HIV: How Bias meets Bigotry

What’s the first thing you think of when you think of STIs?

For most of us, the conversation begins with and sometimes ends at, HIV and AIDS. With its life-altering and potentially fatal stages of escalation when left undiagnosed, it's understandable why the fears around HIV often cast a shadow over other STIs like syphilis or herpes, that can often come with just as much judgment at the hands of medical professionals.

The first documented cases of HIV in India were in 1986. If decades of conditioning are anything to go by, most of us would assume those cases were found among gay men or sex workers. And they were. India’s first six cases of diagnosed HIV were among women sex workers. What does that tell us about the transmission and documentation of HIV in India and across the globe?

1. There is bias in the way we read and share information.

While it is easy to summarise this data by stating that HIV is prevalent among sex workers and gay men, the first point we must acknowledge is that the doctors conducting this program to locate and examine patients with HIV, only chose a sample based on who they deemed to be most vulnerable— sex workers and gay men.

Vulnerability was determined by a combination of multiple factors— likelihood of being coerced into having unprotected sex, likelihood of injuries during sex that could lead to fluid exchanges especially involving blood, and the likelihood of a person to have multiple sexual partners where one or more partners may not have caught their HIV diagnosis in time to break the cycle of transmission.

None of these were supposed to be moral judgments about anyone’s character. Yet, at a time when India viewed itself as heterosexual, God-fearing and monogamous, here were positive cases of something that we wanted to believe was merely targeting the ‘debaucherous’ West. It became easy to misinterpret initial methods for easy sample selection to establish the presence of HIV in India, as a moral assessment of “Who really carries diseases in India?”.

2. There is bias in the way we look at diseases and health.

HIV is transmitted through blood, semen, vaginal and rectal secretions, and breast milk. Anyone having penetrative sex that could result in an exchange of these body fluids was at risk of HIV. Studies from the early 2000s also examined the higher likelihood of transmission among acute (early) cases of infection and chronic (later stages) ones. If you remember the phrase ‘viral load’ when discussions of Covid-19 were at their peak, it’s easy to also understand that viral load in varying body fluids and across individuals also plays a key role in the rate at which HIV is transmitted.

Despite accessing this information for over a decade, India has not felt the need to popularise this understanding of HIV, leaving common myths about transmission to flourish and vulnerable individuals at the margins of healthcare and social acceptance.

3. There is bias in the strategies behind immunisation programs.

Despite the availability of Pre-exposure and Post-exposure medication to prevent or mitigate HIV, access to these medicines remains painfully low.

But why?

PEP and PrEP are not illegal in India— they are available for purchase with PrEP starting at roughly INR1900 and PEP at approximately INR750. However, with decades of medical practice and policy dictating that these medications only be available at government facilities for those who are exposed to HIV through occupational hazards like accidental needle pricks for nurses and doctors, it is possible that this culture of turning down MSM (men who have sex with men) and sex workers at government facilities continues to exist.

Even survivors of assault who are supposed to be given emergency PEP, are often ridiculed or harassed at clinics. Minors who survive assault are unable to seek testing for HIV without a legal guardian, leaving the survivor with little to no medical assistance when they are afraid of discussing their assault or worse, when the assailant is a known individual or guardian themselves.

This is where the concept of STIs as a ‘consequence’ to premarital sex or queer and trans lives comes into play. The idea that you can evade HIV by being ‘good’ seems to be a lesson that our governing bodies seem determined to instil in us, instead of working on the actual availability of medicines like PrEP that are known to reduce the risk of catching HIV through sex by 99% when taken consistently, while PEP is known to reduce the risk by 80% when taken on time for a 28 day schedule.

Both medications are known to have some side effects like nausea, but as of 2024, no resources online describe this policing of HIV medication as a move to manage the population’s drug tolerance or regulate quality of life.

This is medical neglect at its best. Why should you be provided with medication that would lead to a mindset of accepting sexual behaviours that are assumed to fall outside the mindsets of good old monogamous and nuclear families?

Why take responsibility for a health crisis when you can be shamed for catching or transmitting it instead?

While it is a relief to report that HIV cases in India have seen a decline of roughly 40-50% since 2021, it’s important to ask why these medications have still not been talked about. What is the quality of life we offer people who have already been exposed to HIV? What are the changes we have made to our healthcare policies and the attitudes of our practitioners to ensure timely and accurate HIV reporting and testing?

How do we eradicate a disease without first eradicating the biases that surround it?