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Stephanie Nolen

India's troubling miracle Add to ...

When government health workers gave Thenmozhi and her friends condoms, they would blow them up and bat them back and forth in the streets of their slum in Chennai, giggling. It didn't really occur to her that she ought to use the condoms with her clients, the neighbourhood men who paid her for sex, to protect herself from AIDS.

That was a disease of other people, other countries. Thenmozhi (who like many in her community uses only one name) had many problems - a drinking, philandering husband who once set her on fire when he got angry, and feeding her children with no job and a Grade 3 education - but AIDS was not one of them.

And then five years ago, a different kind of health worker dropped by her two-room flat - a woman Thenmozhi knew, who made about $50 a month selling sex like she did. She sat on the cement floor, helped Thenmozhi pick through some rice and told her there was AIDS in India - in fact, right there in their crowded fishermen's slum in the capital of the southern Tamil Nadu province. It had recently killed a man they both knew.

She invited Thenmozhi to a community centre, where she heard informal lectures about the virus and how sex workers must band together to insist clients use protection. When she left, her handbag was full of condoms and the results of her free HIV test: negative.

Thenmozhi went on to do a most remarkable thing: "After that, I always used a condom. With every man who paid." And when she passed the age of 40 last year and transitioned into the role of madam - renting her bedroom to younger women and their clients - she handed each of them a condom, too.

Although her actions may seem logical and obvious, AIDS-education programs around the world have found that people rarely do the logical, obvious thing and use condoms once they learn about the risk of HIV. They may use condoms sometimes, in some cases. They almost never use them with the zealousness of Thenmozhi.

And yet she is no aberration. She is simply one example of the way the country has cut its rate of AIDS infection in half in the last decade, moved away from the brink of catastrophe and quietly achieved a great but unheralded public-health victory.

In southern India, HIV incidence (the rate of new infections) was 2 per cent per year in 2000; by 2007 it was just below 1 per cent. In the north, where HIV is far less prevalent, there was no large decline, but also no increase.

Only much-smaller Thailand, which implemented a mandatory-condom campaign in its sex industry in the 1990s, has ever posted similar declines.

What has happened here is starting to draw global attention. Yet so much of this story is unique to India, with its strengths (such as pro-active governments) and its weaknesses (particularly the rigid control kept over its female citizens) that it's questionable how much its example can be applied anywhere else.

When India announced in 2007 that it had 2.3 million people living with HIV, rather than the 5.7 million reported the year before, the government first attributed much of the change to better data collection. Many in the AIDS field were skeptical.

"We and all the other AIDS organizations think the number of people accessing services is increasing, so why are the infection numbers so low?" says Anjali Gopalan, head of the Delhi-based Naz Foundation and one of India's most prominent AIDS activists.

Northern states have weak mechanisms for reporting AIDS cases, while marginalized populations such as the transgender sex workers and drug users she works with are never part of door-to-door surveys, she says, so tens of thousands of cases may be missing from the official statistics. And in all regions, many people are still going without adequate treatment.

Nevertheless, more and more research points to a substantial change in sexual behaviour and with it a decline in the spread of HIV. Syphilis infections, which closely mirror HIV, have had an almost-identical drop.

"The decline is real. The numbers have plausibility and credibility," says Prabhat Jha, an epidemiologist who directs the Centre for Global Health Research in Toronto, and was an architect of India's early AIDS-control program. "There has been a profound change in behaviour among clients and sex workers that accounts for most of the drop."

While India has a significant population of intravenous drug users - as many as half of whom, in some areas, have HIV-AIDS - the bulk of the HIV transmission in this country happens through heterosexual sex. Men, often married, pay professionals for sex, get infected and then pass the virus to their wives or regular partners, who infect children at birth.

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