THERE IS ONE group in India which probably suffers more discrimination than any other minority in this vast sub-continent. They are effectively barred from most jobs. It is not that they fail the interview – they are turned away at the gate. They face the equivalent of the ‘no blacks’ notices displayed by some landladies in Britain in the 1950s. On public transport, passengers move to another seat if one happens to sit next to them. They are very often rejected by their own families, subject to violence and are even lower down the notoriously caste-ridden Indian social scale than the ‘untouchables’. They are the transgender people, and they are also the group with the highest rate of HIV.

With normal employment opportunities largely excluded, options for earning any sort of living are severely limited. Begging is one option, and this is not just a matter of holding out a begging bowl. The begging is much more organised than that. Hijras have a long recorded history on the Indian sub-continent and historically have been the face of the transgender population. In his portrait of Delhi, City of Djinns, William Dalrymple describes how, after weeks of gradual persuasion, he was allowed to go out early one morning with three hijras accompanied by two musicians. Dalrymple’s group lived together in a small household under the guidance of an older guru, who directed them to a list of local weddings that she had put together. Although in the Hindu tradition hijras are viewed with disdain, they are also treated with caution and some superstition. In particular, newlyweds do not want a possible ‘curse’ hanging over them. The result is that the hijras dance as the musicians play and the guests and the neighbourhood watch. They withdraw only when the guru has extracted the desired amount of money from the family.

Another income opportunity for a transgender person is to work as a dancer in a bar. The last option is to become a sex worker. Many are forced to choose this last way. The younger you are the higher the price, and there are stories of young boys being castrated so that the family can take advantage of his earning power. This, however, is not remotely typical. For most, the journey is entered into voluntarily, in spite of all the difficulties and dangers. The practicalities are perilous. Few doctors will carry out a castration operation. The result is that they are at the mercy of the quack. Operations are done without proper hygiene and the fact that about one in ten die as a result tells its own story. Operations are not cheap. Castration would cost anywhere between 20,000 and 60,000 rupees. That is between about $330 and $1,000 when much of the Indian population live on a few dollars a day. Vaginal construction surgery could cost well over double that and there is also the added cost of hormonal treatment. So why do Indian transgender people spend the money and take the risk?

When I visited India in November 2013, I met Abhina Aher, now a good looking woman in her late thirties and invariably dressed in bright colours, who told me, ‘Transgender women want to be beautiful women. Unless you are castrated then the others look down on you.’ At one stage she worked with a gay organisation but said: ‘I did not want to be loved as a man. I wanted to be loved as a woman with children.’ The whole of this ambition may have eluded her but, like all the transgender people I met, she is happy as she is. She remembers clearly enough the struggles to get to where she is today.

As a young boy of about six or seven she became certain that she was in the wrong body. Her father had died when she was three and, without encouragement, she began to copy her mother who was a dancer. Looking back today she says she ‘got a kick’ from wearing her mother’s clothes, her jewellery and her dancing equipment. On one occasion she was found by her mother dressed up in this way but was roundly told: ‘You are a boy. Boys don’t dance.’

According to Abhina, her overwhelming problem was a lack of understanding and a lack of information. Sex was taboo. ‘You could not talk to anyone about it. You could not talk to your family. You could not talk to your teachers.’ The one time she complained to her teachers about the treatment she was receiving from her classmates, she was told that it was she who was responsible because of the effeminate way she behaved. The only early medical advice she received (if such it can be called) was from a doctor in a public hospital, who said that she should ‘sleep in a dark room’ so that she could come to terms with herself.

In her late teens she made three attempts at suicide. ‘It was a mixture of loneliness and rejection. I felt I had no role in the world. Self-pity took over.’ For several years she took no action. She told me she was shocked at being approached by a hijra and asked for money. ‘If I am like her I don’t want to end up a beggar,’ she said. Instead, she studied and was employed in a software programming company. It was only when, through a lonely hearts magazine, she found others who felt the same that she started on changing her life. She is now successfully employed, giving both men and women the support and information that she was denied. She says that her mother still does not understand, but nevertheless she supports her. ‘We are linked by blood,’ her mother told her. ‘I am going to be with you. I gave you birth.’ It is a happier family outcome than for many others.

