Study on knowledge and attitude

among female migrants about HIV

and STI in the Karur district
at Center for Rural Development Trust –
Karur

by

Vijay Anand.L MPH

Centre for Rural Development Trust – Karur
ACRONYMS

AN Mothers Ante-Natal Mothers

ANC Ante-Natal Check-up
ANM Auxiliary Nurse and Midwifery
ART Anti-Retroviral Treatment
BCC Behavior Change Communication
CBO Community Based organization
CCC Community Care Centre
CSO Civil Society organization
DAPCU District AIDS Prevention and Control Unit
FSW Female Sex Workers
HIV Human Immuno Deficiency Virus
HRG High Risk Groups
HSS HIV Sentinel Surveillance
ICDS Integrated Child Development Scheme
ICTC Integrated Counseling and Testing Centers
IDU Injecting Drug Users
IEC Information, Education and Communication
IPC Inter Personal Communication
MSM Men Having Sex With Men
NACO National AIDS Control organization
NGO Non-Government Organization
PHC Primary Health Centre
PLHIV People Living with HIV
PPTCT Prevention of Parent To Child Transmission
RSBY Rashtriya Swasthya Bima Yojana
SACS State AIDS Control Societies

2
TABLE OF CONTENTS
Vijay Anand.L MPH.....................................................................................................1

ACRONYMS ................................................................................................................2

LIST OF FIGURES AND TABLES ...................................................................................4

Migration and sex risk ............................................................................................... 6

LITERATURE REVIEW...................................................................................................7

METHODOLOGY........................................................................................................10

DATA ANALYSIS .......................................................................................................10

RESULTS...................................................................................................................11

RECOMMENDATION..................................................................................................13

Limitations................................................................................................................14

References................................................................................................................22

3
LIST OF FIGURES AND TABLES

Table 1: Age group

Table 2: Place of birth

Table 3: Language

Table 5: Education

Table 6: Migration status

Table 7: Marital status

Table 8: Job status

Table 9: Work specialty

Table 10: Income category

Table 11: Heard about HIV and AIDS

Table 12: Which means the respondent heard about HIV and AIDS?

Table 13: Who can be tested for HIV?

Table 14: Mother to Child transmission

Table 15: Condoms can prevent HIV transmission

Table 16: Attitude towards STI, HIV and sexual habits

4
BACKGROUND

India has a population of one billion, around half of whom are adults in the
sexually active age group. The first AIDS case in India was detected in 1986
and since thenHIV infection has been reported in all states and union
territories. The spread of HIV in India has been uneven. Although much of
India has a low rate of infection, certain places have been more affected
than others. HIV epidemics are more severe in the southern half of the
country and the far north-east. The highest HIV prevalence rates are found in
Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka in the south; and
Manipur and Nagaland in the north-east. In the southern states, HIV is
primarily spread through hetersoexual contact. Infections in the north-east
are mainly found amongst injecting drug users (IDUs) and sex workers. It is
estimated that 2.31 million People are living with HIV and AIDS of these 39%
females and 3.5% are children and 0.34% constitute the adults. (National
household survey, 2005 – 06)

HIV/AIDS has emerged as the single most formidable challenge to public

health, human rights and development in the new millennium. UNAIDS
estimates 38 million people across the world are living with HIV/AIDS in
2007.

Human migration, people changing their place of residence permanently or

temporarily, is a complex phenomenon with many different faces. Across the
world, more and more people are on the move – from villages to towns, from
towns to cities and across national borders. India, home to the second
highest number of HIV
positive people in the world,
is characterized by
widespread and fluid
migration and mobility. More
than 2 million Indians do not
live in the place of their birth,
and additional hundreds of
thousands of uncounted
Indians live mobile and
uncharted lives. While mobility in other parts of the world is inhibited by
national boundaries, there are few land masses the size of India with such a
good transport infrastructure as this country. Male migrants in India often
migrate alone, leaving their wives and families behind, usually to work in the
5
informal sector, which is unorganized, unprotected and unregulated and
accounts for 93 per cent of the total workforce in India. This amounts to 392
million people or almost 40 per cent of the population of the country.

