Abstract
BackgroundThe 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.MethodsIn 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.ResultsDramatic 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.ConclusionsTargeted 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.
Highlights
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)
The Integrated Behavioral and Biological Assessments (IBBA) is the only independent source of HIV estimates among brothel and street-based FSWs and with the two survey rounds consistently implemented, we found no technical or methodological reason to doubt the veracity of the HIV estimates
Key informants involved in the implementation of programmes included 83 peer educators (PEs) and outreach workers (ORWs) at the grassroots level, seven program coordinators (PC) at mid-level and 21 senior staff in leadership positions, of which three were sexual rights advocates
Summary
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). The response to India’s HIV epidemic with the large scale-up of prevention efforts has been well documented in the last decade [1] Both the National AIDS Control Program (NACP) and the Bill and Melinda Gates Foundation -through its flagship programme Avahan- have implemented targeted interventions among groups at higher-risk, including female sex workers and their clients, men having sex with men and injecting drug users [2]. Linking changes in the prevalence of HIV and other STIs, sexual risk and risk reduction practices to intervention exposure has been central to Avahan’s impact evaluation These changes were measured between 2 rounds of Integrated Behavioral and Biological Assessments (IBBA) surveys in 2006 and 2009 among key population [3]. The size of both brothel and street-based sex worker populations diminished, especially in Mumbai [4] suggesting a substantial shift in the composition of the sex worker population
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