Another transgender woman who has followed the same course is Simran Sheikh. She ran away from home when she was fourteen after suffering years of mockery inside her middle-class family. For three days she sat outside Mumbai railway station without food or water. ‘Those three days were the toughest time of my life,’ she told me. ‘I didn’t want to go back but I didn’t know where to go.’ Finally she was befriended by a hijra who took her home and, over the next months, taught her the basics of her new life. She worked for about five years dancing in bars, but that was brought to an end when the bars in Mumbai were forced to close in 2005. Sex work became the only option and she worked in the red-light area, Kamati Pura, but continued with her education and joined the first ever transgender organisation in 1999. Like Abhina she now works to help others and, also like Abhina, has no regrets about the change. As for her family, she tried once to ring them but was told, ‘You are dead for us.’

It is, of course, this isolation that makes transgender people so vulnerable – and so vulnerable to HIV. At 8.8 per cent, their HIV prevalence is dramatically higher than that for the general public. One reason is that they are in a peculiarly weak position to insist on men using a condom. Unprotected sex is overwhelmingly the main route of transmission in India. Another reason is the discrimination against them in the medical system. Even doctors can make clear their distaste. ‘Go over there,’ they say. ‘We will see you at the end.’ This all adds up to giving transgender people an understandable reluctance to test and a reluctance to seek advice on other sexual diseases which could increase their vulnerability to HIV.

India shows the kind of response that transgender people (who also include the much smaller number who transition from female to male) receive around the world. To an outsider like me, the discrimination and heartache is difficult to understand. All the transgender community wants is to be recognised and treated just like anyone else. As Simran told me, ‘We want to be accepted.’ It is hardly an unreasonable request. It is the cry of every persecuted group over the ages. Transgender people may be the least known of the sexual minorities, but for some their very appearance seems to provoke revulsion – which is ironic given that they are often better turned out and better dressed than their orthodox counterparts.

On the last evening of my visit to Delhi, I went to an event which fell somewhere between a gay pride celebration and a political rally. A long catwalk protruded from the stage into the audience as the hijra dancers in their brightly coloured saris went skilfully through their complex routines in a blaze of purple, scarlet and yellow. Impeccable performances were punctuated by speeches calling for action. A government secretary promised reform, a well-known Bollywood film actor pledged support. The 300-strong audience responded with enthusiasm and the hope that India is seeing the beginning of a new age. That is the hope, but a thousand years of discrimination may not be ended that easily. The prospect is that, for the foreseeable future, many transgender people will continue to be forced into sex work – and their rate of HIV infection will continue to be high.

Of course, given the size of the Indian population, you could argue that the plight of the minority transgender population is something of a side show. Estimates of the number of transgender people vary enormously. The figures I heard ranged from 160,000 at the lowest to 750,000 at the highest. Certainly the National Aids Control Organisation in New Delhi argue their case on a larger canvas – and so would I if I had to cope with a population of 1.2 billion spread over twenty-eight different states and six union territories, as well as the region around Delhi itself. India is not a centralised country like China. You cannot issue instructions here and expect that they will be observed to the letter everywhere from Calcutta to Mumbai. Nevertheless India claims very substantial success in checking the spread of HIV.

There may be over two million people with HIV in India but, when population is taken into account, that means the prevalence is under 0.3 per cent. This is not only way below the figures in sub-Saharan Africa but also rich countries like the United States. If only South Africa or Nigeria could have achieved such results then the world epidemic would have been dramatically less. New infections are estimated to be down to 130,000 a year – a reduction of half over the last decade. Government figures also suggest that deaths from Aids have reduced to around 150,000 a year which is again a big improvement on the position ten years ago. There are some observers who think that the official figures are too sunny but nevertheless no one can doubt the progress that has been made.

