Introduction

Pandemic spread of AIDS has constituted the greatest challenge to public health in modern times. More than 25 million people have died of AIDS worldwide, and another 33 million are currently living with HIV/AIDS.¹ Young people, aged 15–24 account for 45% of new HIV infections.^1,2 An estimated 8 in 10 people infected with HIV do not know it.³ Trucker’s role in fueling AIDS pandemic especially in context to India is highly crucial. India has one of the largest road networks in the world with an estimated 5–6 million truckers, nearly half work on long-distance routes across the country.⁴ Practically truckers take India on fast lane to HIV/AIDS. Richard Feachem, Executive Director of the Global Fund to Fight Aids, firmly said, “India is on the cusp of a major Aids crisis. India is the ticking time-bomb of the global Aids pandemic and the number of infected lorry drivers means the disease will continue to spread to rural areas and destroy entire communities.” It's not hard to figure out that India needs to recognize and admit to the scale and complexity of a crisis that could yet wreck its golden prospects.⁵

Life of truckers is very harsh, hard and hazardous. There is hardly any source of entertainment. It is day-in-day-out driving. When they stop, they drink, dine and have sex with women. Then, they transfer HIV from urban to rural settings.⁶ Thus, truckers constitute a very high-risk group for acquiring as well as spreading of HIV/AIDS and STIs locally and over distant areas. Truckers stay away from home for long duration. So, there is physiological need for sex. They also have working money with them every time. Commercial sex workers (CSWs) are also easily and cheaply available from road side settlements/hotels etc. and their own trucks provide them a needed sheltered privacy. This combination of need and facility makes them more vulnerable to indulge in promiscuity primarily with poor, low paid and unhygienic commercial sex workers. Thus, they contract HIV infection and transmit it to their wives or local partners. Further, the situation becomes worse for general population when such wives/partners also indulge in promiscuity when their husbands/partners are away from home for long.⁷

Various studies in India had indicated that over 80% truckers indulge in promiscuity during their trips and condom use was also reported very low and inconsistent and most of them visited commercial sex workers.^8,9,10 But, for the present study area, it was primarily a mute assumption as no such study was carried out in this area earlier. Hence, the present study was undertaken.

Objectives

To assess the awareness level about HIV/AIDS among long distance truckers

To know the prevalence of high risk behavior.

Material and Methods

The study was carried out among long distance truckers plying on one of the major national highway in North India passing through Haryana. The calculated sample size was 216, at 95% confidence level with 10% allowable error (conservatively assuming promiscuity prevalence of 65%). Inclusion criteria were age between 18 to 55 years and more than a year in the occupation. Major halt points of trucker were identified and those halting at these points primarily for having food and rest were interviewed after taking informed consent and building proper rapport. Help from road side hotel (dhaba) owners was also taken for motivating the truckers for participating in the study. The required information was recorded on a pre-tested semi-structured schedule. Collected data was analyzed using SPSS (version 16.0).

Results

I. General observations: A total of 261 truckers were contacted. 43 (16.5%) denied participating in the study. Of the remaining 218, who participated in the study; 168 (77.1%) were drivers, 38 (17.4%) co-drivers (helpers) and 12 (5.5%) owner-cum-drivers. Religion wise, 80.7% were Hindu, 10.1% Sikhs and 9.2% Muslims. 68.8% were from joint families and 31.2% from nuclear families. 61.5% truckers were married. Caste wise, majority truckers were Jats (19.3%), followed by Rajputs (13.7%), Yadavas (11.5%), Chamars (10.0%), Pandit (6.9%), Gujjar (3.7%), Saini (2.8), Ansari/Meo/Mugal (9.2%) and others (22.0%). More than half of truckers (56.8%) were less than 30 years of age, signifying that mostly young adults are in the occupation. Only 14.6% truckers were of 40 years and above age as shown in table 1. 184 (84.4%) truckers were literate but only 3.7% were above 10^th standard and no one was graduate or above. So, most of truckers were ordinary literate. The income of co-drivers/helpers was in the range of Rs. 1500-2000, that of drivers around Rs. 4000-6000 and owner-cum-driver around 15000-20000 per month in majority cases. Other relevant socio-economic variables were as shown in table 2.

Figure 1

Table 1: Age of truckers

Figure 2

Table 2: Socio-economic variables of truckers

II. Awareness about HIV/AIDS: Most of truckers (93.7%) had heard of HIV/AIDS and were aware of its spread through sexual route and only 11.9% among them were aware of other routes of transmission correctly. Misconceptions regarding transmission of HIV were also there in many truckers. Sources of information about HIV/AIDS were multiple. Peers played the major role, followed by wall writing/ hoarding, radio, TV, news papers etc. Role of health personnel (14%) and others also was very limited as shown in table 3. The lack of conceptual comprehensive awareness about transmission of HIV/AIDS, but for sexual route; can be very well correlated to their main source of information being wall writings/hoardings, TV etc. of which they had only glimpses and so, could not get any convincing through knowledge and the same was propagated among peers by themselves.

Figure 3

Table 3: Awareness about HIV/AIDS among truckers.

III. High risk behavior among truckers: 92.7% truckers were involved in extramarital or premarital sex and all were heterosexual, but some of them also had anal or/and oral sex as well. The average number of partners (ever) and in last 6 months was 22.6 and 3.6 respectively. Only 6.4% were penetrative/active MSM and no trucker confessed of acting as passive MSM. About one third truckers visited Commercial Sex Workers (CSWs) and about one forth had multiple partners. About three fifth used alcohols, one forth used drugs and 70.6% truckers, who visited to non-regular sexual partners did not use condom at all and 16% used inconsistently/irregularly as shown in table 4. Only four truckers revealed of having passive MSM as their non-regular sexual partners. The possibility of social response bias in revelation/confession of high risk behavior can’t be ruled out.

