Female sex workers constitute less than 1% of the infected female population in India. Yet, they are seen as a high-risk group and are the target of various HIV-related interventions. Such targeted interventions only end up further alienating communities instead of empowering them to combat HIV, says Meena Saraswathi Seshu

Women sex workers are mainly portrayed and treated in public discourse and policies as vessels of moral hazard, vectors of disease, and objects of pity. Their everyday lives are often beset by oppressive power relations and they tend to be socially excluded as their presence triggers moral panic in communities. Consequently, they find themselves at the receiving end of instrumentalist interventions because they are perceived as a public health threat to be monitored.

Ironically however, statistics show that female sex workers form less than 1% of the HIV infected female population in India. According to the National AIDS Control Organisation (NACO), in 2003 the number of women infected with HIV in India was 20 lakh, of which the number of female sex workers infected with HIV was 0.103 lakh. Every year, blood samples are collected for surveillance for HIV prevalence among the general population and various groups at risk of HIV. For female sex workers, surveillance is done in 26 states. The number of FSW sites has gone from 42 in 2004, 83 in 2005, and 138 in 2006. Following the 2006 surveillace, it was concluded that eight states have HIV prevalence among female sex workers (FSWs) of more than 5%:  Nagaland (16.4%), Maharashtra (12.8%), Manipur (11.6%), Mizoram (12.4%) , Karnataka (9.6%), Andhra Pradesh (8.8%), West Bengal (6.58%), and Gujarat (6.4%).

We must remember two things: First, it is widely accepted that there are many limitations to the surveillance data on HIV prevalence. Second, while FSWs are much more likely to be HIV-positive than women in the general population, in absolute numbers, positive FSWs are a fraction of the total of HIV-positive women. Despite this, women in sex work have been identified in policy as a ‘high-risk’ group and are the target of various HIV-related interventions on the basis of this (mis)understanding.

Taking control: The SANGRAM story

Sex workers have become the focus of much bio-medical and social research and health programmes since the beginning of the HIV/AIDS pandemic. But these have not necessarily led to self-organisation or the empowerment of sex workers. However, the experience of women sex workers who are associated with SANGRAM presents a different picture. These women, who operate out of six districts across Maharashtra and Karnataka, have made considerable headway in taking control of some of the social and health threats in their lives.

The women formed a collective in 1996, and called it VAMP (Veshya AIDS Muqabla Parishad or Women in Prostitution Confront AIDS) in an intentional reference to the social stigma they face and in an attempt to reclaim the term ‘veshya’ (‘whore’ in local parlance). Five thousand women sex workers from western Maharashtra and southern Karnataka are now members of the VAMP collective.

Through their actions to prevent HIV/AIDS infection and help colleagues living with HIV/AIDS cope with their health and social problems, the VAMP women have challenged common perceptions of women sex workers. In particular, they challenge the notion that women sex workers are vectors of infection and are therefore to be treated as significant threats to the social fabric. They have also drawn attention to the idea of risky behaviour in HIV/AIDS infection, as opposed to high-risk groups, and focused on responsibility in sexual relations. In doing so, they have shattered the culture of silence that surrounds sexual relations and HIV/AIDS in public discourse. 

The experiences of SANGRAM and the VAMP collective have also thrown up some critical issues and observations, presented below, that must be reflected on to make headway in HIV/AIDS prevention in the region.  

Targeted interventions: A critique

In situations where access to treatment services for the general population is itself difficult and sporadic, a service for vulnerable groups is an almost impossible dream. The problem of addressing HIV in marginalised populations like sex workers is compounded by lacunae in the overall management of the HIV/AIDS epidemic in the region. Programmes that view women in sex work as a means to reaching the sexually active male population, rather than focusing on the sex workers themselves, are doomed from the start. Most governments in the region resort to such targeted interventions.

The targeted approach alienates communities and, in essence, continues to blame certain marginalised communities like sex workers instead of empowering them to combat HIV. In such a situation it is inevitable that the control and implementation of programmes will always remain with the implementing agencies rather than being owned by the communities.