As for treatment there again has been progress. About 600,000 patients living with HIV are receiving antiretroviral drugs but that still leaves a massive number either not on treatment or unaware that they have HIV in the first place. Some clinicians make no bones about the position and admit that many will die waiting. Then there is the added problem of adherence, with many finding the difficulty and expense of travelling to a hospital to be almost prohibitive. The result is that one estimate suggests that as many as a third do not stick with their treatment.

Prevention, however, is India’s proudest boast. According to Aradhana Johri, Additional Secretary of National Aids Control Organisation, India is ‘a global success’ in preventing Aids. India, she told me, ‘has focused on prevention’. The government has led from the front, and the result has been ‘the world’s largest mass mobilisation campaign’. So let us examine just how much of a global leader India is and how successful it has been. To what extent is this, the largest democracy in the world, an example to us all?

What sets India apart has been the general consistency of their policy, their emphasis on prevention and the fact that they acted early. They did not wait until they had been partly overwhelmed before responding. The National Aids Control Organisation was formed back in 1992 and is now just embarking on its fourth five-year plan. Even sceptics of national plans might concede their success. In that time, condoms have been promoted in a country which, despite the sexually explicit statues and erotic friezes that can be found, often does not talk openly of sex. A clean-needles policy was introduced early and public health was put firmly in front of the misguided fears that it would lead ‘inevitably’ to a rise in crime. Every opportunity has been taken in prevention publicity, including the Red Ribbon Express, a special train running through India taking condoms and the public health message to small towns and villages. At the same time, India has progressively taken over responsibility for financing both treatment and prevention from international donors.

By any standards these are impressive achievements, but there remain formidable problems to overcome. India says it has a ‘concentrated epidemic’, by which it means that the dangers are concentrated in the high risk groups – sex workers, injecting drug users, men who have sex with men and of course transgender people and hijras. There is no complete agreement on the numbers except that the figures are massive. One official survey in 2007 estimated that there were around three million female sex workers – and that leaves aside an unknown but potentially substantial number of male sex workers. Human Rights Watch put the number of sex workers substantially higher than anything in official reports, but everyone is agreed that women in particular who have embarked on this course find it next to impossible to change their lives.

Another survey estimated that there were over 2,300,000 men who regularly have sex with other men, but again this is thought to be a substantial under-estimate. In addition there are significant transient groups who can easily spread the virus. There are well over two million long-distance truckers moving throughout the country – away from their families and the restraints of their communities. Huge numbers of Indians also migrate within the country, leading unstable lives distant from the health system. They move to where the work is. The area around Surat in Gujurat is one such magnet, where the high employment opportunities in the local industries attract migrants from poorer states, who then live in makeshift shacks by the side of the road. Connecting with all these groups is a mammoth task.

And then of course there are injecting drug users. The overall number of drug users is unknown, although government figures suggest that there are almost 200,000 drug users who inject. In Delhi one survey showed that their HIV prevalence was over 20 per cent – over double the figure for injecting drug users nationally. Not only are they continuing to increase in numbers, the drugs they inject continue to change. Once, the problem centred on heroin and was concentrated in the north east of the country, near China and on the border with Myanmar (Burma that was). Today it is much more widespread and more complex. The biggest problem is the misuse of pharmaceutical products that can be bought over the chemist’s counter. ‘You can go into a pharmacy and can get more or less anything you want,’ one outreach worker explained to me. A well-known antihistamine is a favourite ingredient in the mixture. Although everyone realises what is happening, the police do not intervene and the trade continues. The heavy suspicion is that money has changed hands. It is all too reminiscent of the homemade drugs position in Moscow, but different in one vital respect. India not only allows clean-needle policies, it also finances them. But this comes with a health warning: anyone who thinks that this implies sterilised conditions, spotlessly clean injecting rooms and nurses in white uniforms should think again.

