Sexual Behavior and AIDS in India.

By Moni Nag. New Delhi, 1996, 157 pages. Cloth, Rs250 (approximately $8.20 U.S.). Sexual Behavior and AIDS in the Developing World. Edited by John Cleland and Benoit Ferry. Bristol, PA: Taylor & Francis, 1995, 243 pages. Paper, $24.95.

Reviewed by Michael R. Stevenson, Ph.D., Department of Psychological Sciences, Ball State University, Muncie, IN 47306. E-mail: [e-mail].

I became interested in HIV prevention and education in developing countries while in Indonesia as a Fulbright Senior Scholar. I helped my Indonesian friends and colleagues struggle to create useful prevention programs and develop public policy without access to research findings on indigenous samples. Both in Indonesia and after I returned to the United States, I attempted to locate the available published research on the topic (Stevenson, 1994, 1995). Eventually, J wrote an entry on Southeast Asia for the Encyclopedia of AIDS (Stevenson, in press). Preparing these reports was frustrating. Even with access to the National Library of Medicine in Bethesda, MD, where I expected to find a wealth of material, my attempts to locate reasonable resources were often thwarted. With notable exceptions (e.g., Thailand), little relevant research beyond prevalence estimates provided by the World Health Organization or various national governments had been conducted in most developing countries in Southeast Asia. The research that had been done may have been presented at an international conference but had not been published and was therefore not available to me. Given this history, I was pleased to discover the two books under review here.

These books represent very different but equally useful approaches to increasing our understanding of the parameters of the HIV pandemic in the developing world. In Sexual Behavior and AIDS in India, Moni Nag summarizes what little is known about attitudes and behaviors related to sexual behavior, including many studies that were presented orally but never published. Much of the work pre-dates the HIV pandemic. In contrast, in Sexual Behavior and AIDS in the Developing World, Cleland and Ferry have assembled the "first global report of its kind to contain inter-country comparisons of HIV and AIDS-related knowledge, attitudes and behavior in the developing world" (p. xv).

According to Nag, economic and methodological constraints prevent accurate estimates of the prevalence of HIV infection in India. As in most of the rest of Asia, there have been no national survey's of representative samples. Most available data were collected from groups of people thought to be highly vulnerable to HIV infection through sexual relations. These groups include men and women who have multiple partners (e.g., sex workers, truck drivers) and men who have sex with men. The latter include not only gay men but also members of the hijra community, who are a group of castrated. males who engage voluntarily or are forced by circumstances to engage in higher-risk sexual behavior.

The extant data suggest that HIV infection rates are still relatively low in India, at least as compared to other developing countries in Southeast Asia and Africa. However, a correct diagnosis of HIV infection is complicated by the fact that symptoms commonly associated with HIV infection are also signs of other diseases common in the general Indian population. As is true in much of the developing world, in India, heterosexual intercourse is the most common mode of transmission, and most women become infected through intercourse with HIV+ husbands.

Nag reports that the first cases of AIDS were diagnosed in 1986 in two people who were infected through blood transfusions that occurred in the United States. This apparently led to a common but erroneous belief in India that HIV disease would not become a serious problem among the indigenous populations. However, recent estimates by the Government of India project that by 2000 the number of cases will exceed one million.

Nag provides an important resource by annotating papers that were presented at meetings and never published. Most studies have serious shortcomings, but the alternative is having no data at all! After a brief introduction that provides a critical framework and cultural context for the book, Nag discusses premarital sex, extramarital sex, female sex workers and their clients, homosexuality, hijras and male sex workers, the use of condoms, and sexual abstinence.

A brief chapter concerning priorities of research on sexual behavior demonstrates Nag's insight into the methodological and conceptual problems in this area. For example, Nag suggests that "the common people of India are not as reluctant or inhibited to talk about sex or provide information in anonymous questionnaires as is often assumed from the perspective of middle class sexual morality" (p. 111). He also suggests that male sex workers, "like other sexually exploited groups, also deserve priority in research and intervention programmes" (p. 114). These words of wisdom apply equally to research in developed countries like the United States as they do in the developing world. The final chapter is a summary of the major findings. Those interested in a quick overview might wish simply to skim this detailed summary.

Nag's book demonstrates just how little is known about sexual behavior and HIV transmission. The research he describes is fragmented and poorly executed. Serious scholars must heed his warning about the inherent limitations. Although we can make cautious cross-cultural comparisons, Nag's conclusions are most useful in providing a basis for more systematic future research efforts. Critically evaluating what we already know about sexual behavior and HIV disease in a particular cultural context is a laudable task. However, it cannot be an end in itself I am hopeful that Nag's work will be used as a model by others who wish to provide a summary of the existing research. I also hope that his work will be used to inform more systematic and methodologically sound research in India.

