Disseminating knowledge about AIDS through the Indian family planning programme: prospects and limitations

There is growing concern that HIV is spreading to low-risk population groups and to women in India. Data from sentinel surveillance of women attending antenatal clinics in 2001 showed a prevalence of up to 1.75% [¹]. There is also evidence of spread to rural areas: among a 1998 sample of 1251 women in a rural area accessible to the large city of Pune, Maharashtra, the prevalence was 1.2% [²]. Although generalization to the national level from regional data is not appropriate, and limited information is available about the actual prevalence of HIV in the rural areas of the different states, the large absolute numbers potentially at risk indicate a major challenge to India's health security.

A fundamental condition for protection of the population from HIV infection is the level of knowledge about the disease, which varies considerably between different states in India, between urban and rural areas and between men and women. Overall, 70% of urban and 30% of rural women had heard of AIDS in 1998-1999 [³]. A 2001 survey provided evidence that the urban-rural disparity persists, although overall levels of knowledge had improved [⁴]. Mass media-based efforts to increase knowledge for health protection are under way. We have attempted to quantify the prospects of using Indian family planning services to deliver information about HIV, by undertaking an analysis of the current status of AIDS knowledge in relation to current or intended use of family planning methods.

The 1998-1999 National Family Health Survey (NFHS-2) was utilized in the present study [³]. The survey (n = 90 303) included questions on AIDS knowledge, fertility and family planning use and intentions. The three aspects of AIDS knowledge to which yes/no responses were sought in the survey were awareness of AIDS, knowledge of whether AIDS can be avoided, and knowledge of whether the condom provides protection from AIDS.

Table 1 shows that, as a result of previous sterilization or subfertility, the national family planning programme would not have the capacity to address many women currently lacking knowledge of AIDS in rural India. Some 38% of the rural sample both lacked any knowledge of AIDS and did not require family planning services; 52% were both unaware that condom use can prevent infection and did not require family planning services. In absolute numbers, based on the estimate of 177 million eligible women in the reproductive age group for 2001 provided by the Government of India Department of Family Welfare [⁵] of whom we estimate 131 million reside in rural areas, these percentages would translate to 49 and 68 million women, respectively. Those who have been sterilized or experienced subfertility may be at greater risk of HIV infection through unprotected sex both within and outside marriage. The age at sterilization is currently declining, with a median of 25.7 years in the present survey, potentially increasing women's exposure to unprotected sex.

Table 1

On the positive side, the analysis shows that up to 30% of rural women currently lack any knowledge of AIDS but may also use family planning services in the future. In absolute numbers this represents approximately 39 million women. Many women have heard of AIDS but are unaware of condom use as a specific measure for protection against HIV infection. Including them, an estimated 52 million rural women both lack the knowledge that condom use can prevent infection and are potential users of family planning services. In urban areas, despite a better knowledge of AIDS, 82% of respondents were unaware that condom use can prevent infection. Overall, however, the current use of temporary contraceptive methods is very low both among those with and those lacking AIDS-related knowledge. Although research-based male [⁶] and female condom promotion strategies are required, for women who have been sterilized alternatives such as vaginal microbicides promoted through social marketing mg may offer protection should they prove to be clinically effective.

This survey did not access unmarried but sexually active women, clearly an important group with regard to the transmission of a sexually transmissible disease. Furthermore, it may be argued that in the Indian context of sexual relations, men's sexual behaviour rather than that of married women is of more pressing concern, given the limited capacity of married women to negotiate sexual relations. On the other hand, we believe that the lack of provision of basic knowledge about the disease and its mode of transmission should be considered a denial of the human right to life, liberty and security of person, even if the possession of such knowledge is not sufficient in itself to afford protection.