The goal of the Third Phase of the National AIDS Control Programme of Govt of India (NACP III) is to halt and reverse the epidemic
in India
One of the
major strategies is to enhance the coverage of high risk groups following a
comprehensive framework of targeted interventions both in high prevalence as well
as highly vulnerable states. As the document clearly articulates ‘’High-risk
groups continue to bear the greatest burden of HIV infection. Their social
marginalization, occupations, recreational patterns and sexual preferences also
make them relatively more vulnerable to HIV infection.
In terms of the
transmission risk, prevention efforts towards these groups would constitute one
of the important NACP III strategies’’ This very communication not only
speaks about the epidemiological
importance of these groups but goes further in opening up a discourse on the
underlying reasons behind their vulnerability.
It would be extremely important
to recognize this statement as it reflects a decade long experience and hard
earn knowledge and wisdom of NACO what essentially has helped the NACP 111 team
members in designing and laying down appropriate strategies and programming
principles of targeted intervention program for the country.
WHAT IS SEX-WORK AND HOW
IT IS LINKED TO HIV/AIDS?
Buying and selling of sex services is an age old
practice in our society. Some individuals sell services and some other buy it.
Most of the buyers if categorized from the gender perspective are male however
sellers are from all three gender background [e.g. male, female and transgender].There
are more female sex workers in comparison to male or transgender sex-workers.
However the number of practicing sex workers belonging to male or transgender
community is not small and for all practical reasons their significance can not
be denied.
Over a period of time
direct ‘one to one’ mode of transaction of sex-services has been overtaken by
the growth of market forces with the
development of many other stakeholders in the trade [e.g. police, middleman,
land lord’ etc].However this transition is not very smooth and linear in nature
and the structure and functioning of sex trade varies from place to place .It
has been further complicated due to various social and cultural factors
including the imposition of state control mechanism to guide the sex trade and
practices which are mostly ambiguous and non transparent from the points of its
objective and inclination. As a matter of fact in most part of the developing
countries sex-trade operates in a ‘twilight zone’ of legality and illegality.
All these factors has helped breeding of
corruption and malpractices in the trade in addition to that it has further
strengthened the oppressive and
exploitative practices of both ‘formal’ and ‘informal’ controller of sex trade over the sex workers who are the victim of all
these maladies. One need to recognize all these factors while designing any
intervention program as it relates to sex-workers’ social and occupational
position vis-Ã -vis their relative powerlessness and their inability to exert
agency.
The predominant route of transmission of HIV is through
sexual route and bio medical classification puts HIV/AIDS within the category of
sexually transmitted diseases. Barring few geographical regions [where IDUs has
played the critical role] global HIV pandemic is and has been fuelled through
sexual transmission and south East Asia is no
exception. In India
Persons
having multiple sex partners are more prone to get infections. Sex-worker as
part of their work entertains many clients as sex partner what increases her
chances of getting HIV infection. However there are many possibilities in
averting infection too. Increasing sex-workers accessibility to preventive
services can reduce their chance of getting infection provided they could
negotiate effectively with their clients for safer sex what is again determined
by their ability and power to negotiate. The power of negotiation is immensely
influenced by the relative power bases between the two negotiators and the milieu
where they negotiate. The power of a sex-worker is directly linked to her
social and occupational position [like any other individuals in our society] in
addition to his/her ability and political acumen to access social, financial, legal,
health and other services. There is no debate in putting high priority in sex
workers interventions in any stages of the epidemic [High concentrated, Low or
generalized epidemic].The issue is how better it could be strategize to get
the best result.
INTERVENTION - strategies
and approaches
The basic construct of the HIV
prevention strategy is based on the understanding that if individuals are
provided with information and means of prevention, they would be able to make
reasonably correct decision and would be able to act based on their decision.
The barrier to adopt safer sex-services is seen more of an aberration on the
part of the individual and his/her risk taking practices. The major trend of
these programs is to dissociate behavior from gender, occupation, economic
condition, and livelihood option and for that matter the social identity of
individual and his/her power bases. The prevention strategy thus designed is
limited to focusing on service provision only. The 2nd premise behind these
interventions is that the beneficiaries are free agents with desire and power
to make decisions that would help consumption of HIV prevention related
services. However, the fact remains that they are often not free agents, even
if they have the adequate knowledge and desire they do not have the power to
make decisions or to act based on their decision. The limitation of this
approach owes to the theoretical construct of interventions-what was the
hallmark of 1st generation of interventions. However last two
decades’ experience[both National and Global] has broaden the
understanding of focused intervention strategies and approaches specifically among the
marginalized group what has been duly articulated in the NACP 111 design and
what can freely be considered as 2nd generation intervention
program.
SEX WORKER-AN
OBJECT OF INTERVENTION
Sex-worker; being one of the marginalized
subpopulation is viewed as ‘core group transmitter’ from the point of
epidemiology. The very social exclusion process that forces them to live and
die on the margins of the society put them in a vulnerable position. However
the basic tenets of targeted intervention program project sex-worker as a “high
risk behavioral group” whose behavior has to be changed to reduce society’s
impending risk of getting HIV/AIDS. Focusing sex-workers vulnerability towards
the virus as a behavioral issue and individual’s problem in contrast to
recognizing it as an occupational issue, the intervention thus designed,
concentrates on changing individuals’ behavior through Behavior Change
Communication (BCC) strategy only. In the process it negates all social,
structural and contextual elements what essentially put them in a ‘situation of
no hope’. These categories of interventions not only over simplify structural
issues and the contextual background of sex work, but simultaneously put the
burden squarely on the individual sex worker. In addition to that it further marginalizes
sex workers and alienates them from the program itself.
