July #37 : Ashok to the System - by William M. Hoffman

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The Good Doctor

Dying for a Vaccine

Ashok to the System

Banking on Disaster

International Dream Team 1998

Not Your Average Joe

S.O.S.

To the Editor

Conference Call

Poz Picks

AIDS Is Over

Mourning Star

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Penny Wose, Pound Foolish

River Runs Dry

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HIV, Sir!

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Germs in Sperm

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Indelicate Balance

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The HIV Life Cycle

Shingles

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Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

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July 1998

Ashok to the System

by William M. Hoffman

Here comes Ashok Row Kavi, the Larry Kramer of India


Ashok Row Kavi is a one-man AIDS activist movement. As editor of Bombay Dost, India's only gay magazine, and founder of the Humsafar Trust, he is a lone but powerful voice for many uncomfortable truths in a nation that denies both the large number of people who have HIV and the large number of men who have sex with men. India is the new ground zero of the exploding epidemic, yet of more than 100 registered AIDS service organizations, the Humsafar Trust is the only one to target gay men. Ashok himself is a short, intense man with enormous energy and an accent that can only be described as proper Hollywood British. Space does not permit me to include the many tangents of Ashok's conversation, which ranged from Michel Foucault to the parallels between Hindus and Jews to the beauty of South Indian men.

-- WMH

William M. Hoffman: What do you want the readers of POZ to come away with from this interview?

Ashok Row Kavi: Two things. One, there is a new gay subculture coming up in Asia on a huge scale. We're talking on the order of 100 million gay men -- about 50 million in India and an even larger number in China.

You've just filled hundreds of Air India planes.

And two, this gigantic subculture is so closeted, and Indian culture is so in denial, that most Indians and the rest of the world barely recognize the degree to which the HIV pandemic has already hit India. We're going to have large numbers of gay men dying before they even realize their identities.

How many cases of HIV are we talking about?

I estimate that the number of men who have sex with men in Bombay, which has a population of about 14 million, is about half a million. Out of that, 60 percent are HIV positive. That is in Bombay alone! Perhaps as many as eight million cases -- women and men -- in the whole country.

Where do you get these stupefying statistics?

In 1992, Bombay Dost did a study of HIV prevalence in collaboration with India's world-renowned National Institute of Virology. We advertised anonymous testing and guaranteed anonymity. We got a reasonably good sample of self-identified English-speaking upper- and middle-class gay men -- "gay" in the Western sense, not just men who have sex with men, otherwise they would not have shown up in the first place. More than 20 percent were positive in 1992. That year the HIV rate among Bombay's female prostitutes was 19 percent.

By 1997, the HIV prevalence rate among female prostitutes touched 58 percent, so how can gay men be very far behind? Even with some of us gay men into safe sex, the figure can't be below 60 percent.

You're intimating that the route of HIV transmission is mainly gay. I always imagined India as a bastion of heterosexuality. Surely, with a population of more than 900 million, not all the women are using turkey basters.

In India, boys are married off no matter what their sexual orientation: A boy is money in the bank, a blank check. You can demand what you want from the girl's parents by way of a dowry if you have a marriageable son with some form of employment.

Sounds like a form of social security.

These sons have to marry girls. They have no identity as gay men. Eighty percent of the gay men in Bombay are married. There is a huge gulf between married gay men and single gay men because single gay men can have a gay identity, as you have in the West, which presupposes individuality. And that presupposes that the basic unit of society is the individual, not the family -- as it is in India.

The only thing I've heard about HIV in India is that it's spread along the trucking routes by female prostitutes.

[Bursts into laughter.] We were doing some proxy research at Zion Hospital, one of the biggest hospitals in Bombay. I was startled by what we discovered in the records. The ratio of men to women coming in diagnosed with AIDS was 32 to 1. Even if you make concessions for the fact that women do not have easy access to health facilities in India and that they come in only when it is too late, even if you reduce these numbers by almost two-thirds -- you still come to a ratio of 12 to 1, which is much higher than if this were a heterosexually transmitted disease.