Important source of HIV-related vulnerability is mobility and migration,

mobility being defined as a change of location and migration being defined
as a change of residence. Migrant populations have higher levels of HIV
infection than those who do not move – independent of the HIV prevalence
at the site of departure or the site of destination. An attempt to understand
the vulnerability of mobile populations to HIV must begin with an
understanding of human mobility.

Migrants fall under NACO’s definition of “risk groups”, i.e. those warranting
targeted interventions. Along with truckers, they are bridge populations
requiring a specific HIV response. Migrants have two major routes of
mobility: from rural to urban areas and between rural areas. The definition of
migrants varies widely, hence this document defines migrants and provide
guidelines for working with them from the perspective of HIV prevention
interventions under NACP III.

Classification of migrants from an HIV vulnerability perspective is based on

the following key criteria:

• Pattern, degree and duration of mobility and migration

• Age
• Whether moving singly or with family
• Route of migration
• Destination of migration

The term migrant worker has different official meanings and connotations
in different parts of the world. As definition are broad, including any people
working outside of their home country. The term can also be used to
describe someone who migrates within a country, possibly their own, in
order to pursue work such as seasonal work.

Migration and sex risk

Development projects as well as poverty in developing countries attract
workers from rural areas, resulting in the concentration of large number of
labor migrants in urban areas (Bloom and Carliner, 1988; Cohen, 1992; and
Godwin, 1997). Most migrant laborers live away from their families, and
6
hence, may search for companionship, and sexual intimacy. Further, there
are cultural beliefs linked to sexuality, sexual performance and masculine
identity, which support the search for female partners (Verma, Khaitan &
Singh 1998). Blue films and other forms of pornography provide sexual
fantasies that are played out with readily accessible commercial sex workers
who are reported to be willing to respond to men’s requests for specific
behaviors (Raju and Leonard 2000; Sachdev 1997). Labour migrants may be
exposed to various other environmental risk factors, such as the availability
of recreational outlets like beer bars, discos, video parlors, social mixing of
people from different areas, the very real possibility of unsafe sex due to
drunkenness and drug use, minimal use of condoms, and increasing use of
injectable drugs accompanied by exchange of needles and syringes. The
potential role of migration in spreading HIV/AIDS is further heightened as a
result of frequent visit of migrants to their native places and return
migration, as well as a high propensity of continued migration especially
among transient construction workers (UNDP, 2000). All of these
circumstances, along with disposable wages may result in differences in
individual exposure to opportunities for alcohol and drug use and
unprotected sex with persons of unknown sexual history

LITERATURE REVIEW

Many studies had proved that there has been a steady increase of female
migrants over the last five decades. According to the UNPD data, the stock of
female migrants has actually grown faster than the stock of male migrants in
the most important receiving countries, industrialized as well as developing.
According to the ILO, women now constitute more than half of the migration
population worldwide and between 70 and 80 per cent of the migration
population in the country. This migratory movement, either coerced or
consented, is characterized by the increase in the percentage of women who
migrate. The world-wide trend of feminisation of poverty strongly affects the
so-called "feminisation of migration". It must be recognized that migrant
women, as a result of the lack of opportunities in their own countries, have
come to integrate into the labour market: to offer something and to receive
something in return. For this reason, this migratory movement is
characterized as labour migration of women.

Recent study conducted by NACO in three popular migration corridors in

Mumbai threw up shocking findings. The highest burden of HIV was found to

7
be among migrants, after the high risk groups like sex workers and men who
have sex with men.

The studies have shown that two to four times more number of informal
workers have non-regular partners or visit sex workers with only 25% using
condoms compared to 42% by others. Around 5% male migrants and 13%
female migrants reported sexually transmitted infections, nearly double the
national average. What's worse, the total number of migrants continues to
increase in India. According to the 2001 census, 30.1% of the population in
2001 was considered to have migrated (314 million of the total 1,028 million
people), which shows a considerable increase from 27.4% in 1991.

