Abstract: Despite the fact that HIV/AIDS has become a serious public health problem in Manipur for the last decades affecting people of all social groups, the knowledge and understanding level of the general population is often marred by misconceptions leading to the marginalization of HIV/AIDs and PLHAs. This article is based on prolong fieldwork carried out in two districts of Manipur viz; Imphal and Chandel in the year 2008 with the aim to assess knowledge and understanding level of the general population regarding HIV/AIDS, their attitude towards PLHAs; and to unearth the myth, belief and practices related to HIV/AIDS which might exposed them to HIV infection. A total of 200 respondents i.e. 100 respondents from each district consisting of equal number of male and female from the general population were interviewed for the purpose.
From the study, it was observed that high knowledge regarding HIV transmission, prevention, risks, and symptoms were marred by misconceptions leading to unnecessary fear and marginalization of HIV/AIDS; which in turn led to the expression of negative attitude towards PLHAs. Study also found that despite dreading HIV/AIDS, some of the respondents also engaged in risky sexual behavior. Comparatively, respondents from Imphal were more knowledgeable than those in Chandel. Female respondents from both the areas were found to have less knowledge and more discriminating attitude towards HIV/AIDS.
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Keywords: HIV/AIDS, PLHAs, Knowledge, Attitude, Behavior, Practice, Discrimination
Knowledge, attitude, behavior, and practice towards HIV/AIDS in Manipur, India: a cross sectional study.
HIV/AIDS has spread like wildfire since its first detection in 1981and has claimed millions of lives across the world. According to the UNAID report, there were 33 million people living with HIV, 2.7 million people were newly infected with HIV and 2.0 million people died of AIDS in the year 2007 alone (UNAID report, 2007). The spread of HIV/AIDS continues to escalate with every passing year despite efforts to curb it by the nations across the continents. AIDS continues to be one of the killer diseases of the 21st century without any cure so far. It knows no social, gender, caste and geographical boundary thereby affecting people from all walks of life: young and old, rich and poor, male and female, and cutting across different nations of the world.
In India, HIV/AIDS has become one of the most challenging public health problems. The first HIV/AIDS case in India was detected in 1986 at CMC, Vellore, from blood samples taken from commercial sex workers in Madras. Since then, it has spread heterogeneously and steadily to all the other States and Union territories. India is now, the third largest HIV/AIDS affected country in the world and remains the largest in Asia (NACO, 2007). The total number of people living with HIV/AIDS (PLHAs) in India in 2007 was estimated to be 2.31 million (1.8-2.9 million). Out of this, 39% of PLHAs are estimated to be females (Technical brief, NACO, 2007). Heterosexual is still the predominant mode of HIV transmission in India. However, the transmission pattern of HIV in India is uneven with southern states reporting more of heterosexual transmission than the northern states. In the north eastern states, it is a combination of both injecting drug users and unprotected sex.
Six states in India reported high HIV prevalence of more than 1% among mothers attending ante-natal clinic. Manipur is one such six states besides Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu and Nagaland. With hardly 0.2% of the country's total population, yet contributing nearly 8% of India's total HIV positive cases, AIDS has emerged as a new and serious public health emergency in Manipur.
Though the major transmission route in Manipur still remains through injecting drug users (IDUs'), sexual transmission is not far behind. A recent annual sentinel surveillance report (NACO, 2006) revealed that HIV prevalence among IDUs has considerably come down over the years but Manipur still has HIV prevalence of IDUs' above 10%. The rapid increase in HIV transmission through unsafe sex in the state in recent times is highly concerning. The prevalence of HIV among female sex workers (FSW) in Manipur is 13.07%, next only to Maharashtra (17.9%) and among men having sex with men (MSM) is 16.4%. (HIV sentinel surveillance/technical brief, NACO). Vertical transmission of HIV infection from husband to married monogamous wife in Manipur is gaining momentum over the last few years with a report of more than 1% prevalence of HIV among mothers attending antenatal clinic.