The main clinic in Bombay asks not one question about male-to-male transmission. When we pointed this out, they responded: "Are there homosexuals in Bombay?" The whole epidemiology in Asia ignores homosexuals. They say homosexuals constitute one percent of the HIV cases.

When the Brazilian government found that its country's ratio [of men to women with HIV] went above 4 to 1, they knew there was subterranean male-to-male transmission. There is no way we can take this as a heterosexual disease, as the Indian government swears it is. As for truck-stop transmission, we made some interesting discoveries while doing HIV prevention among hijrahs at one of the major stops.

What are hijrahs?

Ritually castrated men who dress and live as women. We have millions of hijrahs. India has a clever method of sequestering homosexuals. We mix up homosexuality with gender. If you are effeminate in India, your family often assumes you're gay and forces you to live among the hijrahs, even if you're heterosexually inclined, as many effeminate men are. We shunt you off into a caste. Naturally, we assumed that when these big truckers picked up these little guys in saris, well, you can imagine what we imagined. Picture our shock when we found out that a lot of these guys in saris weren't castrated after all, and were fucking the truckers!

The Indian rope trick!

Exactly. So we had to change our intervention model. You should have heard those hijrahs complain: "And he wanted me to fuck him!"

Same complaint all over the world: "Where can a girl find a real man?"

In The Spartacus International Gay Travel Guide, there are practically no gay and lesbian listings between Bangkok and Europe. Please! In this country, you get bruises every time you board a crowded train. And straight Indians have a superiority complex: "Oh, we don't have any homosexuals, thank God. Homosexuality is the product of a debauched, bourgeois middle class." They're trying to tell people that we homosexuals are a complete import from the West. Where did they get their Marxism from? The Ganges?

I'm a traditional Indian. Hindu culture had gays. There are homosexual gods in the Indian pantheon. The main temple, Skanda-Ayappa, was dedicated to Skanda, the son born of a homosexual relationship between Shiva and Vishnu. Last year four and a half million men visited his shrine.

Gay men?

[Shrugs.] It's very interesting. For one month before the pilgrimage to Skanda's shrine, you must not engage in sex with a woman. The rules don't talk about sex with men. So, you can imagine.

There's a good gay soul in India's heart. In Indian culture, you don't get killed for being gay -- you get marginalized. The word outcast is Indian in origin. As a self-identified gay man, I've refused to get married. That is a willful contradiction of Indian social determinism that I am made to pay for. The price: No social invitations. They all go to my mother.

What brings you to the United States?

I was hoping that before a lot more gay Indians die, you people might give us a helping hand. When I go to charity dinners in Los Angeles and New York City, I am fascinated. Gay people in India don't exist as far as you're concerned. You are concerned only with your new combination treatments, which are completely out of the question for most Indians.

How did you become interested in the epidemic?

I was one of the very few out gay men in a country of 900 million. I was making outrageous claims that there might be one or two other gay men in India, and that not all gay men are effeminate.

In 1989 I went to the International AIDS Conference in Montreal. It was my first exposure to militant gay culture. At that conference, one statistic stuck in my mind: Although gay men in America accounted for more than 60 percent of HIV infections, only 6 percent of the AIDS funding was going to them. That really bothered me.

The same thing was happening -- and still is happening -- in my own country. I said to myself: "We're going to be in deep shit because we don't have any gay identity at all. Americans have some gay identity, and that has gotten them some funding, but we in India have none. Oy vey." We have no identity or subculture. We just have networks of men fucking men. And we don't have a strong women's movement to stop opportunistic gay men from getting married, living a camouflaged lifestyle and giving their wives and children the HIV they pick up from other men. All these factors, combined with the pandemic, made me realize we were going to be in the deep shit we are in right now. We are going to go very fast. [Snaps his finger.] No identity, no movement, no diagnosis. A silent mass death.