The most effective education on HIV transmission is done by those trusted by the community at risk. This means that sex workers have the best chance of helping other sex workers protect themselves from HIV. But peer education is not getting a fair chance in India. The police apparently do not recognise the lifesaving work done by AIDS educators, and these people face consistent abuse. Experiences of VAMP’s work in Sangli, and the gay/MSM support service Naz Foundation International in Lucknow are evidence of this. 

Special vulnerabilities of trafficked women

Trafficking by definition refers to the use of coercion, deception, abuse and assault to move people from one location to another across and within country borders. Undoubtedly, women who have been trafficked into the sex trade are more vulnerable to the threat of HIV and more likely to be in a situation where they are unable to control and protect themselves from HIV transmission. As illegal migrants engaged in an underground trade, they are very often subjected to sexual abuse at the hands of the authorities, including immigration and police officials, whose systematic involvement in the trafficking trade is well known and documented. Forcible detention, lack of access to redressal, police corruption, and ‘invisibility’ ensure that women can be violated, controlled and abused. Given the fact that HIV transmission is most efficient in situations of repression and abuse, women in trafficked situations are more vulnerable and at a greater risk of contracting HIV.

However, most NGOs that work on issues of trafficking rarely include an HIV component in their programmes. In attempting HIV prevention with trafficked persons, NGOs find it difficult to build their confidence and trust. As ‘Stateless’ people without papers, trafficked persons prefer being invisible and underground. If they are women in prostitution and sex work, even more so because prostitution in most countries is illegal and it is almost impossible to access women who are under the ‘protection’ of the criminal nexus and trafficking syndicates. Fear of the police and legal repression are also major reasons why women shy away from outreach workers.

While there are many groups that work with trafficked women and illegal migrants, there are very few that actually offer services for HIV/AIDS prevention, care and support. Many women’s groups in source or recipient countries provide services and support to women who are ‘victims’ of trafficking. But HIV/AIDS prevention and education is not part of their agenda. This gap needs to be examined. 
  
Healthcare: Major concerns
 
While the ‘immoral whore’ image makes it very difficult for sex workers to get good medical treatment, illiteracy, ignorance and fear of the medical establishment renders them open to exploitation and extortion. Reproduced here are responses regarding healthcare by women in prostitution and sex work from West Bengal, Orissa, Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu, Kerala and the union territories of Goa and Pondicherry, from a report prepared by the National Commission for Women:

• Medical and paramedical staff at government hospitals have a callous, indifferent and often humiliating attitude. Irrelevant and embarrassing questions about sexual positions, etc, are often asked.
• Forced free sex with doctors and social workers is commonplace.
• Doctors often refuse treatment and admit women to hospital claiming they are AIDS carriers.
• In many centres, doctors make peons and attendants conduct the physical examination and only then attend to the women.

Accessing healthcare is a major concern for women in prostitution and sex work, and such gross violations of their right to healthcare demands urgent attention.

Sex workers as educators

Unfortunately the HIV/AIDS epidemic has singled out people in prostitution and sex work as ‘carriers and vectors of HIV’. Apart from the stigma already attached to their work, society has further marginalised them as core transmitters of HIV infection. It fails to recognise that they are but links in the broad networks of heterosexual transmission of HIV. Today, this perception is beginning to change as it is increasingly being revealed that married women constitute the major chunk of women infected with HIV in the country.

Propagating the myth that women in prostitution and sex work are core transmitters of HIV serves the purpose of ‘prostitution-bashers’ who reinforce the prejudice that AIDS is an ‘impure’ disease that afflicts immoral and evil persons. The net result is to further target the women, which:

• Increases public and police violence against them.
• Decreases their ability to assert themselves.
• Allows customers to demand and force unsafe sex upon them.
• Increases the incidence of HIV among women, customers and the families of customers.
• Denies them access to healthcare services.

The role of women in prostitution and sex work in HIV/AIDS prevention has been slow to gain recognition. In fact, it is only now being grudgingly accepted in some circles that women in prostitution are the best educators of their male clients.

(Meena Saraswathi Seshu is Director of SANGRAM, a non-governmental organisation that has worked with sex workers in Sangli, Maharashtra, since 1992. In 1996 the programme broadened into a collective of women sex workers against injustice, called VAMP or Veshya Anyay Mukti Parishad)

InfoChange News & Features, January 2008