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HIV/AIDS is increasingly penetrating every layer of social strata reaching even to the remotest area in Manipur. Negi K.S et.al (2006) in their study observed that most of the individuals in community do not have correct and complete information about HIV/AIDS and its prevention. The latest report of Manipur State AIDS Control Society (MSACS) revealed that Manipur has 40,000 HIV positive reported cases among the general population. HIV/AIDS has thus, become a serious public health problem in Manipur, affecting people from all social strata. Therefore, keeping the widespread problem of HIV in mind, the present study has been planned to assess the knowledge and understanding of the general population regarding HIV/AIDS, their attitude towards PLHAs''; and to unearth the myth, belief and practices related to HIV/AIDS which might expose them to HIV infection.
Material and methods:
This was a cross-section and observational study carried out in two districts of Manipur viz Chandel and Imphal from June 2008 till mid-November 2008. A total of 200 respondents comprising of hundred respondents each from two sub-divisions i. e Lamphelpat in Imphal west and Chandel in Chandel districts, were contacted in their home and interviewed. The respondents who were at least 18 years of age and above were randomly selected and interviewed after taking their informed consent. Equal numbers of male and female respondents from both the districts were selected for the purpose. A pre-tested questionnaire consisting of items on socio-demographic background, knowledge, attitude, behavior and practice of HIV/AIDS was used for collecting data from each of the respondents. The interview though, based on the questionnaire was a combination of closed and open-ended, and the interview was carried out in free flowing manner where respondents revealed beyond what is being asked. This was supplemented by participant observation.
Imphal is the capital city of Manipur and lies at the heart of the state. It is a commercial and official hub of the state. There are different communities living in Imphal, the bulk of which is constituted by the Meitei community followed by Muslims, different tribal groups, and non-Manipuri migrants. Imphal district being the capital city holds an edge over other districts and has the best health care facilities available in the state. Besides that, it is also home to many apex government and non-government offices including various NGOs' working for the welfare of HIV/AIDS in the state. It also has an edge over other districts in terms of infrastructure, transport and communication, educational institutions, etc. Imphal is divided into two districts-east and west. The area of the study was in located in Lamphelpat sub-division of Imphal-west district. This sub-division is the most thickly populated area (2001 census) in Imphal West. Majority of the people in Lamphelpat follow Hinduism, Muslim, Meitei Sanamahi and Christianity.
Another area of the study is Chandel district, situated on the southern part of Manipur 64km away from Imphal city. It is inhabited by scheduled tribes predominantly belonging to the Naga ethnic group followed by tribes belonging to Kuki/Zou ethnic groups. There is also a minor population of non-tribal communities belonging to Meitei, Muslim and non-Manipuri migrants. The field study was carried out in the district headquarter of Chandel sub-division where the study population comprises of different Naga tribes. Christianity is the dominant religion practiced among the tribal population of Chandel sub-division.
Data was entered in SPSS-Pc version 11.5/15 (Check). Data was expressed in percentages and comparisons between the groups were done using Chi-square test. Unpaired't' test was performed for finding out differences between groups for quantitative variables. 'p' value less than 0.05 was considered significant.
Demographic profile of the study population:
A total of 200 respondents from both Imphal and Chandel districts were interviewed using the framed KABP questionnaires. There were 100 respondents from each of the district consisting of 50 male and 50 female. The respondents in Chandel belonged to the tribal population of the Nagas while that of Imphal belonged to the Meiteis.
The respondents belonging to different age groups were maximum for: 18-30 (45.5%), 31-40 (29%), 41-50 (16%), 51-60 97%) and 61-above (2.5%) in descending order.
In terms of marital status, the respondents comprises mostly of married men (54%) and woman (61%), followed by unmarried men (44%) and women (34%).
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The educational status of the respondents in Imphal areas mostly studied till secondary (33%) or up to graduates (33%) while in Chandel, most of the respondents studied till secondary (30). Gender wise, male respondents were found to be more educated than female. At least 39% respondents in Chandel were either illiterate or have primary education as against 5% respondents in Imphal. Overall, most respondents studied till secondary (31.5) followed by graduates (29%).
In terms of occupation, majority of the respondents were unemployed (28%). Majority of female respondents were housewife (21.5%). Employment status of the respondents was seen to be more (17%) in Imphal than in Chandel (7%). Most of the respondents in Imphal comprise of unemployed (32%), followed by those employed (17%) while in Chandel, housewife (29%) and students (26%) constitute the bulk of the respondents.