And these deaths won't be called death by HIV.

Right. They'll be called death by tuberculosis. Sixty percent of all new TB cases in Bombay are HIV-related.

How much has the AIDS pandemic hit women and children?

In some places, two percent of postnatal mothers have HIV and HIV prevalence among newborns is 0.4 percent. Those are just the reported cases. Underreporting is a classic Indian trait. Always multiply Indian figures by 12. People can't handle so many deaths. We have patients in Bombay hospitals lying in the aisles and even under the beds. The health system in India is at the breaking point even without HIV. HIV will push it over the edge.

You'll soon have corpses lying in the streets.

India is used to dealing with corpse disposal. The River Ganga serves a huge population on its banks. Raw sewage is the main difficulty, but there's a peculiar religious angle here in that Hindus cremate their dead on its banks. It is holy duty. But many don't have enough money to cremate their dead, so the bodies are half burnt and thrown into the river, where they float downstream. To avoid the ghastly sight, the government began to breed carnivorous turtles to dispose of the dead. But the turtles have been major casualties of water pollution. The breeding nurseries have had high mortality rates and there just are not enough turtles to manage the growing number of dead. So, it's back to the drawing board.

The HIV rate in the general population is three percent, and the figures double every 18 months. The total number of hospital beds is 360,000. We are one of the very few organizations intervening and building infrastructure. In 1995 we submitted a proposal for $3,000 -- a grand sum in India -- called "Facilitating Access to Public Health Facilities for Self-Identified Gay Men and Men Who Have Sex With Men."

Would be hard to put that on a building.

Looks good on the proposal. Very scientific. The government finally came through this year. Too little, too late.

How did AIDS first come to your attention?

I reported the first case in 1986. It was a man who came in for a cardiac operation, a man of Indian origin from Africa. There was a huge hue and cry in Bombay. Within a year and a half, the great minds had agreed that AIDS was imported from Africa and that the disease was foreign. Officials went into the red-light district and forcibly collected blood from female sex workers. I hate that word workers here -- they are sex slaves! They determined that some of the prostitutes had HIV and claimed that they were going to infect the population of India. Notice how the prostitutes are marginalized -- as if they were infecting everyone, when we know how difficult it is for men to contract HIV from women. The government wasn't willing to face the fact that the disease was being spread mainly by men.

What has been the reaction to your outspokenness?

Basically, the first reaction is shock. The second reaction is, God, we actually have homosexuals here? We thought such decadent behavior was only in America. The third is, they are bad boys, let them die. Fourth reaction: But I think I may have a relative who is that way. Fifth reaction is, they are good boys gone bad and should be converted into good family men. And the sixth -- OK, we cannot convert them into straights, so why not help them help themselves? There is no homophobia in the Western sense. The usual first reaction is that a single man is a sad case of wasted male material.

With so much male-male sex going on, how can Indians not realize the danger from HIV?

Sex between men is often not thought of as sex. We have many people in my country in very little private space, so we have lots of sex going on in parks and toilets. I give a college course called "Condom Sense," and I end with a special workshop on how to put a condom on in the dark. I blindfold the students to give them a sense of how to do this. Surprisingly, the women listen carefully because they know that sex is furtive. But when we distribute condoms outside the public toilets where men are having sex with men, they say: "Why are you giving this to me? These are for contraception." You say: "What the hell were you doing inside?" They say: "That was musti, man -- that was fun. We're just fooling around." The women pick up on the use of condoms, but men who don't think they are having sex don't.

What is treatment for HIV like in India?

Forget about Western ideas of medicine -- too expensive. No one knows the dosages of the medicines, which are prescribed according to your Western metabolisms anyway.

There is little access to clean water in India. You cannot ask a poor man to boil water every day: There is no money for fuel to boil the water. We have little access to clean air. The whole environment is degraded. How do you expect the immune system weakened by HIV to cope with this?

