Some 61.4% of sex workers are still out of reach of HIV prevention programmes in Nepal, according to the latest UN report. Organisations working with sex workers face many constraints from funding to lack of continuity in programmes, social stigma and insensitive health workers, as Sangeeta Rijal finds out

Till she turned to sex work, Radha (not her real name), a woman from rural Nepal, did not know what a condom was. The sex trade made her aware of the importance of condom-use in preventing sexually transmitted infections such as HIV.

Radha entered the sex trade two-and-a-half years ago to care for her husband, who is ailing with kidney problems, and provide an education for her seven-year-old girl. Without academic qualifications or property, sex work is Radha's only alternative for survival.

Today, Radha has benefited from the involvement of Women Acting Together For Change (WATCH), a non-government group that has worked with sex workers in Nepal since 1999.

"I am thankful to have had access to the Voluntary Testing and Counselling (VCT) and Sexually Transmitted Infections (STI) centre in the early days of my joining the trade. Earlier, I used to have more than three sex partners. But after I joined WATCH, I no longer have multiple partners. I refuse to have any relations with the clients who refuse to use a condom," says the 28-year-old.

Radha's situation is better than that of 61.4% of sex workers who are still out of reach of HIV prevention programmes, as noted by the Nepal 2008 Report brought out by the United Nations General Assembly Special Session on HIV and AIDS (UNGASS).

Many women working in dance, dohari (restaurant-like settlements) and cabin restaurants remain hidden by claiming their work is related to dancing, singing, or public relations. But the minimal pay forces them into sexual liaisons with restaurant guests for additional income. Restaurant owners are also known to force sex work.

"If they don't obey their owner, they are kicked out of the job," explains Shova Dangol, a sex worker, and president of the Society for Women’s Awareness Nepal (SWAN), which works with sex workers. Call girls are also not reached by prevention and education programmes on HIV and AIDS. "If we are given the opportunity, we can work with call girls but we don't have the programmes to reach them," Dangol says, adding, "However, recently, we've started working in dance bars, cabins, and doharis."

"A large number of female sex workers (FSWs) are yet to be reached. We, who understand the sex workers and their concerns, and have easy access to such women, lack funds to work with them," says Bijaya Dhakal, president of Jagriti Mahila Sang, one of two registered sex worker organisations in Nepal.

The organisation has members in 23 of the 75 districts in the country. Of the total number of FSWs operating in Nepal, 8,500 are believed to be 'hidden' populations that are difficult to reach as they are located in remote geographical areas, or have tenuous links with existing networks, says Nepal's 2008 UNGASS report.

The report further states that these sex workers might be receiving services in less 'public' ways and may not be part of large networks. Therefore, they are likely to remain very vulnerable.

"Besides being sex workers, a majority are wives and mothers, which prevents them from revealing their identity," says Dangol. "Once their identity is revealed, they are abandoned by both their maternal and husband's family, and ostracised by society. So, they prefer to remain hidden and unaware of HIV and AIDS."

The other challenge in delivering services is abrupt disruption of funding. The United Nations Development Programme (UNDP) recently collaborated with Jagriti Mahila Sangh in a programme aimed at building the capacity of national civil society networks. The programme is expected to continue till September 2008.

"We just had six months to form 10 groups in the districts. We will be left with nothing once the project finishes. A similar thing happened when we worked in programmes with Family Health International (FHI) to organise meetings with FSWs every month. When the one-year project finished, all the women were scattered, and we don't know if they still have access to treatment and other awareness and prevention programmes," says Dhakal.

Social discrimination against FSWs also needs to be addressed, but FHI, the largest donor in Nepal for prevention programmes among FSWs, does not fund advocacy for FSWs' rights. "We should have access to other funds for such programmes," says Dhakal.

Stigma prevents sex workers from accessing health services. "Most of the clinics are known to the people as clinics for sex workers. Due to this, many sex workers hesitate to go to such places," says Dhakal.

Tulsa Lata Amatya, president of Community Action Centre - Nepal, an organisation that works with about 4,000 sex workers in 126 sites in three districts of the Kathmandu Valley, agrees that it is not easy for sex workers to access treatment and counselling services.

"Hospital staff is not friendly and sensitive to sex workers. Sex workers dislike health workers in these clinics," says Amatya. "Only two government hospitals in Kathmandu have Voluntary Testing and Counselling Services, but many women cannot go to the clinics due to odd timings, stigma and discrimination."

Some sex workers hold alternative jobs in garment, brick kiln and other small enterprises, owners of which do not allow treatment and check-up during working hours. "By the time their work is completed, health facilities are closed," Amatya says. "Despite these challenges, sex workers who have been reached by programmes are aware about HIV. Most of them don't compromise on condom use, and have reduced the number of sex partners. Some have even left the trade and chosen other jobs."

The Nepal Progress Report, prepared for the recently concluded UNGASS summit in New York, corroborates this. The report says that condom use has consistently increased among sex workers who have been reached by programmes. Condom use among FSWs increased from 74% in 2004, to 77.2% in 2006.

The government's Integrated Bio-behavioural Survey 2007 too shows that HIV infection has decreased significantly among sex workers active in 16 highway districts. In 2006, HIV prevalence among FSWs in the 16 Terai highway districts was 1.5% -- a rate significantly less than in 2003, when it was estimated that 3% of FSWs were infected.

This is remarkable progress, but there is still a great deal to be done. The challenge becomes greater as funds for prevention and treatment programmes for sex workers are limited, and there are still no government-run programmes.

Panos 2010, July 2008