Sexual Behavior and AIDS in the Developing World represents a very different but equally valuable approach to understanding HIV and AIDS. Cleland and Ferry (with the help of 6 additional authors an contributors) provide an in-depth comparative analysis of the findings from 16 surveys concerning AIDS-related knowledge and sexual behavior in developing countries in Africa, Asia, and South America (specifically, Central African Republic, Cote d'Ivoire, Guinea Bissau, Togo, Burundi, Kenya, Lesotho, 2 samples from Tanzania, Zambia, Mauritius, Philippines, Singapore, Sri Lanka, Thailand, and Brazil). The data were gathered in 1989 and 1990 under the auspices of the World Health Organization. The original questionnaire was adapted to local needs and conditions and was translated into the national or local languages; therefore, the data vary from sample to sample. The average sample size was 2,467 persons, aged 15 or more, and most samples were nationally representative.

The first two chapters provide the background for the study and a detailed description of the survey's characteristics. Interestingly, like Nag and contrary to the conventional wisdom of researchers in the United States, these researchers observed that "questions on sexual activities do not pose more difficult problems than any other area of inquiry . . . Few people refused to participate or terminated the interview after starting . . . if well prepared and carefully implemented, such surveys in the developing world are not much different from any other demographic or health survey" (p. 22). Later Cleland and Ferry added that "such surveys can be conducted successfully in many--perhaps most--developing countries without causing outrage or offense, at least within the context of a major pandemic involving a sexually transmissible agent" (p. 221).

Chapter authors describe findings concerning knowledge, awareness, and attitudes about AIDS; sexual behavior; awareness, attitudes, and use of condoms; risk perception and behavioral change; and risk factors related to HIV transmission, including sexually transmitted diseases, alcohol consumption, and medically-related injections. The book closes with a detailed summary of the principal findings and a discussion of key policy implications, methodological lessons, and suggestions for future research for AIDS-related surveys of general populations.

Like Nag, the authors contributing to this book are appropriately cautious about drawing broad generalizations from this body of work. The samples are not representative of the developing world, and three were restricted to capital cities. It is unclear how these cities were selected or whether additional studies were attempted. However, "no national surveys of sexual behavior had ever been undertaken in developing countries" (p. 208), so even with its flaws, this research is a giant step forward.

Some results were frightening. In Africa, only 15% to 88% of men have heard of condoms, are aware of a supply source, and live within 30 minutes of the source. The percentages for women are even lower. In nearly half the surveys, there was no clear-cut relationship between reported risk behavior and risk perception. In other findings, the authors found unexpected sources of hope. "In nine of the 15 study populations, well over half of men and women thought themselves to be at some risk of HIV infection, or were unsure of the risk. Thus instead of attempting to explain why denial of personal risk is so common, we are in the unexpected position of having to account for a remarkably high level of perceived risk, particularly among the African sites" (p. 216).

The surveys were limited in some ways. Most did not cover bisexuality and homosexuality, and there was no attempt to provide a cultural context. On the other hand, in other ways the surveys broke new conceptual ground. In contrast to earlier research, any sexual partnership that had lasted a year or was expected to continue for a year or more was defined as a regular partnership, regardless of whether the couple cohabitated or was legally married. This allowed researchers to compare regular, non-regular (those lasting less than a year), and commercial (those involving the exchange of money, favors, or gifts) sexual liaisons. These are far more meaningful comparisons than those based on legal marital status.

Like Nag, the authors of this collection provide insights that researchers in the United States should heed. For example, "in this first cross-cultural attempt to examine aspects of sexual lifestyles, it has been consistently shown that broad generalizations about one particular population or region are misleading" (p. 123).

In spite of these books' limitations, I am in awe of the authors' Herculean effort that produced them. It is truly a crime that in the information age, we still know so little about something so important.

References

Stevenson, M. R. (In press). Southeast Asia. In R. A. Smith (Ed.), Encyclopedia of AIDS: A social, political, cultural, and scientific record of the epidemic. New York: Garland.

Stevenson, M. R. (1994). Acquired Immune Deficiency Syndrome in Indonesia. Antara Kita, 39, 1-5.

Stevenson, M R. (1995, November). Gender and AIDS in Indonesia and the U. S. Paper presented at the meetings of The Society for the Scientific Study of Sexuality, Houston, TX.