NACO, which has now asked the Global Fund for AIDS, TB and Malaria to
grant $50 million for the targeted intervention on migrants, says, "In India,
there is increasing evidence and growing recognition of the importance of
migration in the spread of HIV infection. NACO has, therefore, revised its
migrant strategy and decided to identify high outmigration locations at
source, transit and destination, providing them information about HIV/AIDS,
sexually transmitted infections and safe migration."
Why to target high risk migrant women

As discussed above, female migrants are largely at risk due to the possibility
of engaging in transactional sex, either through coercion or to supplement
their income. To that extent, high-risk migrant women are entitled to receive
the same package of services as female sex workers. The needs assessment
conducted at the start of the project should share information on known
high-risk female migrants with the closest NGO implementing TIs for female
sex workers so the NGO can plan to include them in services.

Women in general have a high degree of sexual health vulnerability for the
following reasons:
• Because of the high-risk behaviour of their husbands and sexual
partners
• Many wives of migrant men are illiterate, and because they remain
largely within the confines of their homes they are mostly uninformed
about STIs and HIV/AIDS.
• Caring for their health is generally not a priority for them or for their
male family members.

8
 • They are often unaware of condoms, and even if they are aware, it is
generally the decision of their husband/male partner whether to use
them or not during sex.
• In the absence of their husbands, they are dependent on the men in
the households or on neighbors for help in managing household affairs.
This may lead to sexual relationships with other family members or
men in the community.
• Women are not supposed to go out alone and hence are unable to seek
health services. The success of migrant programs at destination will be
greatly influenced by whether or not migrant spouses/sexual partners
are educated about HIV risks and related issues.

In the source state, based on the mapping data from the destination
states (shared between the source and destination SACS), the SACS should
take responsibility to cover migrant wives/sexual partners, through link
workers and as part of broader SACS-supported HIV/AIDS initiatives in the
major pockets of high outward migration.
At the destinations, women migrants who are part of transactional sex
networks and at risk of HIV are envisaged to be part of the female sex
worker intervention.

Specific objectives of the study include:

1. To understand the knowledge and attitude of female migrants about

HIV and STI
2. To find out and also to understand the socio-economic and
demographic living and working conditions specific to migration in high
prevalent district.
3. To supplement the estimation of migrants at district level for policy
changes.

Migration is a highly complex

human behaviour, as old as
human existence itself. There are
many typologies (and
combinations of typologies),
some of which are described
below:

9
 • Rural vs Urban - Rural to Urban, Urban to Urban, Rural to Rural

• Persons – Single male, Single female, Couples, Couples with children

(sometimes some), whole family

• Location – Inter-state, intra-state, inter-district, intra-district,

international Distance – Long distance, Short distance Length of stay –
Temporary (up to 3 months), semi-permanent (up to 6 months in a
year, returning to villages during rainy season) and permanent (only
returning for key holidays)

• In and out – From the point of view of a geographical location, In-

migration or Out migration or both Others – Step migration (transit
itself become a place for short migration), relay migration (one family
member living in the destination and others taking turns to relieve,
reverse migration (Urban-Rural)

METHODOLOGY
A descriptive study using qualitative and quantitative method of data
collection was followed among the female migrants at high prevalent
location of migrant site. Quantitative data collection included interviewing 50
respondents randomly across the population. With a support of baseline
data provided by the NGO, the team developed a closed ended
questionnaire. This closed ended questionnaire was piloted with a female
client for the feasibility in-terms of language and understanding the meaning
of questions. After then the change were edited including the suggestions
given and it was finally administered among the female migrants at the
Karur to quantify their knowledge and attitude regarding HIV/AIDS and to
determine their sexual practice. After the questionnaire was filled up, doubts,
myths and misconceptions regarding the HIV and STI were clarified after the
interview.

DATA ANALYSIS
The data collected were subjected to Microsoft Excel for easy data entry
process and for the basic analysis with computed with the SPSS Ver.11.5.
Following data cleaning, variables were recoded to adhere to the
aforementioned definitions. Descriptive statistical analyses were used to
compute frequency distributions of the sample characteristics; migratory,

10
living, and working conditions, knowledge and attitude about STI and HIV.
For univariate analysis, frequencies and medians of all variables and
measures were produced. Bivariate associations between the individual
socio-demographic variables were also found using basic statistical
procedures. The transcribed information were analyzed descriptively
(qualitatively) and used to corroborate results of quantitative analysis where
and when necessary.

