BACKGROUND:
The
period 2006-2009 saw intensive scale-up of HIV prevention
efforts and an increase in reported safer sex among brothel and street-based
sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same
period, the prevalence of HIV increased
in these groups. A better understanding of sex workers' risk environment is
needed to explain this paradox.
METHODS:
In this
qualitative study we conducted 36 individual interviews, 9 joint interviews,
and 10 focus group discussions with people associated with HIV interventions between March and May 2012.
RESULTS:
Dramatic
changes in Mumbai's urban landscape dominated participants' accounts, with
dwindling sex worker numbers in traditional brothel areas attributed to urban
restructuring. Gentrification and anti-trafficking efforts explained an
escalation in police raids. This contributed to dispersal of sex work with the
sex-trade management adapting by becoming more hidden and mobile, leading to
increased vulnerability. Affordable mobile phone technology enabled independent
sex workers to trade in more hidden ways and there was an increased dependence
on lovers for support. The risk context has become ever more challenging, with
animosity against sex work amplified since the scale up of targeted
interventions. Focus on condom use with sex workers inadvertently contributed
to the diversification of the sex trade as clients seek out women who are less
visible. Sex workers and other marginalised women who sell sex all strictly
prioritise anonymity. Power structures in the sex trade continue to pose
insurmountable barriers to reaching young and new sex workers. Economic
vulnerability shaped women's decisions to compromise on condom use. Surveys
monitoring HIV prevalence
among 'visible' street and brothel-bases sex workers are increasingly
un-representative of all women selling sex and self-reported condom use is no
longer a valid measure of risk reduction.
CONCLUSIONS:
Targeted
harm reduction programmes with sex workers fail when implemented in complex
urban environments that favour abolition. Increased stigmatisation and
dispersal of risk can no longer be considered as unexpected. Reaching the
increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main
challenge. Future evaluations need to incorporate building 'dark logic' models
to predict potential harms.
“… Because of the ban we [bar
girls] have to sell our rooms, our jewellery; we are facing lot of problems.
Circumstances have made us to do what we did not wish to do [sex-work].
Previously we used to take one week just to tell our name to the customer. Now
when a bar girl walks on the road, looking at man, at the back of her mind, she
thinks - this is a rich person, he should come to me. … We used to think
several times before taking one customer in a month. Now we take four customers
in a day. Earlier what we used to earn through dance now we are not getting by
sleeping.” [ORWs & PEs, (23)].
“Yes, at the time of breaking
seal (virginity) the condom is not used. For that they pay INR 40,000 to 50,000
[about USD 1000/-] for [being with the girl for] 24 hours. They keep the
girl for one or two days with them, and do the sex with her by drinking liquor.
They [clients] think that since the girl is ‘seal pack’ she does not have HIV
infection. So they do not use condom.” [PE, (6)].
“I have an HIV positive sex
worker … even when she knows her status and after we have counselled her, she
does not use condom with her regular partner. He knows about the fact that she
is positive; … he told us that because he loved her he wouldn’t use condom
[with her].” [Head, CBO (15)]...
- 1Independent Senior Research Professional in Bioethics, Global Health, and Program Evaluation, Pune, MH, 411 008, India. sunita.bandewar@utoronto.ca.
- 2School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, MH, India. sbharat@tiss.edu.
- 3Present address: Norwegian Red Cross, Vestlia 4, Jessheim, Norway. kongelf.anine@gmail.com.
- 4Independent Senior Research Professional, Pune, MH, India. hema_pisal@hotmail.com.
- 5London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK. martine.collumbien@lshtm.ac.uk.
- BMC Public Health. 2016 Jan 28;16(1):85. doi: 10.1186/s12889-016-2737-2.
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