What’s So Moral About AIDS Anyway?
Well, to answer the question in the title, Dr Harsha Vardhan, India’s new Union Health Minister in the BJP-led government, certainly thinks so. In an interview with The New York Times, Dr Vardhan expressed his reservation about the promotion of condom usage in AIDS awareness and prevention campaigns. He said:
The thrust of the AIDS campaign should not only be on the use of condoms…This sends the wrong message that you can have any kind of illicit sexual relationship, but as long as you’re using a condom, it’s fine.
Instead, he added, there should be an emphasis on “promoting the integrity of the sexual relationship between husband and wife….[which is] a part of our [Indian] culture.” To its credit, the New York Times blog offers a succinct analysis on the parts where the Health Minister has gone wrong, namely, the strategy of distributing condoms to high-risk groups, like sex workers, injecting drug users, MSM (men who have sex with men), and so on. It also quoted the director of National AIDS Control Organisation (NACO), V.K. Subburaj, who said promotion of condom usage among high-risk groups will “not change”. However, Subburaj conceded that the “moral fabric” of the country is “thin”; and, in a move that could put the autonomy of NACO’s functioning into question, it was reported that the organisation would now “preach morality” in its AIDS awareness campaign, and tell people to be faithful, and “stay away from extramarital and premarital sex”.
So, what’s the problem in that? For starters, it is the fact that the history of the AIDS epidemic is itself tenuous, and mired in such “moral panic”. So much that, the question of morality has been an inseparable aspect of the AIDS epidemic since it first started to gain attention in the 1980s. In fact, the discourse of fear and ambivalence regarding AIDS has been a result of the above-mentioned moral panic faced by Western society in the late 70s, following what Gayle Rubin has called the “sex wars”, and has led to a repeated persecution of vulnerable social groups, like homosexuals and African-Americans.
The history of AIDS in India, however, while subject to its own “moral panic”, has been more successful in part thanks to the concerted efforts of non-government organisations, which played a significant role right since the late 1980s. A major factor in the early efforts, in fact, was the emphasis on protected and safe sex, i.e., the use of condoms. For many vulnerable groups—including women in monogamous marriages, and for female sex workers—this was a nascent step in recognising and asserting sexual and reproductive rights. But fact remains that women—including and especially married and widowed ones—have been, and still are, vulnerable to HIV/AIDS, precisely because of the misplaced emphasis on “morality” and “Indian culture”, which the Health Minister seems to espouse.
In this essay, I will argue that the Dr Vadhan’s “prevention” strategy for AIDS—and his subsequent pearls of wisdom on sexuality and health—are deeply entrenched in a patriarchal moral-political discourse which is inherently inimical to women’s sexual agency and reproductive agency. In this context, recourse to “Indian culture”—also, exacerbated by our judiciary and political class—tends to obfuscate the multiple forms of control over women’s bodies, which makes them more vulnerable to getting the infection, rather than preventing it. Further, I will also argue that an excessive emphasis on morality will seriously undermine existing AIDS intervention programmes, which are targeted at high-risk groups, like sex workers, drug users and men who have sex with men (MSM), and will lead to what many experts call driving the epidemic “underground”. More importantly, the most glaring omission in Dr Vardhan’s statements so far, is that he has not made any mention of the pending HIV/AIDS Bill (2007).
I will conclude by emphasising that the dominant risk-based approach in the management/control of AIDS deeply flawed because it fails to take into account the multiple forms of vulnerability of marginalised social groups like sex workers, women, drug users, and MSM. Instead, what I will propose is a vulnerability-based approach, wherein, apart from the biomedical dimensions of AIDS (like transmission, prevention, and treatment) the social and psycho-social dimensions (like de-stigmatisation, healthcare and support) also need to be emphasised and undertaken. Unless these factors are addressed, a preaching of morality and culture will certainly bode ill for the 2.5 million people in India who live with HIV/AIDS.
‘Morality’ and Indian ‘culture’, or patriarchal control?