Attitudes toward STI and HIV by female migrant were categorized as agree,
disagree, and Don’t know. Our questionnaire included 16 statements that
respondents either agreed or disagreed with. A composite score was created
based on responses.

RESULTS
Completed questionnaires
were obtained for a total of
50 respondents and it was
made as final sample
inclusive and additions and
deletions. Mean age of
female migrants was 24 years
and it was slightly varying of
25.5 years (Table -1) and the
minimum and Maximum ages
were 17 and 49 years and
92% of respondents were
migrated from West. Bengal and used to speak Bengali (94%), Tamil (16%)
and Hindi, Oriya, English and Sanskrit were locally spoken respectively. In-
terms of education 36% of the respondents were illiterates and 42%
constitutes middle schooling at-least in the source or destination locations.

In case of migration status,

for the past one year 12% of
the respondents were
migrated from one place i.e.
may be from the source
location to the destination in
regards to the job or any
emergency basic need. Most
of the respondents go for
work i.e. 54% to run their
11
family and other acting as a home maker i.e. housewife and 6% of
respondents said that they do work at their home or even some self-
employment. Women at the local location go for Mosquito Net Company as
helpers, damage menders and other support job. 42% women said that they
had been going for a mosquito net company for part time or a full time work
and 14% for textiles and 2% for other nearby companies.

In terms of income, the mean income of respondent were Rs.2675.00

Median- 2400, Mode-2000, Standard deviation 839.79 per month and i.e.
50% the respondents fall in low income and 42% in high income category.
The mean age of first sexual intercourse was 16.08 years.

In terms of knowledge 70% of the respondents had heard about the HIV and
AIDS through people who constitutes the major one (28), and next comes the
media (15) and family
member infected by HIV
(3).

35% respondent believe

that High risk group (FSW,
MSM and IDU’s) are the
special groups needed to
get tested first and then
comes all the general
people (34%). 78% of
them answered that
mother to child
transmission is true and
condom also prevents
from HIV as 34% and most of the answers pertaining to condom use and
condom related questions were unknown or non-known by the respondents.

Attitude regarding STI and HIV knowledge was very poor, as most of them
have many myths and doubts in the STI and HIV knowledge. 45% percent of
the respondents said that HIV spreads due to immoral behavior, and stigma
pertaining to PLHIV such as 44% responded that patients with HIV should be
kept at distance from the other patients, and still many responded and
believe that 24% of them are poor and uneducated fell under category that
are getting HIV risk. 14% responded that STI is HIV and 8% of the respondent
said that HIV positive women shouldn’t get pregnant.

12
RECOMMENDATION
Migration is associated with greater risks for poor health in general
Disconnected from social norms and supports, alienated from the larger
urban landscape in which they reside, prone to life and job dissatisfaction,
the propensity for adverse health risk behaviors is great2

The role of family in inculcating the basic knowledge about sex and HIV is
minimal and it has been found that the respondents barely or never
discussed these things with their parents or relatives. Most of the respondent
seems to have acquired knowledge about sex and HIV from their social
networks at their native place before coming to Mumbai. One of the
respondents revealed that;

“When I was 14 or
15 years old, learned
about sex from some
senior boys. They
used to make some
gestures by their
hands… they
explained me in
detail and that was
the first time
somebody taught me
about
masturbation...”
said by an migrant who is spouse of an respondent whom was interviewed.

From findings, we suggest that young rural-to-urban migrant women are

more susceptible of HIV risk as they are not aware of even the basics of HIV
transmission mode and non –transmission modes and also about the
treatment and diagnosis of STI. The unique social situation and their quality
of life of these young migrant women may facilitate increased HIV and STI
risk through sexual route.

The separation that migrant women experience from their communities and families in the
destination may make them more prone to peer or urban influences, ultimately may also
lead them to engage in high risk activities.

13
Limitations
Limitations of this study are related to a small sample size and convenience
sampling in a single district, and the difficulties to inherent in sampling
migrant populations. The conventional risk factors found to be significant in
this study may not be generalizable, given the small sample size, differential
sampling, and lack of comparability with national surveys. Major limitation
was the language as they the most of them are from northern states and not
locals, and also the convenient time was also not available for administering
the questionnaire.

