Women's Forum: Inclusive Prevention Efforts Fight Stigma in Rural India

To support a group of stigmatized women sex workers vulnerable to HIV, a rural prevention project reaches out to inform and empower their neighbors as well.

Every December, on the day after the full moon rises, an age-old ceremony takes place in Soundatti, a town in south India. At the famous shrine of the Hindu goddess Yellamma, people from all over the Belgaum region assemble to mark the traditional date of initiation for the devadasis, women who devote their lives to worship of the goddess and to maintaining her temples.

Many of these women were tiny girls when they became devadasis, "dedicated" to the sect by poverty-stricken parents unable to pay their future dowries and hopeful that a pleased goddess would make the next pregnancy a boy. Tradition has for centuries locked devadasis into a proscribed and highly stigmatized social role. Forbidden to marry or work outside the temple, they have spent their lives tending the shrines and decorating altars, singing and dancing, telling devotional stories and collecting coins from worshippers to support themselves and their religious work. Historical records show that some also served the royal family as courtesans.

"As donations slowly dwindled, this form of concubinage evolved over many years into socially sanctioned prostitution," said public health specialist Sudha Sivaram. "Over the years, the caste of women who were devadasis by profession were forced by social, legal and, most importantly, economic circumstances to resort to sex work as their source of income."

Sivaram knows the devadasis and their plight well. From 1994 to 1996 she worked with U.S.-based PLAN International and its regional partner, MYRADA (the Mysore Resettlement and Development Agency), as manager of an HIV/AIDS prevention project funded by the AIDS Control and Prevention (AIDSCAP) Project's grant program for private voluntary organizations.

MYRADA, long active in rural Belgaum, had already established close ties with the devadasis by creating economic self-help groups to give them an alternative to sex work. The discovery in 1993 that more than 9 percent of these women were infected with HIV prompted PLAN/MYRADA's original proposal to target devadasis and other sex workers. But the project soon took on a much broader scope.

"MYRADA's extensive experience in rural development in an integrated manner, and our knowledge of the social stigma that is attached to HIV infection and AIDS, helped us soon realize that it would be a mistake to direct prevention messages to devadasis alone after learning that people in the area were already accusing them of spreading AIDS," said Sivaram. "It would only brand them further as outcasts and give the rest of the community the false impression that AIDS prevention isn't an issue for everyone."

What ultimately evolved during Belgaum's AIDS/STD Awareness Prevention and Control Programme was an extraordinarily broad-based campaign that reached into every sector of this rural district and involved many thousands of its residents as outreach educators, condom sellers, street performers, youth leaders, health promoters and much more. Project staff -- almost all of whom were born in the area -- perceived early on how to tap the energies of community groups and to motivate the activism they knew had long been part of Belgaum's civic culture. In two short years, they created an unusually successful and sustainable grassroots project that confirms the value of using and building local capacities to design and lead HIV/AIDS prevention efforts.

Raising Awareness

At the beginning of the project, PLAN/MYRADA staff conducted group discussions to assess the general awareness of HIV/AIDS and other sexually transmitted diseases (STDs) among the population. The results were discouraging: A majority of the women had never heard of HIV/AIDS, and few of the respondents -- female or male -- who did know about it also knew how to prevent it. Many held misconceptions about the disease: that it can be caused by mosquito bites or casual contact, that chewing betel leaves puts one at risk, that barbers spread it on their scissors. The discussions also revealed that many people did not see HIV/AIDS as an immediate threat, given other pressing survival concerns such as employment, food and other better-known diseases.

Raising awareness among all adults and young people of reproductive age in the project's four targeted administrative divisions thus became a primary goal. The scale was ambitious: 525 villages of about a million inhabitants. To reach as many as possible within the project's relatively short time span, PLAN/MYRADA staff conducted an informal survey of community groups -- student and youth clubs, professional associations, women's groups, the truck drivers' unions -- to get a sense of the various organizational routes through which they could recruit and train their goal of 1,000 outreach educators and conduct AIDS awareness activities.

MYRADA's long history of work in regional development, extensive community contacts and excellent rapport with the district government and health agencies made the task much easier. "MYRADA has worked in the region for 25 years and is very well respected," said Dr. Thomas Philip, AIDSCAP's resident advisor in India. "Their grassroots relationships with the people and organizations the project wanted to reach meant much quicker access and thus a faster start-up."

With training modules created for specific groups, staff eventually trained nearly 12,000 people as outreach educators, about 800 of whom have become involved in ongoing outreach activities. They included educators recruited from the professional organization of barbers (a group once regarded with suspicion as "spreaders" of HIV), the devadasis' economic self-help group, government agencies, a wide variety of youth groups, artistic societies, performance groups and many others.

Other awareness-raising strategies were equally successful. In a rural area with high rates of illiteracy, PLAN/MYRADA decided to take prevention messages directly to the community. Information rallies drew thousands in village squares, as did folk music concerts and major multi-attraction events such as those scheduled for World AIDS Day 1995. A bike-a-thon sent ten teams of enthusiastic young people into the countryside to many of the more remote villages to spread the word about HIV/AIDS prevention. Printed educational materials such as brochures and posters were designed with a sensitivity for illiterate or low-literate populations, using design and illustration rather than type alone to deliver prevention messages.

Perhaps the most popular public prevention education events PLAN/MYRADA organized were some 1,900 street theater performances in nearly 500 villages that drew hundreds of thousands of spectators. The plays incorporate HIV prevention messages, condemn the devadasi tradition as exploitative of women and encourage the sexes to communicate better with each other about sexual matters.

"There were few educational outreach activities we didn't try," said Sivaram. "We continually reinforced our messages through various media as well as sheer volume."