Figure 4

Table 4: High risk behavior among truckers

IV. Differentials of high risk behavior among truckers: Risk behavior of visiting to CSWs increased significantly with increasing duration in the occupation. Visits to CSWs increased with duration of occupation up to 10 years and then declined and the visits were the least in truckers with duration more than 20 years of occupation (table 5). Visits to CSWs also increased with monthly duration of stays outside home; but the association was not found statistically significant as shown in table 6.

Figure 5

Table 5: Association b/w duration in occupation and visit to CSW

Figure 6

Table 6: Association b/w monthly stays outside home and visit to CSWs

Figure 7

Table 7: Association b/w duration of occupation and No. of partners in last 6 months.

Figure 8

Table 8: Association b/w monthly stays outside home and No. of partners in last 6 months

The duration of occupation was highly significantly associated with the number of sexual partners in the last six months. The number of partners was more in first 10 years of occupation and then the number declined to one only as almost all truckers by ten years of occupation limited themselves to one partner only as shown in table 7. The average monthly stays outside home were also highly significantly associated with the number of sexual partners in the last six months as shown in table 8. The association of other factors e.g. literacy, caste, age family type etc. with high risk behavior was not found significant. This showed that trucker occupation alone or its co-variables were very dominant determinants to affect high risk behavior of truckers.

Discussion

Truckers at large were aware of HIV/AIDS and its transmission through sexual route, though conceptual and comprehensive knowledge about HIV/AIDS was lacking. The findings of the present study of 93.7% awareness about HIV/AIDS also corroborated with the findings of other recent highway studies;¹¹ although the findings of such studies in nineteen nineties were otherwise i.e. 94% truckers ignorant of HIV/AIDS.⁸ But, unfortunately there was not much change in the high risk behavior of unprotected sex as evidenced from the results of the present study and from that of various other studies as well.^12,13,14 What are the factors responsible for such a risky behavior? –It needs to be explored decisively. For this, at least three things, which play key role in this regard, need to be analyzed critically i.e. ‘life of trucker in totality’; ‘probable effects of HIV/AIDS program interventions on a trucker’ and ‘status of condom in Indian social context’.

‘Life of trucker in totality’: Driving for long, sitting on engine steering in hostile weathers or terribly hot summers on narrow and damaged roads, weaving around bicycles, rickshaws, bullock cart, autos, camels, dogs, herds of goats and cattle and flocks of chickens and what not; facing the fear of dacoits or harassment by corrupt officials and above all, ‘miles and weeks’ away from home are the hard realities of routine life of a lowly paid and low literate trucker. When the whole life is full of risks/dangers which the trucker has to take and bear for earning livelihood; then avoiding the risk of HIV/AIDS alone is meaningless for him. On being probed for reasons for putting life at risk by indulging in unsafe promiscuity; the majority truckers said, “If we have to think of risks in life, then we will have to leave our job first. It is much more hazardous than HIV/AIDS.” Further, they continued, “This risk entertains, relaxes and refreshes us for the moment: an oasis in the desert.” Hence, the elements of entertainment and safety have to be introduced in the life of truckers so that they start taking interest in it.

‘With regards to possible effects of program interventions’: It was evident from the study results that most truckers are not being benefitted from the institutions based program interventions due to paucity of time and not aware of facilities in unknown areas. While plying on highways, they just have the momentary glimpse of HIV/AIDS messages repeatedly without proper in-depth understanding and this leads to ‘message fatigue’. They also expressed the feelings of being stigmatized from this publicity propaganda. So, hardly any positive impact of such messages could be seen on truckers as the conceptual and comprehensive knowledge about HIV/AIDS was lacking among most truckers. Thus, the present program interventions are proving practically ineffective for the bridge populations of truckers.

Finally, about the ‘status of condom in Indian social context’: Condom has virtually failed to establish itself to be talked about without any hesitation in the Indian socio-cultural milieu where talking of sex is still a taboo. Ideally, condom ensures ‘safe intercourse’ and needs to be accepted socially as safety tool. But, unfortunately it could get this status and got identified with promiscuity only and its safety component is totally submerged. Mere possession of condom signifies mutual distrust between sexual partners specially the spouses. Apart from the hurdles associated with its timely procurement; difficulty in disposal and reported discomfort in use are its added problems. Hence, condom, the main weapon of HIV/AIDS Control Program is not able to anchor its roots in Indian socio-cultural milieu. Thus, most of the current efforts to contain transmission of HIV/AIDS are proving ineffective in case of truckers. Therefore, comprehensive interventions addressing the “truckers’ total life” are indispensable. These may include: Improving roads and working environment, making truckers’ lives meaningful, safe and worth living; program interventions emphasizing more on behavior change communication and initiating social interventions which facilitate status of a ‘safety tool’ rather than a ‘distrust symbol’ to condom.

Presently the ‘Memories of recent deaths’ and ‘Fear of Deaths’ due to AIDS are standing-in as deterrents for promiscuity or as compulsions for condom use among truckers; but ideally these are blemishes on the face of a civilized society. Rationality, not the fear, should govern the actions of members of a civilized society. Further, the effect of fear fades away fast without a lasting change in behavior. Therefore, fear can force the high risk behavior to be, at best, an intermittent only. Hence, program interventions have to go beyond inking the walls with slogans or providing lip services and likewise.

Conclusion/recommendations

In spite of increased awareness about HIV/AIDS, there was no discernible decline in high risk behavior among long distance truckers. Enhanced focus on behavior change communication could be an early effective intervention. For a long term impact, an additional holistic comprehensive approach addressing their occupational hazards and hardships is essentially required.