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Special coverage of 43rd IDSA meeting
Married, monogamous women are at risk for HIV infection in rural South India
A new study that looks at HIV infection among men and women in rural South India has found that women have no behavioral risk factors other than being married to men who were infected.1
"In India, we’re concerned the epidemic could progress into the general population," says John A. Schneider, MD, MPH, a fellow at the University of Chicago in Chicago, IL.
"Everyone thought the epidemic was in urban areas, but we’re finding that urban areas are approximating the rural in terms of infection," Schneider says. "We’re trying to figure out how this is spreading, who’s spreading it, where’s the disease, and that’s what led to our study."
What the study found is there is no specific high risk group, and among women there are no known and obvious risk factors, Schneider notes.
"None of our sample were commercial sex workers," he says. "So all of the women are getting HIV infection from their husbands, and everyone in our sample was married."
The study enrolled 60 people, with a mean age of 37 years, of which 20 were HIV positive, and all were selected from a population-based voluntary counseling and testing program in rural Andhra Pradesh, India.1
Men had two main modes of HIV transmission: one was having sex with a commercial sex worker, and the other was having sex with men, Schneider says.
Investigators found that 50 percent of the HIV-positive men had sex with commercial sex workers, versus none of the HIV-negative controls.1
The men who had sex with commercial sex workers did not use condoms and all were married, and the men who had sex with men also were married and did not use condoms.1
"We did find that there were a few men who had sex with other men, and this was in a rural area, and that has only recently been described as a phenomenon in India," Schneider says. "Homosexuality in India is very complicated, and it’s not like in the West where there are identified groups we can target with intervention."
Indian men who have sex with men (MSM) typically are married and do not identify themselves as MSM, he says.
For instance, when truck drivers were asked about their sexual behaviors, sometimes they would say they have to let the heat out of their bodies from riding in the truck all day, Schneider explains.
"And they do that with commercial sex workers or having sex with men," he adds.
The study found that even HIV-infected women had limited sexual experiences.
"Only one HIV-infected woman had two or more partners in her life," Schneider says. "Of the HIV-infected men, 50 percent had two or more sexual partners that lasted more than a month."
None of the HIV negative men had paid for sex, and only one of them had sex with another man, Schneider says.
"As far as lifetime sexual partners, 100 percent of the women who were uninfected had zero to one partner, and 90 percent of the HIV positive women had zero to one partner," Schneider adds. "The income was no different between the two groups, and also sexually transmitted diseases (STDs) were not different between the two groups."
The study divided participants by Indian caste into the four caste groups of other caste, scheduled caste, backwards caste, and tribal caste, Schneider says.
The tribal caste is the lowest caste in social terms, and investigators were attempting to see how HIV transmission relates to the caste system, he explains.
"Essentially, people marry within their caste," Schneider says. "The commercial sex workers we assume are casteless."
The tribal caste members often are excluded in surveys since they are difficult to reach and often are rural, he notes.
"We didn’t interview thousands of people, but from our small numbers we did have a couple of individuals who were of the tribal caste," Schneider says. "There were no statistical differences in HIV infection in the castes, but it had disseminated in every caste."
This small study opens the door for future research that could look at the different caste groups to learn more about HIV risk behaviors, Schneider suggests.
"Even when I was trying to get this through an institutional review board (IRB) in India, there were physicians on the board and a judge who didn’t understand any of this and didn’t have any idea about what sexual behavior was occurring within castes, especially in rural areas," Schneider says. "They thought people in the rural areas would be offended by the questions we asked, because we asked very detailed sexual history questions, and it turned out to not be true—they were quite open."
Researchers elicited detailed behavior information from subjects through a careful survey process that paired men with male surveyors and women with female surveyors, Schneider says.
The Indian Health and Family Life Survey has 336 questions and is based on the National Health and Life Survey (NHLS).1
"This is a survey that’s been used extensively for looking at sexual networks in both the United States and China," Schneider says.
It’s formulated in a way to make subjects comfortable with the increasingly private questions. For example, the first questions are about socio-demographics, followed by childhood sexual experiences, ending with questions about homosexuality, Schneider says.
"The first question we ask in the homosexual section is Do you consider yourself to be homosexual?’ and the second is Do you ever have thoughts of having sex with another man/woman?’" Schneider says.
Other questions on the survey are:
* Have you ever kissed another man/woman?
* Have you ever had sex with another man/woman?
The study’s findings show that it will be difficult to target prevention messages to women, other than to target commercial sex workers, Schneider says.
Just as researchers sometimes find in Africa, women in India have difficulty with autonomy and negotiating their sexual life, such as asking their husbands to wear condoms, he says.
"So that’s why there’s a big push for microbicides and things of that nature to give women more control over their ability to contract the disease," Schneider says. "The other thing is this society does not talk about sex or homosexuality or anything really that relates to reproduction."
Also, women’s perceptions of their husbands’ risk behaviors did not match their HIV status, Schneider says.
"It was fascinating, and I didn’t present that data, but we actually asked whether they felt their partners were cheating, and none of the HIV-infected women thought that was the case," Schneider says. "Whereas, some of the HIV-uninfected women reported that."
What can be done to help stem the epidemic in rural South India are more programs for voluntary testing and counseling, he notes.
Massive screenings in rural areas will raise the awareness of the epidemic and serve as an education program, Schneider says.
"Right now, India does not offer antiretrovirals to their population, and the problem in India is that people don’t think about the poor," Schneider says. "But if they do, I don’t think the epidemic will be close to what it is in Africa."
Coverage presented at the 43rd Annual Meeting of the Infectious Disease Society of America, October 6-9, 2005, San Francisco.