Reaching Women

When women were already organized into self-help groups, labor unions or clubs, PLAN/MYRADA staff found it relatively easy to gain access to meetings and to engage members in educational sessions about HIV and STD prevention. But women in more traditional households seldom participate in such organizations, nor did they feel it appropriate for them to attend some of the public events where discussion of HIV/AIDS took place. Rather than forfeit the opportunity to reach all women with prevention information, PLAN/MYRADA developed a new tactic: organize activities that even women from conservative families would feel comfortable attending.

"Some women are almost never released from duties at home," said Sivaram, "so we learned to take advantage of the narrower range of activities that had long been acceptable for them to be part of."

For example, on World AIDS Day PLAN/MYRADA sponsored competitions in the traditional art of rangoli, intricate floral patterns on doorsteps that women create with colored powders. After the winners were announced, staff were able to talk to the participants about reproductive health and HIV and give them brochures about HIV and STD prevention. Similar contests involved other arts and crafts, such as knitting and crocheting -- and all presented an opportunity to reach women with prevention messages, sometimes for the first time.

Another traditionally acceptable form of assembly for women is arshana-kumkum, the practice of praying in groups for the long lives of their husbands. Through the Family Planning Association of India, PLAN/MYRADA staff received invitations to address these gatherings about AIDS prevention.

Broadening the audience of women the project could reach was only one benefit of using these creative approaches. PLAN/MYRADA staff were especially pleased when women attending such events volunteered to become health educators.

"Their participation helped extend our ability to educate traditional women even further," said Sivaram. "As they became confident about playing a public role in health education, they really made a difference."

Comprehensive Prevention

All training modules for outreach educators included information on the importance of early treatment for STDs to reduce one's risk of HIV as well as to preserve fertility and health. The message that STDs increase vulnerability to HIV was also incorporated into most of PLAN/MYRADA's materials.

The project sponsored periodic health camps that targeted specific groups more likely to be at risk for STDs, such as truck drivers and sex workers, giving underserved communities access to doctors who could diagnose and prescribe for STDs. In addition to treatment, the camps provided an opportunity for doctors and other staff to counsel patients one-on-one and to offer long-term education and care to organized groups that can be more easily followed and contacted later. More than 250 members of the devadasi groups received health cards that enabled them, their partners and their partners' spouses to seek treatment for STDs and other reproductive tract infections.

"Conducting health camps with organizations such as the devadasis' self-help groups is probably the most important achievement of the project," said Sivaram. "The success of the partner referral element had the potential to reduce HIV prevalence and perhaps prevent incident cases of STDs."

The project also organized workshops to introduce local doctors and clinics to syndromic management of STDs, which bases diagnosis not on test results but on syndromes, which are groups of clinical findings and symptoms. Treatment is then offered for all diseases that could cause that syndrome. The benefits of syndromic management in resource-poor settings such as Belgaum are several: the complex diagnostic process is simplified for health workers without advanced skills, expensive and sometimes unreliable lab tests are no longer needed, and treatment begins immediately.

"We got a mixed reception at first, depending on the kind of medical professional we worked with," said Sivaram. "Doctors from big teaching hospitals were slightly skeptical, but private practitioners felt this was important information for them."

Condom education and promotion were also a major programmatic emphasis for PLAN/MYRADA staff. Until the project began, condoms were a less-than-preferred method of family planning, not disease prevention. PLAN/MYRADA incorporated education about condoms and training in their use into all its training and prevention programs and included condom promotion in community events. In partnership with social marketing experts DKT International, PLAN/MYRADA helped create more than 240 community-based sales points for condoms, including convenience stores, roadside betel nut shops, street theater teams and hairdressers. The project has met an important goal: creating enough new outlets so that no one in Belgaum need walk more than ten minutes to buy a condom.

An Ongoing Commitment

The PLAN/MYRADA project, originally conceived as an intervention targeting the vulnerable devadasis, instead succeeded in transforming a large, traditional rural community by improving knowledge and attitudes about HIV and involving community members in their own education and prevention activities. The more inclusive focus on the entire population rather than a marginalized sector ultimately changed the context in which that minority is viewed and treated.

Launching and completing an effort on this scale in such a short time took an enormous amount of hard work. "I think the team effort is responsible for this," said Sivaram. "But I also credit MYRADA for the years of building such a strong rapport with the community and the government that gave our project such a solid foundation from the start."

That solid foundation keeps many of the Belgaum prevention activities going strong, even though AIDSCAP funding ended in 1996. The project's emphasis on widespread regional participation and capacity building of local nongovernmental organizations helped create an ongoing community commitment to maintaining effective prevention efforts until more financial support can be found.

The devadasi community also continues to reap the benefits of both the prevention project and MYRADA's long-term economic empowerment program. Many have been able to leave sex work for new careers as weavers, basket makers or vegetable vendors. Some have married their former boyfriends, or are limiting their sex work to one or two steady customers.

Back in Soundatti, the annual celebration at the Yellamma temple has also been transformed. What had traditionally been a devadasi initiation ceremony has now become its opposite -- a "de-initiation" ceremony, where local religious leaders symbolically release the devadasis from their vows.

For the day, the square in front of the temple becomes a fairgrounds packed with food vendors and sellers of trinkets and jewelry. Health educators offer information about condoms and HIV, and prevention videos are presented at booths throughout the day. Drama groups perform street plays about the evils of the devadasi system and the need to learn about safer sex. The town fills with people arriving from every part of the region and neighboring states.

Later, these same crowds cheer, sing and dance as the priests perform the de-initiation ceremony for a group of devadasis seeking a new life. It's a simple ritual, but one with great psychological power. At its conclusion the women smile and laugh joyfully, their spirits freed of the chains they once feared would imprison them forever.

-- Margaret J. Dadian