One is rightly curious as to what exactly Dr Vardhan refers to by “Indian culture” and an “emphasis” on morality. Of course, monogamy and fidelity are important components, since he very explicitly refers to the terms, “marriage” and “husband and wife”. But what the Health Minister seems to be oblivious about is how, with respect to HIV/AIDS, marriage in the dominant Indian patriarchal context is (a) inherently inimical to women’s sexual agency and reproductive rights, since a majority of women still cannot exercise choice in using protection; and (b) is actually a major factor which leads to the “passive infection” of several thousand women and children, which in turn leads to (c) stigmatisation and discrimination of AIDS widows and orphans. Let’s look at these a little more specifically.
Perhaps, the most vulnerable among all social groups in terms of being infected and affected by HIV/AIDS are women. A fundamental aspect in this form of vulnerability is the deep, entrenched gender inequality in most patriarchal societies today—a condition exacerbated by social and economic depravity. Lack of sexual agency, or reproductive rights, human trafficking, prostitution and sex work, and passive infections are among the many ways in which women continue to be infected. Geeta Rao Gupta articulates this gender imbalance as a difference in men’s and women’s rights over components of sexuality as the four Ps, i.e., practices, partners, pleasure/pressure/pain and procreation. However, she adds one more element: power. This unequal power imbalance in gender relations, she argues, “favours men in which male pleasure supersedes female pleasure and men have greater control than women over when, where and how sex takes place”. With respect to women’s vulnerability, she says, there is a culture of silence that surrounds sex that dictates that “good women” are ignorant about sex and passive in sexual interactions, which result in women’s unquestioning subordination to men’s sexual desires and rob women of autonomy in relation to their own bodies.
This unequal power imbalance between genders is configured in politico-moral discourse of the family, as well. This is evident when a majority of women, quite accidentally, find out about their HIV status when they are tested in antenatal clinics (ANCs) during pregnancies. The narrative, as I realised during my interaction with HIV-positive women, is very similar. Almost always, the woman is stigmatised on grounds of morality—even when it is evident that she did not have multiple sexual partners. In many cases, an uneasy silence prevails: there is a suppression of the knowledge that the individual(s) are infected with HIV, and that they require immediate medical treatment. After the husband’s death (which is a strong pattern emergent across social and economic demographic lines) there is absolutely no support for women; they are forced to live in hostile domestic atmospheres, and are denied access to treatment and counselling; they are also doubly stigmatised on account of being widows and HIV-positive.
The politico-moral configuration of the family, then, is central to the understanding of vulnerability of social groups in India. Almost all the ‘high risk groups’, are married, including men who have sex with men, since marriage is virtually universal in Indian society. Even women engaged in prostitution and sex work have regular lovers, or husband-like figures, with whom they have sustained, intimate relationships—often, as within marriage, without the consistent usage of condoms. Thus, Ramasubban and Rishyasingra argue: “The distinctive nature of the Indian epidemic is that the sexual networks through which HIV transmission is taking place…is fairly intermeshed and widespread…and not confined only to small ‘high risk groups’”. In fact, given the debates on the “feminization of poverty and AIDS”, researchers have now proposed looking beyond the ABC approach (‘abstinence, be faithful and correct and consistent) condom usage)—the second component of which Dr Vardhan overemphasises. Dworkin and Ehrhardt, for instance, argue that “the [HIV] virus is no longer confined to high-risk populations; it is being increasingly feminized and it is clearly linked to cumulative patterns of gender inequality, economic disruption and population movements”. Thus, they point out the need to look beyond ABC, and propose a gender, economics and migration (GEM) approach.
In the light of the arguments made above, Dr Vardhan’s simplistic solution—of promoting fidelity, through the “sexual relations between husband and wife”—misses out the unequal gender relations in marriages in India. Further, we must also remember that the judiciary and political class have routinely undermined and setback struggles for recognizing equal rights for women. Thus, the fact that marital rapes are not criminalized because “they have the potential of destroying the institution of marriage”; that community panchayats and police arbitrate between rape victims and rapists by getting them married; that a woman failing to perform “conjugal rights” is grounds for divorce, are all indicative of how the notion of “family” is anything but equal; and that, in the context of AIDS, is actually responsible for women and children being infected.
