San Francisco Chronicle - July 6, 2004
Sabin Russell, srussell@sfchronicle.com.

Thirty-five-year-old Thennarasu is waiting for them as well, standing by an outdoor table with a satchel of AIDS prevention pamphlets, a box of condoms and a willingness to chat about trucks, diesel engines or sexually transmitted diseases.

"Do you think that only drivers are messing around?" asks one of the truckers, who had stepped out of a tank truck hauling drinking water to Madras.

Thennarasu is unfazed by the hostility.

"When they are asking questions," he explains enthusiastically, "I am sure they are getting the message."

Within minutes, another trucker and his young apprentice -- a companion known as a "cleaner" that accompanies almost every driver -- are edging toward his table, watching Thennarasu unwrap a condom from its foil packet.

He flips the latex deftly in his fingers, unrolls it and snaps it like a rubber band, showing off its strength. Then he rolls another one down a brown plastic penis model, demonstrating ease of use and proper technique.

As Thennarasu chats up the driver, the cleaner surreptitiously palms another foil packet, slipping it into the folds of his blue mundu, a traditional wrap that coils around the hips and hangs like a skirt. It's another small victory in Thennarasu's war against AIDS.

Six days a week, Thennarasu and fellow outreach workers from the Hope Foundation fan out to truck stops along a 37 -mile stretch of Highway 45, which runs from the coastal port of Madras to the center of Tamil Nadu, India's southernmost state. They are foot soldiers in the country's most ambitious and effective effort to curb the spread of HIV.

"We are now actually achieving a reduction in HIV transmission," said Dr. M. Senthamizhan, chief epidemiologist for the Tamil Nadu state AIDS control office. By focusing their efforts on the trucker-prostitute relationship -- a key factor in the spread of AIDS in Africa -- prevention experts hope to break the chain of HIV transmission where individual risk is highest and where the danger of spreading the disease across geographic regions is most acute.

Almost 10 percent of truckers tested in Tamil Nadu were HIV-positive in 1997. In 2003, the infection rate was 4 percent.

Among Tamil Nadu prostitutes, HIV infection rates have fallen to 9 percent, from 30 percent seven years ago.

Most significantly, the rate of HIV infection among pregnant women in the state -- the standard measure of how widespread the disease has become in the general population -- had fallen by one-third, from 1.1 percent in 2001 to 0.75 percent at latest count.

Public health officials from India's 34 other states regularly trek to Madras to learn how it's done. The trucker program in Tamil Nadu is vast and constant. Program managers meticulously document each step in the process -- mapping out truck stop sites and documenting each conversation with a trucker or a prostitute and each referral to a medical clinic to test for HIV or sexually transmitted diseases.

"Small interventions do not work," said Dr. Charles Bimal, director of the Madras-based AIDS Prevention and Control Project, which runs the trucker program. "It takes a lot of effort. You have to have resources."

The organization relies on a $15.5 million, five-year grant from USAID --

the American foreign aid program -- and the national government of India. It costs $400,000 a year to run the trucker intervention programs at 12 major Tamil Nadu sites.

Key to its success are professional counselors such as Thennarasu and a network of 9,000 "peer educators," who are truckers, restaurant owners, shopkeepers and prostitutes enlisted in the effort to educate their own communities about the danger of AIDS.

Most of the India's 5 million truckers live away from home for one week to three months at a time, hauling goods over the subcontinent's 5,000 miles of national highways. According to a survey by the AIDS Prevention and Control Project, typical truckers have three to five sexual partners each week on the road. Alcohol and drug use are high. Drivers and their cleaners spend a great deal of their time together on the road talking about women and sex, and about 10 percent also have sexual relationships with each other.

India's secret weapon against AIDS may well be the dedication of people such as Santhosh Kagoo, who chucked his career as an electronics marketer and moved to Madras with his wife and three children to set up an AIDS orphanage.

A cheerful little 9-year-old named Meena was one of the first children they took in. She was the daughter of an HIV-positive trucker and was placed at the orphanage by her mother, who was too sick to care for her. AIDS first killed her mother, then her younger sister. When she was 11 years old, Meena died of AIDS as well.

"Her story made me think of taking care of the truckers," Kagoo said. "Only by teaching HIV prevention to the truckers can we avoid their children suffering from AIDS."

So Kagoo and the Hope Foundation took on the management of this stretch of Highway 45, where 4,400 trucks by his count pass by daily. He identified 37 "halting points," where the drivers and their cleaners stop for refreshment, and hired experienced outreach workers such as Thennarasu to work at the four busiest sites.

There's a similar sense of dedication in Villupuram, 40 miles south of Madras, where the trucker intervention program was first honed into a model for other Tamil Nadu sites, and is now being duplicated throughout India.

In Villupuram, the AIDS prevention project puts equal emphasis on working with prostitutes, providing them with condoms, counseling and medical attention.

The years of attention have paid off, and the women of Villupuram's highways are now known for their insistence on condom use.

"We are able to protect ourselves," said a young prostitute, "Selvi," during a discussion at a roadside dhaba, a restaurant catering to truckers. Speaking in her native Tamil, she added, "The awareness of AIDS among the common people is not as high, and they are the ones getting sick. For sex workers, the fear is there. We insist on condoms. This is our profession."

At Hindustan Automobiles, an auto parts shop off Highway 45 in Villupuram, store owner Shajahan sells spark plugs, fan belts and oil filters, and throws in condom demonstrations, using the plastic penis, free of charge.

While truckers and mechanics wait for their parts or for their engines to be repaired in nearby garages, Shajahan also offers AIDS pamphlets and advice about sexually transmitted diseases. He has been doing it for six years.

"This is a social service," he said. "I want to save my friends and my community."

Benjamin Franklin, a senior consultant to the Villupuram program, said role models such as Shajahan had been crucial to its success. There has been an added benefit for Villupuram.

"Peer education," Franklin said, "has created new leaders in this community."

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About the series

World attention will focus on the threat AIDS poses to Asia next week when the 15th International AIDS Conference convenes in Bangkok -- and key to that, experts believe, is what happens next in India, the second most populous nation on Earth. Will India aggressively pursue AIDS prevention and treatment and keep the epidemic under control? Or, as many fear, will it become the next Africa?

Day 1: The subordinate status of women in India mirrors their second- class standing in Africa, and experts say that could lead to the epidemic affecting women in disproportionate numbers.

Day 2: In the red-light districts of Bombay, prostitutes are learning how to refuse clients who want sex without condoms.

Today: AIDS in Africa spread along the vast highway network, and to prevent that happening in India, counselors in Tamil Nadu fan out at truck stops to spread the word on safer sex.

Day 4: With AIDS spending amounting to just 11 cents per capita, luck plays a large role in determining which ailing Indians get the drugs they need.

Day 5: The decisions made by the new government just taking office in New Delhi will largely determine the future course of the AIDS epidemic in India.

Chronicle medical writer Sabin Russell visited India for five weeks in March and April under a fellowship from the Henry J. Kaiser Family Foundation in Menlo Park.

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