With respect to religion, 71% respondents in Imphal follow Hinduism, 25% Meitei Sanamahi, 3% Christianity and 1% other religion. As compared to this, all the respondents in Chandel follow Christianity.
Knowledge: From the study, it was found that except for one respondent from Chandel, all the other respondents in both the study areas have heard of AIDS. On further query about what AIDS disease was, majority of them could not give correct answer. Only 5% respondents in Imphal and 6% respondents in Chandel gave correct answer to this. Male respondents (8%) were slightly knowledgeable about what AIDS disease was than female respondents (3%).
With respect to the question on what is HIV? 17% respondents in Imphal gave correct answer as against 22% correct answer in Chandel. Gender wise, the number of male respondents (32%) with correct response was highly significant (p<0.000) than female respondents (7%). 57% respondents from Imphal and 47% respondents in Chandel knew about the difference between HIV and AIDS. A significant difference (p<0.001) was observed between the two genders as male respondents (65%) who gave correct response was significantly higher than female respondents (39%).
Regarding the etiology of HIV/AIDS, majority of the respondents from both the areas i.e. 69.5 % were knowledgeable about the causative agent for HIV. The remaining number of respondents had misconceptions. A significant difference of p<.020 and (p<.006) was observed in Imphal and Chandel respectively in this aspect.
Regarding the mode of HIV/AIDS transmission, majority of the respondents i.e. >90% from Imphal and Chandel had correct knowledge about it when it concerns shaking hands, infected blood transfusion, sharing towels, unprotected sex, coughing/sneezing, and sharing infected needle. >75% had correct knowledge on mosquito bite, kissing/hugging, and infected mother to child. A significant difference of p<0.022 was noted in Imphal with respect to sharing of towels while in Chandel, a significant difference of p<0.001, p<0.005, p<0.001 was observed with respect to mosquito bite, sharing of towels, and kissing/hugging respectively.
The response on the knowledge of common symptoms of HIV/AIDS was met with 93% and 87% respondents citing weight loss and loss of complexion/appetite as the most common symptoms respectively of PLHAs. Respondents also considered fever/cough (79%), diarrhea (74.5%), OI like T.B/cancer (74%), rash on the skin (73%) and swelling in groins (71%) in descending orders as other symptoms of PLHAs.
On the sources of information on HIV/AIDS, majority of the respondents i.e. >90% from Imphal area have mass media like TV (local channel), radio, newspaper; street plays, as their main source. Another, 72-88% reported NGOs', and a negligible 18-4% reported church as their main sources of information. No significant difference was observed in imphal. In contrast, Chandel reported high percentage i.e. =84% of respondents getting information from church, and NGOs. A significant difference of response i.e p<0.037, p<0.002, p<0.001 and p<0.013 in the sources of information was noted in radio, television, newspaper and NGOs.
The study found that majority of the respondents from both the study areas i.e. 53.3% were strongly in favor of the attitudinal statements that HIV/AIDS is a punishment of God for bad behavior. A significant difference (p<0.012) was observed in Chandel as female respondents (68%) were highly in favor of the statement than their male counterparts (42%).
83.5% and 91.5% respondents also considered HIV/AIDS as a problem mainly associated with immoral behavior and injecting drug users (IDU) respectively. No significant difference was observed in the above statements. Respondents (71.5%) also opine that PLHA should not get married. A significant difference p<0.005 was observed in chandel with respect to this response. A whopping 94.5% also expressed their concern for compulsory HIV testing prior to marriage while 85% respondents voiced the need for separate health centre for PLHAs.
46.5% respondents said PLHAs should be isolated to prevent further transmission while 46% respondents said they would not like to mingle with PLHAs. A significant difference of p<0.047 and 0.002 respectively was noted in the above statements in chandel.
67.5% respondents also said they would feel ashamed if they were infected with HIV/AIDS and 39.5% respondents agreed that PLHAs should not be operated for any surgical problem. A significant difference with respect to these statements was seen at p<0.023 and p<0.002 respectively among male and female respondents of chandel.
As regards to pre-marital sex, only mere 16% respondents had no issue while the majorities were not in favor of it. There was a significant difference of p<0.040 in the response among male and female respondents in chandel.
76.5% respondents strongly believed that PLHAs are destined to die sooner or later. No significant difference was observed in both the two study sites. However, when it comes to teaching school children about safer sex, whopping 96.5% respondents agreed to it with no significant difference seen in the response in both the two study area.