Whither the HIV/AIDS Bill?
Surprisingly, then, the fact that the Union Health Minister, in a government which rode to victory on a wave of promises of acche din (good, prosperous days), misses out the complexity of one of the most widely-discussed, and politically contentious, epidemics in recent history, is simply staggering. Even Dr Vardhan’s later clarification, in which he stresses his credentials as a “medical professional”, fails to convince. This is mostly so because, despite his obvious lack of understanding of vulnerability, his clarifications and follow-up comments on modifying sex education syllabi (or expunging “vulgarity” from them, apparently), he fails to mention the most landmark aspect in India’s strategy to combat HIV/AIDS and provide equal rights to those infected/affected by it: the HIV/AIDS Bill (2007).
The HIV/AIDS bill was drafted by the civil society organisation, Lawyers Collective, in 2006, after consultation with PLHAs, vulnerable communities, women’s groups, healthcare workers and other civil society group, and submitted to NACO. The 2007 draft of the bill lists its objectives as:
A Bill to provide, keeping in view the social, economic and debilitating effects of the HIV epidemic in India, for the prevention and control of the HIV epidemic in India, the protection and promotion of human rights in relation to HIV/AIDS, for the establishment of National, State, Union Territory and District Authorities to promote such rights and promote prevention, awareness, care, support and treatment programmes to control the spread of HIV, and for matters connected therewith or incidental thereto.
The main provisions of the Bill are concerned with prohibition of discrimination, informed consent (for testing), disclosure of information, access to healthcare (testing, treatment, and counselling), safe working environments, and strategies for reduction of risk, among other factors. However, what makes the Bill truly landmark is a broad-based focus of addressing the complexities of the epidemic itself, and its attempts to be inclusionary and ensure social justice. For instance, under its strategies for reduction of risk, it advocates promoting practices like “provision and use of safer sex tools”, like condoms, and drug paraphernalia, like clean needles. It also provides for the strengthening of interventions with sex workers and drug users. Such strategies have, internationally, been recognised as helpful since it gives healthcare providers access to these vulnerable groups, who are often rendered invisible or driven “underground”, due to criminalization of “illicit activities”—factors which clearly seem to perturb the current Health Minister. The previous government, too, seemed to share his discomfort. In fact, the revised Bill deleted provisions which worked towards creating an “enabling environment” for high-risk groups, since it thought that doing so would actually promote prostitution, homosexuality, and drug use, thus completely ignoring the plethora of data from around the world which would prove otherwise.
A case in point here is the decriminalization of consensual same-sex relations contained in Section 377 IPC in 2009 by the Delhi High Court—and the Supreme Court’s verdict which “set aside” the lower court’s ruling. While the Supreme Court bench didn’t seem to think that Section 377 violated any Fundamental Rights, and that the “miniscule population” of LGBT people didn’t matter anyway, the evidence contained in NACO’s own Annual Report (2012-13) proved to counter that claim. The NACO Annual Reports of 2008-09 and 2012-13 state that the prevalence rates of HIV among MSM are 7.4% and 4.4%, respectively. In other words, since the decriminalization of consensual same-sex relations in 2009, there has been a 3% drop of HIV prevalence among MSM—a group routinely persecuted by authorities under Section 377, and as vulnerable to HIV transmissions—indicating that decriminalization has had a positive impact on intervention and advocacy by healthcare workers and NGOs. One of the ways this was achieved was through condom promotion—which one must remember, also greatly prevents “passive infection” of women. Another important provision of the 2007 HIV/AIDS Bill, which reflects my earlier arguments regarding the vulnerability of women and children, is listed under ‘Special Provisions’. Under this, the rights of women to access healthcare and treatment, right to residence, property rights of children, and the rights against discrimination by family members are enunciated. Incidentally, it also provides for ‘HIV-related IEC (information, education and communication) before marriage’, wherein the risks of unprotected sex with multiple partners, among other risks and safe-sex practices, are also listed.
