Monday, February 1, 2016

Considering Risk Contexts in Explaining the Paradoxical HIV Increase among Female Sex Workers in Mumbai & Thane, India

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.

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.

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.

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)]...

Full article at:

  • 1Independent Senior Research Professional in Bioethics, Global Health, and Program Evaluation, Pune, MH, 411 008, India.
  • 2School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, MH, India.
  • 3Present address: Norwegian Red Cross, Vestlia 4, Jessheim, Norway.
  • 4Independent Senior Research Professional, Pune, MH, India.
  • 5London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK. 
  •  2016 Jan 28;16(1):85. doi: 10.1186/s12889-016-2737-2.

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