Regarding collective responsibility of the society to care for PLHAs, 84% respondents were in favor of it. However, a significant difference of p<0.006 was noted only in respondents of chandel.
Behaviors and Practices: The general mean age for the onset of sex was 23.37±5.73. However, it was noted that respondents in Chandel (20.21±4.08) had earlier onset of sexual intercourse than those in Imphal (27.36±4.99). Out of 200 respondents, a total of 113 respondents responded to this question of age at first sexual encounter. Education was found to be directly proportional to the onset of sex. Less educated respondents had earlier onset of sex than those educated ones.
The mean for age at marriage was 25.51±5.64 and education was found to have some influence on the age of marriage as well. Less educated respondents marry earlier than those educated ones. A significant difference was observed in the age of marriage among female respondents from Chandel as the initiation of marriage begins as early as the age of fourteen (20.42±41).
From the analysis, it was found that few or more respondents were found to have risky behavior susceptible to HIV infection. 7.5% respondents admitted having been exposed to blood transfusion for various medical problems. 41% said their bodies have been injured by sharp objects such as blade/knife. The response to the latter statement was favorably high in chandel >53%. However, no significant difference was observed.
Negligible male respondents i.e. 3.5% revealed to have used abusive drugs such as alcohol, heroin, drugs, etc. No female was found using abusive drugs. 62% admitted being physically involved with their partner i.e. either with spouse of non-regular sexual partner. Here, a significant difference of p<0.002 was observed in imphal with more male admitting to it. Another 10.5% comprising mostly of male respondents were found to be indulging in sex with non-regular partner. A significant difference of p<0.018 in imphal and p<0.001 in chandel was observed.
With respect to use of condom in sex either with regular (spouse) or non-regular sexual partners, 18.5% respondents said they used it consistently. In chandel, a significant difference of p<0.004 was noted with male respondents using condom in sex.
17% respondents of the married couple used family planning of any form. 40.5% respondents comprising mostly of male respondents said they have attended awareness camps/programmes on HIV/AIDS. A significant difference of p<0.014 and p<0.011 in imphal and chandel respectively, was observed.
It was also noted that 34% respondents had done HIV testing at least once in their life. Another 39% respondents showed their willingness to go for HIV testing if necessary. More male respondents were seen to show willingness to go for HIV testing. A significant difference was observed in both the study areas i.e. p<0.007 in chandel and p<0.035 in chandel.
Another 28% respondents said they would assign specific utensils if anyone in their family was infected with the virus. No significant difference was seen here. 16% respondents also admit that people do insult/tease people with the virus. A significant difference of p<0.001 was observed as very less female respondents in chandel admit to PLHAs being teased/insulted. Another 50.5% also said religious positions are normally denied to PLHAs which is considered noble position. The response from female respondents was more and a very high significant difference of p<0.000 was observed between the two genders in chandel.
The present study revealed that though all the respondents heard about AIDS, many of them did not know what AIDS exactly was. For most respondents, AIDS was commonly synonymous with sexual promiscuity, immoral behavior and injecting drug users. This belief was mainly propounded by the fact that most PLHAs'' in the study areas were believed to be associated with at least one of the above characters. Similar findings were reported by Viser MJ et.al, 2006; Smith DJ. 2004.
When it comes to HIV, very few respondents had correct knowledge about it despite the fact that AIDS has become a 'dining table talk'. Out of the few respondents that have correct knowledge on HIV, male respondents were more. This may be due to the fact that the overall educational status of male respondents was slightly higher than their female counterparts. The other reason could be because male members of the society are more outgoing, hence are more updated about their social environment through media sources like newspaper and magazines.
Majority of the respondents also could not state the difference between HIV and AIDS. It was interesting to note that some respondents had completely different notion about HIV as a separate disease not related to AIDS at all. Many of them were still unaware of the term HIV when used in isolation from AIDS. It was found that HIV and AIDS were often times used together without really understanding the difference between the two. Respondents from Imphal were found to have slightly better knowledge about HIV than respondents from Chandel. This could be due to the fact that unlike respondents from Imphal, respondents in Chandel had less or no access to media such as newspapers, local channel, and street plays, etc whereby HIV/AIDS education is given out at regular intervals.