Picture showing the researchers interviewing with the migrant women at Tholilpettai
– a migrant site at their home and it was taken with the consent

14
Figures and graph showing the knowledge and attitude of STI, HIV and other sexual
habits among the female migrants

Attitude towards STI, HIV and sexual habits

Sex is sacred and should be performed by married people 50

Patients should be tested for HIV before surgery 47

HIV/AIDS spreads due to immoral behavior 45

When a person tests positive, doctor should inform the patients… 44

Patients with HIV should be kept at a distance from other… 36

Sex workers are the only women who have to worry about… 36

Should people with HIV continue living in their family 35

If you found out that you have HIV, would you willing to tell… 24

Most of the people who are HIV positive are poor and… 24

If you knew that a shopkeeper had virus, would you buy food… 20

Clothes used by HIV patients should be disposed or burnt 20

Would you be willing to share a meal with a person with HIV 16

STI will lead to HIV 14

Is it acceptable for person with HIV continue to have sex? 11

HIV positive women should not get pregnant 8

Will keep STI status a secret from sexual partner 4

0 10 20 30 40 50 60

15
TABLES
Table 1: Age group

AGE
GROUP N %
15-19 8 16
20-24 19 38
25-29 10 20
30-39 10 20
40+ 3 6

Mean – 24
Minimum - 17
Maximum - 49

Table 2: Place of birth

PLACE OF
BIRTH N %
West 46 92
Bengal
Tamil Nadu 2 4
Orissa 2 4

Table 3: Language

LANGUAGE %
Bengali 94
Tamil 16
Hindi 12
Oriya 4

16
Table 5: Education

EDUCATION
N %
Illiterate 18 36
Primary 4 8
Middle 21 42
High 6 12
Higher 1 2
secondary

Table 6: Migration status

MIGRATION STATUS N %
Migrated within last 6 12
one year

Table 7: Marital status

MARITAL STATUS N %
Married 46 92
Unmarried 3 6
Widowed 1 2

Table 8: Job status

JOB STATUS
N %
Housewife 20 40
17
Going for work 27 54
Self employed 3 6
Table 9: Work specialty

WORK SPECIALTY %
Mosquito-net company 42
Textile 14
Other 2

Table 10: Income category

INCOME N %
No income 21 42
Low income 25 50
High income 4 8

Mean- 2675.00,
Median- 2400,
Mode-2000,
Standard deviation- 839.79

Table 11: Heard about HIV and AIDS

Heard about HIV and AIDS? N %

Yes 35 70
No 5 10
Don’t Know 10 20

Table 12: Which means the respondent heard about HIV and AIDS?

18
Which means heard about
HIV N
People 28
Media 15
Having family member 3
infected by HIV
NGO 2
School 2
Nurse 1

Table 13: Who can be tested for HIV?

Who can be tested for HIV? N

HRG 35
Everyone 34
Truckers 32
People who have Extramarital 31
relationship
Patient look weak 30
Migrants 29
Don’t know 7

Table 14: Mother to Child transmission

Mother to Child transmission N %

Yes 39 78
No 10 20
Don’t know 1 2

19
Table 15: Condoms can prevent HIV transmission

Condoms can prevent HIV N %

transmission
Yes 17 34
No 13 26
Don’t know 20 40

Table 16: Attitude towards STI, HIV and sexual habits

Attitude towards STI, HIV and sexual habits ( Agreed N

responses)

Will keep STI status a secret from sexual partner 4

HIV positive women should not get pregnant 8

Is it acceptable for person with HIV continue to have sex? 11

STI will lead to HIV 14

Would you be willing to share a meal with a person with 16

HIV
Clothes used by HIV patients should be disposed or burnt 20

If you knew that a shopkeeper had virus, would you buy 20

food from them?
Most of the people who are HIV positive are poor and 24
uneducated
If you found out that you have HIV, would you willing to 24
tell your colleagues
Should people with HIV continue living in their family 35

Sex workers are the only women who have to worry about 36
getting HIV
Patients with HIV should be kept at a distance from other 36
patients
When a person tests positive, doctor should inform the 44
patients partner
HIV/AIDS spreads due to immoral behavior 45

Patients should be tested for HIV before surgery 47

20
Sex is sacred and should be performed by married people 50

21
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