By the side of the Yamuna-Bazar River on the outskirts of Delhi there is a treatment centre that, when I visited it in 2012, reminded me of something straight from the pages of Charles Dickens. The centre is on a large untidy site bounded on one side by the river. Emaciated men stand listlessly in small groups. A few yards away a young man in a filthy shirt and cap is injected by another user wearing an old track suit top. An old man is being treated for an abscess brought on by his injecting habit. A young boy of fourteen or fifteen, who I’m told started injecting himself a year previously, looks up from a rudimentary lesson a helper is giving him. As he is under eighteen he, like many others, will not appear in the official statistics. At night there is a spartan shelter for up to a hundred drug users, who are packed into the space, sleeping side by side on the bare floor with a ration of one blanket each. Drug users raise what funds they can from rag picking or, even better, from collecting empty cans, for which they can expect a price of between 50 and 200 rupees. Sacks full to the brim are stored at the corner of the site.

In the main building itself a small queue forms outside what might be called the dispensary. This sets out to help users who are trying to come off injecting altogether. A helper marks off each name and then, one by one, they are seen by the nurse who starts work each day at 8 a.m. and carries on into the early evening. The nurse grinds the tablets (buprenorphin) and feeds the powder to the users. As in Kiev, there is no question of simply handing over a full tablet – it might be taken away and sold. For the same reason the users are required to wait for fifteen minutes before leaving.

You wonder how a system like this can produce success, but it does. In 1998 HIV prevalence among the clinic’s clients was 44 per cent. Today only 11 per cent of the current injecting drug users are infected. Much of this improvement is due to the utter dedication of the staff and the civil society organisations that carry out this work. Some of the staff are former drug users themselves. ‘If you have not experienced this yourself then you don’t know what they are feeling,’ one of the workers on the site told me. Other staff, like the dispensary nurse who has worked on the site year after year, are just examples of pure dedication. To come in each day to what is little more than a kiosk and then to minister to an endless line of drug users – some of whom are on the look-out for an opportunity to smuggle out the drug – requires a dedication which few possess. It is just as well such people and such organisations exist for without them the figures would not look anything like as good.

Another priority group are the sex workers and here Indian officials take particular pride in the fact that the national prevalence has reduced to 2.4 per cent a year. Certainly that has nothing to do with the clarity of the law. The regulation of prostitution is the usual muddle to be found in most countries around the world. The exchange of sexual services for money is legal but (and it is a very big ‘but’) soliciting in a public place, owning or managing a brothel, pimping and kerb crawling are all criminal offences. In practice the uncertainty leaves the way open for exploitation, including exploitation by the police.

In a small house in a dingy part of West Delhi I interviewed a group of four sex workers. They were in their thirties or forties. All had children, and that was their priority. One woman told me, ‘There was no choice. My husband left. You have to live somehow.’ Sometimes they have been very successful. A small woman in a pink sari said that she had financed her son through Delhi University, although often as they grow up the children turn against their mothers and their way of life.

I asked, what was their main problem? Almost in unison they complained of their pimps. The pimp would probably be an ex-sex worker herself. She would rent a house and have a pool of between ten and fifteen women who lived locally who would come in most days. They would have ten clients during the day and for that the pimp would be paid about 2,000 rupees. Out of this sum the sex worker would receive 200. Condoms would usually be used but if the client wanted sex without it then the pimp would agree to what the client wanted. The sex worker would be in no position to refuse.

Not all sex work in this part of Delhi was organised this way. Others worked in the local Chameli Park. ‘The younger you are, the better,’ said one of the women I interviewed. A fourteen- or fifteen-year-old (possibly the daughter of a sex worker herself) might be paid up to 1,000 rupees for a day’s work. Like the young drug users, at under eighteen she also would not appear in the official statistics. There was one other point on which the women were united. They would never go to the police for help. ‘I have never even tried,’ said one. The police are viewed as both corrupt and violent. The sex workers’ plea was: ‘Tell the police not to exploit us. They come every week asking for money. They keep coming back.’ It is the all too common global problem.

