Every morning, Neharika Ravalkar takes a pill that shields her from joining the millions of Indians living with HIV. As a trans woman, Ravalkar falls into the high-risk category for HIV, but she is among the fortunate few who have access to pre-exposure prophylaxis (PrEP) medication. In India, the cost, lack of awareness, and stigma surrounding HIV hamper its availability, leaving many vulnerable populations without adequate protection.
PrEP, a highly effective daily pill against HIV, remains below global targets and is primarily accessible in a limited number of countries, according to the U.N. agency for HIV and AIDS. Among the key populations at risk are gay men, sex workers, intravenous drug users, and trans individuals.
India, home to the world’s second-largest HIV caseload, recorded over 2.3 million people living with the virus in 2020, as reported by the National AIDS Control Organisation (NACO), a government body. While the number of new cases has declined since its peak in 1996, tens of thousands of people continue to contract the virus each year, according to UNAIDS data.
Unfortunately, access to PrEP in India remains inconsistent and is not provided through government-funded healthcare programs. Although several brands are available for sale at prices ranging from 1,500 to 2,200 rupees ($18 to $27) per month, the cost is prohibitive for many individuals at risk. With the average monthly wage for a salaried job being around 18,500 rupees in 2022, and approximately one in ten people living in extreme poverty, affordability is a significant barrier.
Many individuals who can access the medication do so through non-profit organizations. However, these charities are predominantly based in urban centers, often overlooking vulnerable populations in smaller towns and rural areas. Medical student and LGBTQ+ activist Vignesh Dhananjayan pointed out that local professors and doctors lack knowledge about PrEP and rarely prescribe it.
In order to address this pressing issue, Dhananjayan stressed the urgent need for the government to subsidize the cost of PrEP nationwide through legislation. Furthermore, he emphasized the importance of providing free access to PrEP in government centers and creating a centralized database of dispensaries, clinics, and hospitals where the medication can be obtained.
Efforts to increase PrEP access in India face additional challenges due to prevailing stigma and stereotypes associated with the medication, often linking it to promiscuity. Delhi-based communications professional Abhishek Desai encountered difficulties while attempting to raise awareness about PrEP within the LGBTQ+ community. Desai found it hard to find individuals willing to discuss the topic openly and faced discrimination regarding his own PrEP usage.
For sex workers, PrEP can be their only means of protection, given the challenges they face in negotiating condom use. Widespread discrimination against hijras, including crossdressers, trans women, and intersex individuals, forces many into begging or sex work as a means of survival. However, these marginalized groups often exhibit reluctance to embrace PrEP due to a lack of hope for a better life.