Kajal Bharadwaj, a member of Lawyers Collective’s HIV/AIDS Unit, presents one of the most nuanced and argumentative essays on the need for the HIV/AIDS Bill. She states: “One of the key visions of the Bill is to establish a government initiative on HIV/AIDS that is completely accountable and that is implemented at every stage with consultations.” She also adds that the Bill, by instead of seeking to criminalize sex workers, drug users and homosexuals and MSM, ensures that they have access to IEC (information, education and communication) materials; and that “by protecting needle exchange, condom promotion and sexual health information programmes, we help those most marginalised in society by morality and law to protect themselves and others from HIV.”
Clearly, if the Health Minister had bothered to have read a hugely pertinent Bill, under his own official capacity, he would have known that actual, effective and scientific provisions are already in place to ensure that citizens of the country are protected from HIV transmission. His failure to do so reflects the fact that he is advancing the moral panic of conservatives, especially the Rashtriya Swayamsevak Sangh (RSS), of which he is a long-term member. Indeed, this raises serious concerns about the nature of the Uniform Civil Code, which features prominently in the BJPs election rhetoric and Manifesto.
Towards a conclusion: from a management of risk to the recognition of vulnerability
Even after nearly three decades, there is no denying that AIDS is still a politically contentious issue (a fact that explains the reasons why this essay was written). However, the nature and core issues of AIDS have substantially changed. While we are still concerned with what I described a risk-based approach—which still is pertinent, we must keep in mind—we must also recognise the need for an approach that recognises the vulnerability of certain social groups, and also historical and political contingencies, which make more people vulnerable to contracting HIV, and more tragically, deny them the adequate conditions for treatment and care, which leads to AIDS, and more transmissions. Thus, a closer look at the so-called high-risk groups—sex workers, drug users, homosexuals, MSM, and migrants—would indicate that their vulnerability to social, economic and political conditions is what puts them at risk of being infected by HIV; that it is their persecution, and not perversion or something inherent in their character or morals, which makes them vulnerable.
Thus, in using broad, unscientific terms like “illicit”, the Health Minister risks reinstating morality as a dominant ideology for the prevention and control of people’s sexuality, and not of HIV/AIDS; his invocation of the glorious Indian culture is completely ignorant of the throwbacks to Victorian notions of morality and sexual conduct, which underscore his biases. This ultimately trivialises the contentious history of AIDS itself, and the struggles made globally to ensure and preserve the rights of people living with HIV/AIDS, and that of those most vulnerable to being infected and affected by it.
Perhaps, the fact that Subburaj mentions that interventions with high-risks groups would continue is a good sign. But I am apprehensive. This is so because, although the interventions, like distribution of condoms is like to continue, the rights of these vulnerable at-risk groups are far from being recognised. The Supreme Court’s verdict of reading down the decriminalization of consensual same-sex is a chief reason—and this is so even after giving rights to transgenders, and recognising the ‘Other’ option for gender. The lack of any initiative to pass the HIV/AIDS Bill (2007), with all its original provisions for vulnerable groups in place, is another reason.
This is ironic because, it runs contrary to the one of the promises of the newly formed Narendra Modi-led government: the promise of “good governance”, which supposedly takes into account scientific and rational ideas of experts. The opinions of experts and healthcare professionals (Dr Vardhan should be reminded that his status as a Union Minister, and his credentials, are not beyond critique) are being bulldozed to accommodate what is essentially a moral panic, and archaic ideas of sexual conduct. As the Health Minister, his mandate is to ensure that treatment and healthcare services are made available to all sections of the population—in spite of his biases and notions of morality; and that it is not his mandate to promote any sort of morality. If that need is felt, I am more than certain that Baba Ramdev can assist the government to do the needful.