The position here cries out for reform. By common consent, the whole system is shot through with corruption and the violence of gangsters, who demand protection money, or of clients who for one reason or another are dissatisfied and refuse to pay. You would think that any logical policy would demand some form of proper control which would not only be good for the sex workers but also benefit the cause of public health. But this would also mean official regulation of sex work and, like so many other countries around the world, India has no intention of travelling down that path. The politicians would not accept such a solution – and neither would the religious leaders.

The vast majority of the country is Hindu (about 80 per cent) and after that come Muslims (about 13 per cent). If you were to generalise (which is a perilous venture in this vast nation) you would say that India is a religiously conservative country where most of the population engage in religious rituals on a daily basis. Religious conflicts periodically break out: the worst by far being the widespread riots and murders in the years around Indian independence in 1949. But there are other long-standing divisions. Circumcision, for example, is a non-starter with the vast majority of the Indian population. As one health worker succinctly put it: ‘Hindus are not going to get circumcised and Muslims are already circumcised.’

On other sexual matters, however, there is widespread agreement between the religious groups. Neither the leaders of the Hindus nor the Muslims would take the lead in seeking a radical solution to help the position of sex workers. Nor is there much support for such a policy among the general public. There is a widespread contempt for women who, for whatever reason, have fallen into sex work, but there is also a residual male contempt for the rights of women generally. Charges of exploitation and police corruption fall on deaf ears. Traditionally, Indian women occupy a subservient position. You only have to go to a mixed-gender meeting to see the women respectfully occupying the rear rows. One sympathetic worker in the area set out to me how he saw the traditional position: ‘A woman is not supposed to be macho. She is not supposed to be sexy. A woman is meant to be submissive. She is not supposed to have power.’ More and more of the younger generations, of course, do not accept this for a moment, but some measure of the distance still to go is shown by the recent spate of attacks on women in Delhi. It is at least some measure of progress that such attacks are now reported in both the national and international press, when once they would have been all but ignored.

Nevertheless, the old attitudes persist and from the point of HIV this has a very direct consequence. Out of the 2.1 million people in India living with HIV the government estimates that over 500,000 are undiagnosed. Many of these are women and even when they do test that can come very late – dangerously late – for treatment. In the vast majority of cases, the women will have been infected by their husbands or other male partners but in the eyes of their families that does not absolve them. According to one worker in a charity trying to protect the position of mothers, ‘The family blame her for getting the infection. She did something.’ If the man dies then the prospect is that the woman will be forced to leave the home – there are many widows living as single women in Delhi. Inside the public health system women with HIV are often treated as second-class citizens, disdained by the doctors and segregated from the other patients. As one woman remarked to me, it is a form of apartheid. In the private sector those living with HIV can be asked to pay more on the grounds that ‘we have to throw away the instruments afterwards’. Against such a background it is not surprising that many women do not come forward for testing or put off the day for as long as they can – by which time it is often too late.

It is for reasons like this that men who have sex with men are also reluctant to come forward. According to some I spoke to in Delhi, their position is even lower down the scale of public acceptance than transgender people. It is the familiar story: ostracism for gay men and lesbians, family disgrace, particularly in rural communities, and violence directed against them. Worse still, such hatred was for many long years sanctified by a law which had been passed by the British in 1860 when Lord Canning, who had served in the governments of Peel and Melbourne, was Governor General. The law (section 377 of the Indian penal code) prohibited ‘carnal intercourse against the order of nature with any man, woman or animal’ and laid down sentences of up to life imprisonment.

Then in 2009 everything changed – or so it seemed. The Delhi High Court lifted section 377 for consenting adults, effectively decriminalising homosexuality. In a memorable phrase the court held that ‘discrimination is the antithesis of equality and it is the recognition of equality which will foster the dignity of every individual’. Of course the ruling did not mean that immediately the clouds of prejudice lifted. It was also unclear just how far the writ of the Delhi court ran. But at the very least it meant that a significant step had been taken towards acceptance. It looked as if a nail had been driven through the heart of a very Victorian law. In fact, the law had fallen into disuse and only existed as a threat hanging over the heads of gays and lesbians and to be used to advantage by police prepared to exploit it. If any law should have been pensioned off it was this.

