The action of the Delhi high court to repeal the decades-old section 377 legislation is a landmark legal decision to strike down a punitive barrier and impediment to effective public health action. We salute the lawyers and the plaintiffs who brought the case and say “job well done”.
The baton now passes over to the public health community who have to ask themselves very clearly what can be done—and done quickly —that was not possible before, because it was outside the law. After the euphoria, what next?
As the head of UNAIDS in India (the UN agency specially set up to support governments and communities address the HIV epidemic, and to coordinate joint UN workings), I see several very different areas where we can now act, where before this was not possible by government, and very difficult for non-governmental organizations. The vision is based on a wide, non-judgemental perspective of what was illegal and is now permissible; and is happening every day.
Illustration: Jayachandran / Mint
Of course, action must start with reducing the risks of HIV transmission through “gay sex” that is practised consensually between homosexual or bisexual men, and by transgendered people. We all start from here. Knowledge is power; and this must be imparted with understandable and relevant messages that connect with very disparate communities in ways that promote effective behavioural change and that can be acted upon. Condoms, of course—but something more is usually needed. Immediately here we run into a roadblock: rear-end sex needs a bit of help, water-based lubricants to be specific, and this is only available in large costly tubes and bottles.
Products must be available to support risk reduction. As the marketeers of Omo know very well, many commodities are often best sold in small single-use sachets. What is true for washing powder is the same for “lubes”—and we hope very soon to pilot the manufacture and distribution of such single-use products, and field test their acceptability and pricing. The idea is to co-pack a small sachet of lubricant with two ordinary condoms.
If we get the product right, then think who else may want to use it, or more specifically have a use for it. Here we get into rather unexpected “markets” or clients, which for most may at least initially be surprising and even shocking: prisoners and female sex workers.
There are at least 350,000 male prisoners at any one time in India —on remand or sentenced. Shut away from women, but with no reduction in libido, there is (obviously) much sex between men in prisons—critically practised by men who would never see themselves as gay or who would listen to messages targeted at gay men. Such situational sex between men remains just as important a risk factor for HIV transmission as gay sex between men who are willing to label themselves as homosexual. To cover risky behaviours with new products in prison is not easy. We need to get the policy environment supportive of such bold preventative approaches. With this, we believe that several jails would we willing to pilot the use of lubes and condoms co-packaged together. Few countries have gone so far, so India could again be a groundbreaker; just as it is leading the judicial way for repeal of 377 in other former British colonies.
There are many more female sex workers who part-time or regularly sell sex to paying customers. This is another market for the product. Perhaps rather startlingly (although not for those of us familiar with sexual practices) rear-end sex is frequently requested and thus supplied—with risks for both sex worker and client. It is notoriously difficult to get reliable information on sodomy because it is considered deviant or perverse, and was, of course, previously illegal; where data exist it seems that the levels are similar to that found elsewhere suggesting that from 5-15% of female sex workers have this additional risk factor on top of their existing vulnerabilities. Quite how much this contributes to the HIV epidemic remains to be seen—and we hope to support more research in this very important area. Whatever the figure, it is a risk that could be minimized with knowledge, information and products delivered through the impressive network of clinics targeting interventions for sex workers in the national AIDS control programme.
Finally, the most challenging: we need to think very hard and carefully about what we individually tell our children; and what information we expect to be imparted to our children by educators and teachers. Part of this comes down to what we are comfortable with, some is what we believe is right or wrong. Whatever our individual beliefs, sex between men is now legal (and has always happened). The excuse to omit sex between men, or discussion of rear-end sex because it is illegal, is now worthless. I would argue we have a duty of care to our children to give them appropriate knowledge about the sexual world they will soon enter or are already entering—to equip them with the skills to safely love and be loved. A major new health-promotion window that has the potential to save many young children’s youth and health has opened—and need very carefully and delicately discuss how to realize the opportunity without offence and with results.
The public health community has many opportunities now and must not drop the baton. If we do, then in reality little has been achieved by repealing 377. The work starts now.
Charles Gilks is country coordinator, UNAIDS, India. Comment at firstname.lastname@example.org