In my opinion, however, the most crucial step that must be addressed by non-governmental and non-state actors (mostly because I do not envisage the state doing so) is the contradictions in the logic of existing intervention strategies. To reiterate, this approach must engender a transition from the “risk-based” management of HIV/AIDS, to a “vulnerability-based” approach of ensuring that crucial healthcare services and social support systems are made available to – as also a need to ‘empower’ – people living with HIV and AIDS, and those who are at risk of contracting it, due to their vulnerable and marginalised statuses. This involves not only a biomedical understanding of AIDS, but also a politico-moral one. As Stuart Hall reminds us,
AIDS is the site at which the advance of sexual politics is being rolled back. It’s a site at which not only people will die, but desire and pleasure will also die if certain metaphors do not survive, or survive in the wrong way. Unless we operate in this tension, we don’t know what cultural studies can do, can’t, can never do; but also, what it has to do, what it alone has a privileged capacity to do.
Thus, the debates on the rights of sex workers, and on legislations, like decriminalising consensual same-sex relations in Section 377 IPC, criminalizing marital rape and ensuring gender equality, and also, the HIV/AIDS Bill, are but a few ‘sites’ wherein these struggles against AIDS come to be define. There has to be an engagement with people from across the vulnerability divide; because, there is a possibility that it would still occur at the margins—that the middle class would still care more about an anti-corruption bill, and not a well-formulated HIV/AIDS one. Any concerted effort on AIDS must seek to bridge this schism in social discourse. Until then, the struggle against HIV/AIDS—and that against discriminatory, biased laws—can only be fought from the margins.
Disclaimer and Acknowledgements
Most of the central arguments presented in this essay were taken from my bachelors dissertation titled, ‘AIDS in the realm of biopolitics, governmentality and representation: reconfiguring risks, vulnerability and affectedness in the AIDS epidemic in India’. The full paper can be accessed here. My arguments have developed considerably while working as a member of several independent research teams for the Mumbai District AIDS Control Society (MDACS), and other AIDS healthcare providers.
I would like to express my gratitude to Genevie Fernandes, my project supervisor and colleague. I am indebted to her for my continued and enduring interest in HIV/AIDS and social justice.
Endnotes & References
 Vyawhare, M. (June 23, 2014). ‘Health Minister Questions stress on Condoms in AIDS Fight’, The New York Times: India Ink. Accessed from: http://india.blogs.nytimes.com/2014/06/23/health-minister-questions-stress-on-condoms-in-aids-fight/
 Ghosh, A. (June 26, 2014). ‘After minister’s nudge, NACO to stress on morality’, Indian Express. Accessed from: http://indianexpress.com/article/india/india-others/after-ministers-nudge-naco-to-stress-on-morality/
 Rubin, G. (1999). Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality. In R. Parker, & P. Aggleton (Eds.), Culture, Society and Sexuality: A reader, Cambridge University Press, pp. 143-178.
 The most seminal work in this regard is done by Paula Treichler. See, Treichler, P. A. (1987). ‘AIDS, homophobia and biomedical discourse: An epidemic of signification’, in Cultural Studies, 1(3), pp. 263-605. Accessed from: http://www.penelopeironstone.com/Treichlersignification.pdf
 For an exhaustive review of AIDS interventions in the first two decades in India, see Sighal, A. and Rogers, E. (2003). Combatting AIDS: Communication Strategies in Action. New Delhi: Sage Publications.
 Gupta, G. (2000). ‘Gender, Sexuality and HIV/AIDS: The What, the Why and the How’, XIIIth International AIDS Conference. Durban: International Centre for Research on Women, pp. 1-8. Accessed from: https://sfol.net/HEART/030106/Gender,Sexuality,andHIV.pdf
 See, for instance: Kausalya, P. and Ganju, D. (2008). ‘Exploring Positive Women’s Lives in Namakkal District, India’, Health and Population Innovation Fellowship Programme Working Paper, No. 7, New Delhi: Population Council.