So people in India die at early stages of the disease?

The average life span between diagnosis and death is 18 months. People get diagnosed very late in the course of the disease and often come down with symptoms like diarrhea, which is endemic in India anyway.

Life is cheap. India is a country in which machine-made goods are more expensive than hand-made goods. Five million children go blind doing embroidery. No one cares. Our elite is very good at mouthing socialist slogans. The whole fucking lot of English-educated ass-lickers live in this fantasy about revolution. I've heard ministers say "I don't care about HIV. My children are in Canada." That's when I pray that Canada is devastated by HIV. Those fucking bastards know how to mouth the World Bank phraseology, but they don't do a fucking thing. The only ones in India fighting this epidemic are community-based organizations, and there are numbers of them, thank God. No one else gives a shit. This is my message to the world: Only gay organizations will be able to tackle the AIDS pandemic in India. The grass roots.

In 1995, the World Bank gave India a $90 million low-interest loan to fight AIDS. Three years later it was returned by the government -- with only $30 million spent. I privately pleaded with the Bank not to give the money to the government, but no one listened. The money wasn't used because of an ideological debate: The Communist Party argued that AIDS could not be an Indian problem because AIDS equals Western debauchery. So the loan lapsed, unused. The government showed us reports: The Calcutta red-light district reported 100 percent condom use. Sure! Our small group of middle-class, self-identified gay men in Bombay isn't even showing 50 percent use. We have condom-wearing competitions every week. It's bloody tough to change human behavior.

Considering the number of people with HIV in India, there seems to be a concerted effort to hide this from people.

We are a very clever, old culture. We know how to marginalize, how not to see something that is too uncomfortable. We pretend that HIV will go away. We don't want to face it. But HIV might make us face reality. That's the way I see it.



LETTER FROM INDIA

A Tour Beyond the Taj Mahal

Though much has changed in India since I first traveled there in 1986, the culture, in my eyes, has remained unchanged for 5,000 years. Twelve years ago there was very little HIV in India. Today, WHO estimates there are five million Indians with HIV, and if the trend continues, it will soon have the highest seroprevalence rate of any country in the world.

What I find most intriguing about India is that reality there is not what it appears to be. There is always another layer of truth to be explored. Take AIDS, for example. Statistics on India's epidemic are sketchy and contradictory. Even the clinical definition of AIDS varies from state to state. However, one consistency in all the government reports and journal articles is the near-total silence about same-sex behavior as a route of transmission. Perhaps India's antisodomy law, a legacy of the British, is so effective that sex among men doesn't happen like it does everywhere else in the world. Diary entries about my own experiences there, however, suggest otherwise.

1997: After several months in India, I become somewhat adept at knowing when I'm being cruised and when I'm just being stared at as a novelty. Never have I been in a more cruisy place than Calicut. It's more cruisy than Fire Island on a Sunday afternoon in June. The men hike their ankle-length lunghis above their knees and, like dancers at the Follies Bergeres, sashay them before tucking them in at the waist while strutting down the street. There aren't many women around.

Calicut is one of the world's oldest ports, and I'm told that in the days of Columbus, Indian sailors would only be hired if they were paired with a lover. That evidently cut down on shipboard fights. Now it's a point of embarkation for Indians going to work in the Gulf countries, so a lot of the population is transient.

As the sun sets over the Arabian Sea, I watch as pairs of men disappear into the shadows of the coconut tree-lined beach. Groups of boys and men sit together laughing, smoking and cuddling on the steps leading to the sea. Two men jump off a motorcycle and walk past me a couple of times until I finally say hello. Ten minutes later I'm sandwiched between them on the bike, heading back to their place for a drink. They take me to a big house on a hill. One of them has a wife and four children who are away visiting an auntie.

