Like the rest of India, Karnataka is changing rapidly due to a fast-growing economy and recent new investments in education and technology. The HIV epidemic is just one of the new social stressors and what we have observed in this study has to be seen in that light. The HIV epidemic remains a concentrated one with the burden of infection still in high risk groups and with little expansion into the general population [
32]. News of the epidemic has spread into the community only recently, partly because the nature of the epidemic means that intervention efforts have mainly focused on high risk groups rather than on the general population. The HIV prevention program in Bagalkot has included some general population activities (such as sexuality and gender training of a few community members) and the creation of link workers whose job it is to educate the community and to be involved in village health committee activities. An earlier evaluation of the sexuality and gender training [
33] showed that there had been little diffusion of information to the community at large, partly because the training did not include enough agency for participants to take the training further. Our study shows that by 2009, awareness of HIV in Bagalkot was almost universal. However, awareness of condoms and other prevention modalities was still not very high in 2009, even among the educated. In fact as HIV prevention strategies, the most educated people were more likely to mention the not very sensitive issue of injection avoidance, than limiting of the number of sexual partners, though this might merely reflect that participants do not want to reveal personal knowledge of such sensitive issues. In addition, attitudes to safe sexual practices such as masturbation were more negative in 2009, even among the well educated and young people, suggesting that sexually conservative mores had increased in this community.
Fear and stigma, however, appeared to have reduced significantly between 2003 and 2009. Fewer people in 2009 were superstitious about the role of God in punishing people with HIV, and fewer felt that HIV-infected people should be ostracised or stigmatized, showing that the community feels less fearful of the new epidemic than it may have done initially, and pointing to the success of the intervention programme. However, as in other studies [
10,
12,
13,
16,
22‐
27] we observed that people increasingly blamed victims for the HIV epidemic (for example sex workers). Women and the more educated women were the most likely to feel this way, and young people appeared to be no more enlightened than older people. It is not clear, however, whether this “blaming” is just associated with increased awareness of vulnerable groups in their communities rather than to any real finger pointing, though the reducing levels of stigma might point to the former.
Studies have shown that when faced with a social stressor such as an HIV epidemic, many communities react conservatively and develop what has been described as moral and sexual panic, whipped up by the media, politicians and religious leaders [
13‐
16,
19,
20]. In India as in other countries, there have been demonstrations instigated by politicians reacting to events such as films about lesbianism or that involve kissing, or practices (such as homosexuality, the sex trade, dressing inappropriately) that are deemed as culturally inappropriate, or threats to Indian mores and identity [
20,
34]. Often as a reaction to HIV authorities have developed education campaigns that promote unrealistic prevention methods, such as abstinence [
16,
20]. These are common reactions in India too, where the majority of people support “moral” education in schools (generally meaning abstinence promotion), but not “sex” education [
4]. Evaluations of such programmes in many countries, however, have demonstrated that abstinence-only programmes have not been effective [
35,
36]; in addition, sex education that includes discussions of HIV and condoms does
not increase promiscuity among those who are sexually naive but does have a positive effect on safe sex among those who are already sexually active [
36‐
39]. Similarly, although the common prevailing wisdom in many societies is that condom availability promotes promiscuity [
40], there is no evidence for this [
37,
41]. In a study by Das and colleagues, the authors assert that HIV has contributed to the inertia of sexual conservatism, because of the presumed negative effects of sexual liberalism [
28]. Indeed in our study looking at attitudes over time, we found that there appeared to be increasingly less openness around discussing sex, AIDS and condoms; access to sex education and condoms were both increasingly thought to promote promiscuity. However, this conservative reaction might be the consequence of seeing widely promoted and sexually explicit condom packaging. In the study by Das et al., building on the work of others such as Kamwendo [
42], the authors contend that HIV/AIDS as a social episode in a community influences some groups to become more sexually conservative than others. For example, more educated people are able to understand the negative meanings of sexual liberalism and react accordingly; young people are thought to react negatively because they are more vulnerable to HIV/AIDS and therefore might instinctively feel the need to protect themselves by holding conservative views about sexuality; and women might start to realize that sexual liberalism may affect them greatly [
28]. In our study, we found indeed that young people, especially young women were the most resistant to change in terms of sexual conservatism around sex education and condom promotion. Level of education did not seem to influence responses to these questions, with just as much negativity in the most educated groups as in the least educated groups.
In summary, despite increased knowledge and positive changes around HIV-related stigma, resistance to change was apparent, with increased unwillingness to embrace openness and discuss sexuality. Young and educated respondents appeared to react as conservatively as others, reflecting a cultural inertia that mirrors studies of other pressures on traditional societal values. This is not to say that HIV intervention programming has been a failure, or that communities are in a heightened state of moral panic but that sexual conservatism is a natural reaction in communities that are pressured by a new social stressor. Progressive social change takes time, and without specific efforts to educate people so that they do not misunderstand the causes of the epidemic, conservative social reactions may occur. More effort is therefore required to educate young people in particular about healthy sexuality, openness and safe sex.