, he said. A lot of local men went to two nearby cinemas that screened sex movies, he said, and then to brothels. "We want to close the 'talkies' down," he said, "so people will not do this."

A Fragmented Industry

In almost every doorway in the red-light district of Chilakaluripet, in Andhra Pradesh, women drape, wearing bright clothes, garish makeup and come-hither expressions that have served to lure both men and disease.

For half a century, the town has been a center of sex work, combining its location on the national highway with women from its Domara community, which has come to specialize in prostitution. Truckers passing through know where to stop; if they do not, there are hotel boys, rickshaw pullers and others willing to guide them.

In recent years, the town and surrounding area have also become a center of H.I.V. infection, and, given the number of long-distance truckers tarrying here, a likely source for its spread elsewhere.

The sex industry has been organized in some cities, like Calcutta, but mostly it is as fragmented as the trucking industry. Chilakaluripet features brothel-based and home-based prostitutes, secret prostitutes and women who sell sex along the highway. A police crackdown on brothels in recent years has further dispersed the women.

Venkaimah, a 25-year-old widow, is part of a "highway brothel" - a small moving coterie of women who work in bushes or fields or restaurants along the road. Her workday starts when the light is gone and the truck traffic heavy. She leaves her two daughters, 10 and 2, behind, and on a good night may get 8 to 10 customers who pay 50 cents to a dollar each.

Some prostitutes now use condoms, but the disease continues to spread. One local organization, Needs Serving Society, estimated that 1,000 people had tested positive for H.I.V. in the town and nearby villages, most of them not prostitutes, but locals who may have patronized them. No one, though, had any real idea of the true number. On one narrow lane alone, 20 prostitutes were infected, said one of them, Konda, 38.

Venkaimah's children motivated her to use condoms - if she did not, she knew that sooner or later they would be orphaned. But loneliness can loosen defenses: like many prostitutes, she had "temporary husbands" - longtime boyfriends - with whom she did not use a condom at all.

Chilakaluripet, known for sex, was now marked by death.

In a courtyard, Venkateswarmma, a mother of two, as thin and brittle as a doll, sat on a cot, unable to move. Her husband, a brothel owner's son, had died 10 days before, infected after sleeping with its employees. She was near death herself, unable to walk for her husband's death ceremony. Her 2-year-old son had already died from AIDS; she would leave behind an 11-year-old boy.

A Mobile Society

For 15 years, Vilas Jaganath Kamkar had been taking the bus from his village in Maharashtra state to Mumbai, its capital, where he worked as a taxicab driver. In 1994, he had taken a wife, Manisha, but he kept working in Mumbai, with monthly visits home.


In this migrant nation, his life was not unique. Nor, in this age of AIDS, was his fate. Migrants may be the hardest group for AIDS educators to reach. As Indian society becomes more mobile, people are leaving villages for urban work at increasing rates.

In Maharashtra, new plants and factories are springing up along the revamped highway. As rural migrants come to work in the factories, poor women follow to sexually service the men. Newly rich locals patronize the abundant supply of women, spawning H.I.V. "hot spots" along the highways.

In cities, the migrants live in slums, three or more to a room, and may move often. Away from their families for months at a time, they seek the companionship not just of prostitutes but of girlfriends, with whom safe sex is often ignored.

Migrants leave home to work, but go home to die. At the hospital in Satara, a prospering city on the highway south of Mumbai, Mr. Kamkar, the taxi driver, now 32, lay breathless on a hospital bed. His luck had run out, and not just because he had contracted H.I.V. Only 25 hospitals and health centers were prescribing antiretroviral drugs. They were available in Guntur, but not 12 miles south in Chilakaluripet. They could be had in Mumbai - but not in Satara.

All Mrs. Kamkar, 25, a mother of two, could do was take her husband back to their village, try to ease his pain and nurse him until the end.

"It's a matter of his destiny," she said.


 
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