Regarding the mode of HIV/AIDS transmission, majority of the respondents had correct knowledge about it especially pertaining to the four primary mode of transmission i.e. through unsafe sexual contact, blood transfusion, sharing infected syringe and mother to child transmission. However, few respondents had misconceptions when it comes to transmission through mosquito bite, shaking hands, sharing towel, coughing or sneezing, and kissing/hugging. These misconceptions is mainly to do with the false beliefs that HIV/AIDS is transmitted through any blood product and body fluids (sweats) and as such anything that makes direct contact with the blood as in the case of mosquito or body fluid is considered risky. Thus, there is urgent necessity to sensitize properly the general population about the correct mode of HIV/AIDS transmission. Similar findings in the line of lack of proper sensitization/education on HIV/AIDS leading to misconceptions, was also reported by Hartwig K.A et.al 2006. As was observed in the analysis, many of the respondents from chandel especially female respondents tend to rely on information obtained from local gossips, which are often times marred by exaggerations and misconceptions responsible for stigmatization and discrimination of PLHAs and the disease HIV/AIDS.
The misconceptions pertaining to HIV/AIDS was closely related to the ways through which information about the disease is obtained. Respondents from Imphal had mass media like local channel (T.V), and newspaper, etc as their main source of information whereby HIV/AIDS education is given out by reliable sources whereas, in Chandel, media role was negligible. This could be explained on the basis of inaccessibility to local channel (T.V) and newspaper. In Chandel where cent percent of the respondents are Christians, church act as one of the major sources for dispensing information/knowledge on HIV/AIDS. It was found during participant observation that not all church leaders were properly trained nor well equipped with information on HIV/AIDS yet many of the church leaders did not hesitate to condemn HIV/AIDS as a shameful, despicable and fatal disease fated to befall upon promiscuous and immoral person in the society. So, church members were encouraged to practice abstinence from sex till marriage and be in sync with the biblical moral principle so as to avoid HIV/AIDS disease. This could be one of the reasons why stigmatization of PLHAs was more severe in Chandel than in imphal.
It is also interesting to note that female members of the society in both the study area were found to be 'social conscious' i.e. what society thinks and were more prone to participate in and rely on local gossips which is mostly influenced by 'socio-cultural feelings' than medical truth. Therefore, it is not surprising that more number of female respondents had misgivings on HIV/AIDS and stigmatization towards PLHAs.
Another interesting thing to note was in the way how people perceived PLHAs. Knowledge on the symptoms of HIV/AIDS patients revealed that many of the respondents considered loss of weight and complexion, body rash, etc as the major symptoms of HIV/AIDS. This knowledge supposedly comes from the cultural belief that most PLHAs in the study area physically exhibit such symptoms. However, lost of weight and complexion is not medically exclusive to PLHAs and as such, if not properly sensitized on this, it will lead to the wrong assumption that anybody with weight lost or complexion who may not necessarily be infected with HIV/AIDS have a strong potential, if not already, to be stereotyped and marginalized as PLHAs''.
Data also shows that a massive number of respondents still see HIV/AIDS as immoral disease or diseases of injecting drug users. A large number of respondents from chandel also considered HIV/AIDS as punishment of God for 'bad' behavior. This belief as analyzed was mainly influenced by which HIV/AIDS is transmitted i.e. through unsafe sex and sharing of infected syringes. It may be mentioned here that sexual promiscuity and injecting drug users are culturally viewed in the society as 'fallen' or 'immoral' person in both the study area and as such, anybody practicing any of the said behavior are generally considered immoral and thus, stigmatized. This could be one of the main reasons why HIV/AIDS is highly stigmatized since it is believed to be mostly associated with people of low morality or whose moral characters are questionable in the society. Notwithstanding the fact that many innocent female PLHAs may get infected through their spouse or some could have been infected through accidental blood transfusion, PLHAs are generally regarded as 'wayward' in the eyes of the society and as such, are stigmatized. The other reasons stated for HIV/AIDS being considered as the most stigmatized disease is also because of the nature in which PLHAs, at an advanced stage of the disease, died an ugly death, physically looking dreadfully haggard with skeletal like physique and complete loss of one's natural complexion and medically, from multiple opportunistic infections. However, the physical perception may not always be true for all PLHAs.