 Dworkin, S. and Ehrhardt, A. (January 2007). ‘Going beyond “ABC” to include “GEM”: Critical reflections on progress in the HIV/AIDS epidemic’, in American Journal of Public Health, 97(1), pp. 13—18. Accessed from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1716252/
 Jain, B. and Chakrabarty, R. (Feb 20, 2013). ‘Govt. in no mood to criminalize marital rape’, Times of India. Accessed from: http://timesofindia.indiatimes.com/india/Govt-in-no-mood-to-criminalize-marital-rape/articleshow/18583796.cms
 Agarwal, K. (Jun 19, 2014). ‘Panchayat urges rape survivor to marry rapist’, Times of India. Accessed from: http://timesofindia.indiatimes.com/india/Panchayat-urges-rape-survivor-to-marry-rapist/articleshow/36851230.cms
 Haneef, M. (Jun 22, 2012). ‘Husband moves high court over conjugal rights’, Times of India. Accessed from: http://timesofindia.indiatimes.com/city/kochi/Husband-moves-high-court-over-conjugal-rights/articleshow/14329591.cms
 See also, Mahdok, D. (June 30, 2014). ‘These nine Indian laws make Indian women less equal than men’. Scroll.in/qz.com. Accessed from: http://scroll.in/article/668709/These-nine-laws-make-Indian-women-less-equal-than-men
 Press Trust of India. (June 27, 2014). ‘Union Health Minister clarifies his ban on sex education in schools’, Indian Express. Accessed from: http://indianexpress.com/article/india/india-others/harsh-vardhan-clarifies-on-ban-on-sex-education-in-schools/
 PTI. (Jun 27, 2014). ‘Sex education should be banned in schools: Health Minister Harsha Vardhan’, Deccan Chronicle. Accessed from: http://www.deccanchronicle.com/140627/nation-current-affairs/article/sex-education-should-be-banned-schools-health-minister-harsh
 ‘The HIV/AIDS Bill 2007’, p. 3. Accessed from: http://www.lawyerscollective.org/files/Final%20HIV%20Bill%202007.pdf
 Biswas, R. (January 2009). ‘Seeking a more equal bill’, HIV/AIDS Information Getaway. Accessed from: http://www.hivaidsonline.in/index.php?option=com_content&view=article&id=179:seeking-a-more-equal-bill&catid=16:hiv-a-human-rights&Itemid=21
 See, Department of AIDS Control, NACO. Annual Report 2008-2009 and Annual Report 2012-2013, Ministry of Health and Family Welfare, Government of India, p. 5 and p. 8, respectively. Access the 2008-09 report here, and the 2012-13 report here.
 Bharadwaj, K. (January, 2008). ‘Do we need a separate law on HIV/AIDS?’, Infochange India. Accessed from: http://infochangeindia.org/agenda/hivaids-big-questions/do-we-need-a-separate-law-on-hivaids.html
 The HIV/AIDS Bill was introduced to the Rajya Sabha in February 2014, and will now be referred to the Parliamentary Standing Committee on health and family welfare for their recommendations. See, Krishnan, V. (Feb 11, 2014). ‘Pending since 2006, HIV/AIDS Bill tabled in Parliament’. LiveMint. Accessed from: http://www.livemint.com/Politics/bWfH8nmMkMCfyP6zvPJEKL/Pending-since-2006-HIVAIDS-Bill-tabled-in-Parliament.html.
However, with the Health Minister’s recent comments and the fact that he never made any mention of the Bill, one is rightly sceptical if the final bill will reflect the visionary approach of the original draft.
 The Manifesto lists: “The BJP believes that there cannot be gender equality till such a time that India adopts the Uniform Civil Code which protects the rights of all women” (p. 41). However, given how the politico-moral notion of the family itself is inimical to the recognition of “gender equality” and “rights of all women”, and that now the morality of the family itself is being reinstated, one is curious as to how such an aim will be possible. Accessed from: http://bjpelectionmanifesto.com/pdf/manifesto2014.pdf
 Here, I am referring to the concerted efforts by activists and experts to oppose discriminatory laws that persecute homosexuals and women, such as the Uganda’s new HIV & AIDS law; and also in trying to expand access for these groups to testing, healthcare and treatment, in regions like Sub-Saharan Africa, Asia Pacific, and so on. For an overview, see Gill, P. (2007). The Politics of AIDS. New Delhi: Viva Books.