Then, a month after my visit to India, the position changed again. An appeal had been lodged in the Supreme Court and, on his last day in court before his retirement in December 2013, one of the two judges, G. S. Singhvi, ruled that only Parliament could repeal the 1860 British law. So, ironically, in the year that Britain itself moved on to allowing equal marriage, India appeared intent on marooning itself in a bygone age. The gay community was outraged. One of their most influential supporters was Vikram Seth, the author of A Suitable Boy, who appeared on the front page of the magazine India Today holding a large notice saying ‘Not a Criminal’.

In an interview with BBC India he said, ‘A judgment which takes away the liberties of at least fifty million gay, bisexual and transgender people in India is scandalous. It is inhumane – and if you wish you can remove the “e” at the end of that word.’ As for posing for the magazine photograph (described in the press as an ‘unprecedented’ action) Mr Seth replied, ‘There’s nothing heroic in what I have done. There are gay people who live lives of quiet desperation in India’s towns and villages. They need people to voice their dismay and disappointments.’

Predictably, this was not the view of the religious leaders. In a remarkable show of unity, they put aside their usual quarrels to back the Supreme Court judgment. One religious leader said, ‘This is the right decision. We welcome it. Homosexuality is against Indian culture, against nature and against science.’ Another called homosexuality ‘a bad addiction’ which could be cured. A third said bluntly that ‘homosexuality is a crime according to scriptures and is unnatural’. There was even a suggestion that banning homosexuality would help in the fight against HIV and Aids – when all the evidence (together with common sense) suggests the opposite is the case. Making homosexuality a criminal offence simply puts up a massive barrier to testing and treatment.

Caught in this crossfire, it would have been easy for the government of India to have postponed any decision until after the 2014 election and indeed that was the immediate forecast of what their tactics would be. But, to their credit, instead they petitioned the Supreme Court on the basis that the ruling ‘violated the principle of equality’. The law minister, Kapil Sibal, said ‘let’s hope the rights to personal choices is preserved’, while the President of the ruling Congress Party, Sonia Gandhi, described the Victorian statute as ‘an archaic, unjust law’.

That, however, was not the end of the matter. In January 2014 the Supreme Court rejected the petitions and effectively put the decision back to the government. New legislation seems now to be the only way forward, but that is by no means certain. The main opposition to the Congress Party comes from the Bharatiya Janata Party (BJP) whose roots are in the deeply conservative Hindu religious and cultural organisations and who support the reinstatement of the legal ban. Any attempt to legislate will be deeply controversial, and irrespective of the eventual outcome, the case has confirmed one truth about India – that this vast country contains a very substantial homophobic population. True equality is a distant prospect and without it the battle against HIV and Aids will always be shackled.

The sadness is that there is so much that India has got right. In particular it is a nation that explicitly puts prevention first. What other nation would boldly state that ‘prevention has been and will continue to be [our] primary response to the HIV epidemic’? That is certainly not the message that comes from Moscow or Kampala, but nor is it the message from Washington or London. To these nations, prevention is too difficult to measure, too uncertain in a competition for funds. They know what should be spent on treating those who are infected but are unable to make the jump on what to do to prevent infection. India deserves the utmost credit for its efforts in this regard, as do those early decision-makers who set up the National Aids Control Organisation and prevented Aids becoming an out-of-control crisis in India.

Yet in spite of this brave action it is difficult for an outsider like me to see India as a model for the rest of the world. You cannot have as a model a nation where the divisions of the caste system still throw a long shadow of discrimination and prejudice. You cannot have a model where that same prejudice extends to the very priority groups you are trying to reach and where transgender people and many others are treated with such contempt. You cannot have as a model a country where the argument still continues to rage over a 150-year-old law which criminalises homosexuals, which discourages testing and treatment, and gives cover for the views of bigots.