I'm not one to read "gay" into a place if it's not there. In India, same-sex behavior runs a close second to cricket as the national pastime. The gay cruising spots in Indian cities are well known and busy. Truck stops offer not only female sex workers, but male sex workers as well. Hotels usually have massage or "towel" boys available to exchange pleasure for the equivalent of $2 or $3 U.S. of rupees. Because private space is at a premium, consensual sex between men often happens in spaces not particularly conducive to negotiating safe sex. People get it where and when they can, whether that means going to sex workers or having sex in public toilets, cinemas, parks or even in crowded trains in the light of day. In addition to the danger posed by HIV, the police are usually nearby. They wield India's antisodomy law to harass, extort, molest and rape those caught or suspected of engaging in same-sex acts.

By ignoring same-sex behavior, politicians, funders and researchers ensure that HIV will spread not only among men who have sex with men (MSMs), but to their wives and children as well. Interventions aimed at MSMs aren't created, and there's very little information about the risks involved in same-sex behavior. So, many homosexuals assume they aren't at risk. Owais Khan, who runs a Men's Sexual Health Hotline in New Delhi, says, "Even of the men who self-identify as gay, 90 percent are married. And safe-sex -- if they know about it -- is not common."

The invisibility of gay men in India is also perpetuated by gay men themselves. There are plenty of rich, influential gays who could make a difference but choose not to upset their comfortable lives. Coming out would distress their mothers and shame their wives, adversely affect the family business and, worst, make it difficult to get inexpensive sex.

1997: It is unusually cold in Calcutta. We sit on the park bench and she gazes up at the night sky. The moon draws a line on the profile of her classic Bengali features. It is a beautiful, serene face. Her name is Hiroo and she sways to the music from the traveling circus that has settled in the park for the winter. My Bengali is hopeless, so Ranjan interprets for me. She never would have spoken to me anyway, except to sell some sex. She trusts Ranjan though -- he's been doing AIDS education for years. "She had the operation two months ago," Ranjan tells me. "The last time I saw her, she wore a sari, but she was a man then." A doctor had done her surgery, and it had gone quite well. Her hijrah community paid the doctor's 5,000 rupee fee. She gives the community two thirds of the money she makes from dancing at festivals and weddings and selling sex.

"Business will be slow tonight," Ranjan tells me. "It's cold and it's Ramadan. The men are trying to be pure." Still, he says that Hiroo and the other sex workers in the park will probably have nine or 10 clients that day, and earn the equivalent of $1 U.S. from each of them. Although he's done AIDS education with them, he says condom use is rare at best.

"Tomorrow I go to Delhi to dance in a festival," Hiroo says. "Tonight I must earn the money for the fare. It's an early train, so I must go." She stands and I see her eyes for the first time. A sweet smile crosses her face as she covers her head with her sari and disappears into the night.

Although valiant efforts at prevention are being made by a handful of grass-roots organizations across the country, their resources and energies are stretched thin. Angeli Gopalan is one of the best known women in India battling AIDS at the grass-roots level. She operates the NAZ Project, a non-governmental organization in Delhi, on a shoestring budget, and has created an effective program. She has the kind of knowledge and savvy needed to cajole bureaucrats while courting funders and bringing services to communities. Her office acts as a kind of think-tank for the movers and shakers in the South Asian AIDS world.

1998: Angeli sat cross-legged as her staff buzzed in and out of the room. The flurry of activity came to a halt when Tahira finally arrived. She was visiting from Pakistan, and came to talk about the Karachi Reproductive Health Project. "Our objective is to improve women's sexual health. We train women to train other women. Men are more free to go to a doctor and talk about sexually transmitted diseases, but women lack the freedom to travel to clinics and the ability to talk about such private matters.

"When we go into communities, we find that women don't want to hear the standard 'reproductive health' rhetoric -- they want to hear about incest, homosexuality, sexual harassment, molestation, bestiality. They know these things happen in their communities but they never knew they could talk about it.

