Manish Swarup  /  AP file
A customer reads an AIDS awareness booklet during a haircut in New Delhi, India. With more than 5 million HIV-positive people, the second highest in the world after South Africa, health activists in India are anxious that prevention messages should reach the widest possible audience. 
By Reporter
NBC News
updated 2/28/2006 11:35:32 AM ET 2006-02-28T16:35:32

“What kind of man are you?”It’s not a question that President Bush is likely to receive when he travels to the Indian subcontinent later this week, but it isone that has all of India abuzz.

The question, posed by Breakthrough, a human-rights organization based in New Delhi and New York, is the slogan for a national HIV/AIDS awareness campaign meant to bring attention to the high rates of HIV infection among married Indian women. 

Launched last May, the campaign has jolted the Indian public with an alarming fact: that two million Indian women are currently infected with HIV/AIDS. But the majority of them are not the sex workers often associated with the disease — more than four-fifths of new infections in women result from sex with their husbands or male partners. 

“That’s why we wanted to talk about married women with HIV/AIDS because all these women are getting infected ... by their husbands,” said Mallika Dutt, Breakthrough’s founder.

The TV, radio and print ads, which show the fear of contracting HIV/AIDS from a woman’s perspective, call on men to wear condoms to protect their wives. The campaign has succeeded by working within cultural norms and capitalizing on the male domination of marriages and sexuality in India. 

Second wave
As Bush meets with Indian leaders to discuss the future of Indo-U.S. relations and India’s growing role as an economic powerhouse, AIDS is not on the public agenda. 

But it is strongly in the background. The promise of India’s future is built on its most important asset — its burgeoning, brainy, billion-strong population — and the good health of this workforce over the next decade or so is vital to the nation's success. 

The HIV/AIDS projections for India, though, threaten to send this house of cards tumbling down. India is considered part of a potential “Second Wave” of the AIDS epidemic, one that includes huge nations such as Russia and China — and where AIDS crises could have global implications. 

The situation is considered so important that in 2005, India was one of two countries added to President Bush’s Emergency Plan for AIDS Relief (PEPFAR).

Governments and international organizations are not the only ones expressing concern.

At the recent World Economic Forum in Davos, Switzerland, a report presented on the business impact of HIV/AIDS found that 25 percent of firms in South and Southeast Asian countries reported that the disease had some effect on their business operations, and 8 percent believe that they have been seriously impacted. Globally, 46 percent of survey respondents expected HIV/AIDS to affect their operations within the next five years.

Currently, India, with 5.1 million HIV-infected people, has the world’s second-highest number of HIV/AIDS infections (behind South Africa). However, that figure, provided by India’s National AIDS Control Organization (NACO) is widely disputed, and critics charge that the actual infection rate is much higher. 

Nation at a crossroads
What is not in question is the potential for the disease to spread to large swaths of the population in the next five to 10 years if it goes unchecked. 

Breakthrough
In an effort to curb the spread of AIDS/HIV in India, public service announcements with theme “What Kind of Man Are You?” have been broadcast on TV, radio, and in print.
According to U.S. National Intelligence Council estimates, India could have 20 to 25 million infections by 2010. The World Health Organization predicts that by 2033, HIV/AIDS will account for 17 percent of all deaths and 40 percent of deaths from infectious diseases in India.

And by the country’s own estimates, one-third of new infections are among people between 15 and 25.

Rema Nanda, the Director of Public Health-HIV/AIDS for the American India Foundation, a U.S.-based aid organization, said the social ramifications of such high infection rates could place India on a downward cycle that could take decades to overcome. 

It’s a grim picture the bears a marked resemblance to the social disintegration that is taking place in sub-Saharan Africa. The difference, says Nanda, is that India has yet to reach the same level of crisis while at the same time possessing the resources to pursue a different path, akin to those taken by Brazil and Thailand.

“It’s five million infections. It’s not eight million, it’s not ten million, it’s not twenty million,” stressed Nanda. “We can do this. We have the ability to do this. We just need the will to do it.”


Let’s talk about sex
One of the first sparks of the political will needed to combat the disease came by way of India’s Prime Minister, Manmohan Singh, who surprised many in the largely conservative country by publically highlighting the very private way that HIV/AIDS is transmitted in India — 85 percent the result of sexual encounters. (Most other infections are mother-to-baby and among intravenous drug users.)

“Leading a healthy and safe sexual life is one of the commitments we must all make,” Singh told a crowd of 1,000 youth leaders on World AIDS Day, which took place last December. “This is particularly important given our traditional inhibitions on discussing such matters within our families and among colleagues — quite apart from doing so in public.”

However, although Singh’s comments were symbolically significant, the Indian government has yet to follow his words with a national message regarding HIV/AIDS prevention.

And that's where Breakthrough’s “What Kind of Man Are You?” campaign has stepped in, broadcasting its ads on satellite television that reaches about 44 million.

But, Breakthrough was unable to get India's National AIDS Control Organization to agree to air its ads on government television, cutting off large segments of the rural and urban poor from the campaign’s message.

Despite that hurdle, said Dutt, Breakthrough’s message has seeped into pop culture — a question about one of the ads was included on India’s version of the game show “Who Wants To Be A Millionaire.”

Also promising are signs of a greater openness about sex in the larger culture. For instance, Lakshmi, a former actress who is Tamil Nadu’s equivalent of Oprah Winfrey, recently focused one of her talk shows on homosexuality — a first for this culturally conservative state.

It hasn't all been plainsailing, though. Despite initial feedback showing that men in the north and western parts of the country understood and responded well to the campaign’s dual goal of gender sensitivity and HIV/AIDS awareness, in the south, where HIV/AIDS rates are the highest, men bristled at the idea that they did not care enough about their wives.

Pandora’s box
Part of the government’s reticence is steeped in cultural tradition and widespread belief that unfettered sexuality is promoted by discussion of safe-sex practices. In addition, says Breakthrough, publicly acknowledging the need to protect against HIV/AIDS would mean acknowledging that sex takes place outside the sphere of marriage. 

It is a dilemma that has dictated the AIDS debate in many cultures, but in largely conservative India it forces the country to confront issues that it has long avoided, including men having sex with men and women’s unequal status in their sexual partnerships.

Neilesh Shelat, a former HIV/AIDS outreach worker in Chennai, the largest city in southern India, said the stigma surrounding sexual activity is one of the biggest barriers to curbing the spread of the infection. Sex “is everywhere, but people won’t talk about it.”

Shelat cited the example of Khoovakam, an annual religious festival in Tamil Nadu, a state with one of the highest rates of HIV infection.

“Men from all over the country gather in a field to celebrate religious rites during the day, and at night it becomes a sexual free for all,” said Shelat. “These men then go home to their wives. Do you know what a public health nightmare that is?”

Breaking through the cultural taboos
To counter this, as well as the generally weak societal position of Indian women, the ads place the burden of responsibility of condom use on men. The idea behind the campaign is that “What kind of man are you?”becomes code for what kind of husband, father, protector are you? 

Dutt, Breakthrough’s founder, cautions that these are but initial steps on a long road to HIV/AIDS awareness and acceptance.

“Sex and sexuality is a difficult conversation in every culture,” said Dutt. “It was just as difficult in the U.S. when we started to grapple with gay identity and sexuality with HIV/AIDS.”

Aswini Anburajan is an NBC News Associate.

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