Another notable observation made in both the society was pertaining to the prevalence of gender disparity when it comes to morality and promiscuity. Culturally, sexual promiscuity and 'immoral behavior' such as drug and alcohol abuse, or waywardness are tabooed yet society tends to be more tolerant towards male members than female. It is an open secret for male members in the society to be accepted more readily than female despite violating unsanctioned social norms. This explains why many of the female respondents expressed that they would feel embarrassed if infected with HIV/AIDS, a disease symbolic of immoral behavior. This finding is in conformity with the findings of Smith DJ, 2004.
A discrepancy between knowledge and behavior/practice of the people towards PLHA was also observed. Though most respondents excepting few were aware about the primary mode of HIV/AIDS transmission, they admitted to have maintained some distance or reservation in mingling with PLHAs despite knowing well that doing so will in no way put them at risks. Gray LA and Marle S, 1991 reported similar observations. This could probably be a case of extreme cultural stigmatization of PLHAs in general whereby common people fear the stigma of being stereotyped by associating with PLHAs.
Respondents also expressed the feeling that PLHAs should have separate health centre on the ground that it will be safer for both the infected and non-infected population as they could not trust the instruments of health care centre to be fully safe from HIV infection. Majority of the respondents also viewed that PLHAs should neither get married nor have children as doing so will only increased the number of PLHAs who in all probability will only live to suffer and died a torturous death. However, few people were of the view that as long as PLHAs marry amongst themselves, that should not be a problem.
Since HIV/AIDS is a highly stigmatized disease; majority of the respondents expressed the need for compulsory HIV testing between couples prior to marriage so as to avoid a doom future as was put in by many respondents. This is because of the belief that HIV/AIDS is a transmissible and an incurable disease which when infected will invalid and shorten the life span of the person concern. As one respondent said "once you get infected with HIV/AIDS, it is for keeps and you cannot run away from it rather you'll die with and by it". The stigmatization towards PLHAs is also revealed in that the general populations tend to have negatively preconceived notion about anyone infected with HIV/AIDS even if that person happens to be morally well-behaved.
Despite having negative perceptions about HIV/AIDS, when it comes to collective responsibility of the people towards PLHAs, majority of the respondents from both the areas expressed their sense of taking responsibility to care for PLHAs. However, the validity of this statement may not withstand social stigma as discrepancy between knowledge and practice has been discussed in previous statements. One of the reasons for owning such responsibility could be due to the humane side of man underscoring other negative feelings. The humane nature is highlighted further when the respondents said PLHAs should seek medical help at the earliest with a caution that all patients seeking surgery should be thoroughly tested for HIV/AIDS.
Premarital or extra-marital sex was not favored by many and more so in Imphal. Respondents in Imphal were slightly more reserved about sex than those from Chandel. In Imphal area, premarital and extramarital sex was seen more as social taboo while in Chandel it was more to do with the violation of biblical moral principle besides it being considered socio-cultural taboo as well. Few respondents mostly male, had neutral view on this, saying it was a matter of personal choice. It may also be mentioned here that generally people have reservations about discussing sex and sexuality in the open or in public because of the cultural upbringing whereby discussion of sex or sexuality is confined to or between married couple. A study by Goyal RC,et al 1994; Hartwig KA et.al, 2006 also reported similar findings on the reservation of openly discussing sex and sexuality.
Another interesting feature noted in this study was the initiation of sex for both male and female and the age at marriage. The overall mean age for the initiation of sex was 23.37±5.73 years. The overall mean age at marriage observed in the study was 23.04±5.22 and 28.65±4.52 years for both female and male respectively. The mean age at marriage in the study site was found to be above the legal age at marriage in India which is eighteen for female and twenty one for male. Here, education is seen to play an important role in delaying initiation of sex and age at marriage. A significant difference was observed in the age at marriage among female respondents from Chandel where the initiation of marriage begins as early as the age of fourteen (mean 20.42±4.1 years). This may be because female respondents mostly middle age in Chandel had little or no education at all. Besides education, cultural upbringing is also seen to have indirect impact on the age at marriage. The patriarchal structure of the society in both the study area is such that male members of the family are given preferences over female in any matters as it is through male line that generation of the family is continued.