"It's also important to have male groups -- to tell them what we are talking about and why -- because we're looking for a change in attitude toward women. Women's empowerment will only come if the men realize that women have rights. The communication must be two ways."

Another woman with a vision and ability to break through bureaucracy is Dr. Latha Jaganathan, who runs a donor-based blood bank in Bangalore. According to Jaganathan, although the voluntary blood-donor movement started more than 30 years ago, a large proportion of the blood used in India still comes from commercial blood sellers. Safety is very difficult to monitor.

1997: "Blood donors are usually from lower economic groups and get paid so little -- 50, 60 rupees. No records are kept. People can sell at one commercial blood bank and the next week go to another. You can usually make them out by the track marks. The government makes statements like 'there is 100 percent blood safety in our state' because it gave out one testing kit. The funding is there, but there is no monitoring. What we need in terms of safety is fewer blood banks and larger facilities where the volumes of blood could be tested efficiently.

"When the National AIDS Control Organization (NACO) was created, it started looking at blood safety because, of course, it's easier to say 'blood' than 'sex.' Ministers made speeches about how blood safety is being improved, but no one would say anything about sex. When they did start talking about sex, they'd say things like 'prostitution should be banned' and 'we live in the country of Rama,' which had nothing to do with what was happening practically. A couple of weeks before World AIDS Day, everyone wakes up and decides something must be done. So they get someone to make a speech. 'Who will attend?' 'Don't worry, we'll get the nursing students to sit there.' Then they decide what to have for tea."

It seems, too, that the more marginalized a community, the less likely it is to receive the education and resources needed to avoid risk. Often, the first thing low-caste Hindus and poor Muslims learn about AIDS is that they have it. Although statistics show a rapid increase in the rate of children with HIV, few efforts exist to educate them about AIDS. Jaganathan conducted surveys which showed a tremendous increase in sexual activity as soon as children leave home to go to college. She decided it was important to try to educate them at an earlier age.

"The children have so little information. Girls don't know why they are having periods, boys think masturbation will make them unable to have children. We taught the teachers about AIDS and how to discuss these issues. But they're too embarrassed to do it.

"When we did a workshop at a Catholic school, a rich benefactor told us not to talk about sex or condoms. That left us with very little practical information to give the children. Afterward, two young nuns who had been sitting in the back came to me and said, 'We know they won't let you talk, but we're the ones these children come to when they're in trouble. We're the ones who visit the homes. How do we talk to those whose uncles raped them? How do we treat their gonorrhea? What do we do when their rectums and vaginas are torn and bleeding?'

"When I wanted to incorporate more AIDS education into our programing, I went to one of the state ministers for AIDS policy. His response was 'Ooohhh, Madam Doctor, so many people on our streets are injured by automobiles. Why not forget about this AIDS business and work on trying to make the streets of Bangalore safer?'

"There are many NGOs doing good work, but we need more government support. The money is there, but the will is not. They keep saying condoms are freely available, but we keep finding that they are not. They won't put condoms in the public toilets, and men are too embarrassed to go to the shops to get them. In Thailand they've achieved almost 100 percent condom use among sex workers -- why can't we do that here?

"And all the risk groups are not being dealt with. For instance, homosexuality -- well, it's illegal, so people don't come out. In Bombay it's somewhat different -- you must know about Bombay Dost and Ashok Row Kavi -- so something is being done there. First the government said there was no AIDS in India, then they said there was no sex, now they say there is no same-sex behavior. So the message goes out that you only get HIV from female sex workers. There was an article I read a couple of days ago in The Times of India that said 70 percent of people interviewed on the street didn't even know what AIDS was."

So you see: Sex happens in India. It happens among all ethnic types and religions. It happens among all social classes and castes. It happens among men and among women. Sex is carved into India's temple walls and written into its ancient literature. And its continued denial invites the spread of HIV infection.

-Paul Knox




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