Analysis of sexual behavior and practices also revealed that most of the respondents who do not consider themselves at being risk to HIV infection were in fact, practicing risky sexual behavior. Quite a number of respondents admitted practicing unsafe sex within and outside marriage. Though, sexual relation outside marriage is a socio-cultural taboo, yet it is not strictly upheld. Theoretically and culturally, majority of respondents were not in favor of sexual relation outside of marriage. However, during the study, it was found that such cultural understanding of sexual taboo did not really prevent some of them from indulging into it as was admitted by few respondents. The sexual behaviors/practices of male respondents were at higher risk for HIV infection than female respondents. This could be due to the prevalence of gender disparity in the social set up whereby society is more tolerant towards male promiscuity and immoral behavior than that of female. As such, female respondents from both the area were more reserved for the obvious fear of shame and incurring stigma. Therefore, none of the female respondents from Imphal admitted to have indulged in extra-marital affair while in Chandel, a negligible number of them reluctantly admitted indulging to it after initial evasion. Male respondents were comparatively found to be more frank and open about their indulgence in sexual relationships in and outside of marriage.
For those respondents who admitted to have engaged in 'tabooed' sexual relation, very less number of them admitted using condom consistently. Here, it may be noted that despite many of them accepting condom as a good option for safer sex, it is not being used consistently on the ground that condoms do not give full sexual satisfaction. The reason given to explain was that culturally; condom is stigmatized and is considered meant for sexually promiscuous people. Condoms are also believed to have adverse effect on women health and as such use of it, in most instances is preferably ruled out. In case of married couple, use of condom is considered not a necessity as the socio-cultural meaning of marriage is for the purpose of procreation and sexual fulfillment. Therefore, use of condom is simply taken as obstructing the very purpose of marriage. This is one of the reasons why some respondents who admitted of resorting to family planning preferred contraceptive pills. A study carried out in rural Lebanon by Kulczycki A, 2004, reported similar findings on the use of condom and the stigma attached to it.
It was also observed that some of the participants had undergone blood transfusion for either medical or surgical reasons, increasing the chances of HIV transmission. Many respondents were willing to accept PLHAs and even take responsibility for them but this is contradicted by the admission that they would not necessarily want PLHAs to be neither a resource person for any socio-religious event nor a religious figure in the society because according to the local people, a religious figure should be someone whose moral character does not transgress the normative moral laws of the society whereas in the case of PLHAs, their moral character is always questioned and as such cannot hold a religious position unless the person in question sincerely repents and lead a repentant, reform life.
Conclusion: From the analysis of the present study, it can be concluded that false socio-cultural notion of HIV/AIDS as a morally degrading disease is taking precedence over medical facts, leading subsequently to stigmatization and discrimination of PLHAs in the society. The study revealed that although majority of the respondents have high knowledge about the four primary mode of HIV/AIDS transmission, such knowledge are often times marred by socio-cultural misconceptions. It can also be inferred that behavior of the people are greatly influenced by cultural beliefs rather than by medical facts. Therefore, inconsistency is observed between high knowledge about the four primary routes by which HIV/AIDS is transmitted on one hand and high negative attitude towards PLHAs on the other hand. Local gossips which are mostly diluted with cultural misconceptions act as the fastest medium for the propagation of news on HIV/AIDS. Church elders/leaders especially in chandel have strong influenced on people's attitude towards PLHAs. This could be one of the reasons why despite efforts from NGOs to educate people on HIV/AIDS, the disease is fast spreading in the study area.
Therefore, proper sensitization of the people about HIV/AIDS along the socio-cultural line is the need of the hour in order to remove several misconceptions which are responsible for the marginalization of PLHAs. It is also suggested that religious leaders should be given special attention when considering of imparting proper education on HIV/AIDS in order that their influence on people may dispel cultural misconceptions leading to stigmatization of HIV/AIDS. The study also may conclude that stigmatization of the disease was one of the root causes for the spread of HIV/AIDS in the area as fear of social stigma and shame have discouraged many PLHAs to come out in the open about their status thereby endangering others in the process as such PLHAs continued to lead a normal sexual life.
This research is financed by UGC under the scheme of Rajiv Gandhi National Fellowship for ST/SC students to pursue M.Phil/Ph.D....................
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