SOCIAL EXCLUSION
AND VULNERABILITY
It is accepted that without access to
information related to transmission, people are put in a vulnerable situation.
In case of the sex workers access to information and services are greatly
compromised because of their social position and status. Factors that determine
their position and status in the society essentially put them in a vulnerable
situation e.g., Stigma attached to sex and sex work, low socioeconomic and caste
background and powerlessness of sex workers as manifested by their inability to
interact with the “mainstream society” with respect and dignity. The legal
framework in most countries and the process of criminalization of sex work and
workers enhances her/his level of vulnerability further, Contrary to popular belief criminalization of
sex work has been used as a major means of controlling profit from the sex
trade, rather than reducing entry of women in the trade.
Comprehensive
approach to HIV prevention focuses more on vulnerability reduction in addition
to risk in addressing HIV transmission.UNAIDS policy position paper [intensifying
HIV prevention, August,2005] stresses strategies of risk, vulnerability and
impact reduction as an integral approach to HIV prevention. The same document
is unambiguous in illustrating the significance of rights.’’ HIV
disproportionately affects those groups and individuals are already
marginalized and /or least able to realize their human rights. Prevention
efforts will not be successful unless the underlying determinants of
vulnerability to infection are addressed and the rights of all people are respected,
promoted and protected’ so it would be crucial to address the social and
structural power relations including ideologies that put them in a vulnerable
position.
STRUCTURAL BARRIERS TO
PREVENTION
Factors
that determine structure and functioning of sex trade predominantly control
sexual practices. It is the buyer who keeps control over the nature and type of
sex practices. Other structural barriers, which are manifested by the legal
status of the profession, attitude and practices of law enforcing agencies,
criminalization of sex trade etc put an insurmountable barrier both in
providing and procuring safer sex. The primary issue is not the ‘behavior’ of
the sex worker but the way her work and work environment is managed in the
society and in the country in question. Wo(men) who choose to be in sex work
not because of her behavioral impulse or due to her attitudinal problem, a
sex-worker continue to engage in sex work and can’t change her occupation due
to the stigma attached to her occupational identity. A sex worker gets STI or HIV
infection because of her work and the hazardous work environment where she
negotiates her job.
Sex
workers ability to negotiate condom use, power to influence working conditions,
access to health, legal, financial and other basic services appears to be more
complex and is determined by various extraneous factors... The power relations
between various stakeholders both within and across the sex trade and society at
large are at points invisible but are governed by a set of complex unwritten
rules and customary practices. It is highly unlikely to expect from an
individual sex worker to enforce safer sex with his/her clients in an
environment where s/he has very little power and confidence to exert agency. Under
these circumstances adoption of empowering strategies as the cornerstone of
prevention program became so obvious to achieve the stated objective of the
program.
SEX, SEXUALITY AND SEX WORKERS INTERVENTION
The
persecution of the sex worker – men, women and trans-gendered, is rooted in the
understanding of sex, sexuality and power which in turn is governed by the
dominant social norms that views them as “lesser mortals”.Sex workers rights
issues are more often relegated to the back seat as they are judged from the
‘high moral ground’ imposed by the mainstream society. The issue of trafficking
is unnecessarily conflated with the sex
work what further victimizes sex workers and their livelihood option In our part of the world most sex workers more
often than not belong to lower caste, low income groups, sexual minority, or to groups seen as fallen,
promiscuous, and prosecutable (by law and morality). They are seen more as a
burden to the society and the very approach of intervention has narrowed down
the target to ‘genitalia’ of the person as there are not viewed as an average
human being with all senses and faculties. This approach seldom allows society
at large and policy makers and implementers to look at the sex workers as a
group having desires, needs, responsibilities and rights.
CREATION OF AN
ENABLING ENVIRONMENT
Laws,
systems and procedures that control structures and functioning of sex trade,
further intensify their state of marginalization. Sex workers are especially
vulnerable to contracting HIV infection and are often not in a position to
ensure condom use due to their “inferior” position and the related bargaining
power associated with it.. An individual sex worker has little ability to
change the systems that affect her life. The beating of a sex worker by police
for extortion may be overlooked, while beating a
shopkeeper for extortion will not as the shopkeeper occupies a relatively
higher position in the society.NACP II did recognize the importance of enabling
environment and took initiative to articulate it as an integral component of
targeted interventions as early as 1999.Under NACP III it is now considered as
an critical element to achieve program objective.
NACP III strategy document illustrate further to look into
this overreaching issue of enabling environment…. ‘’review and reform of
structural constraints, legal procedures and policies that impede interventions
aimed at marginalized populations such as sex workers, IDUs and MSM. A legal
framework that promotes and protects the rights of people infected, affected
and vulnerable to infection is important to ensure an enabling environment’’.NACP
goes further in commenting....’’ A conducive local environment is crucial for
TIs because HRGs face legal and structural constraints such as criminalization
and violence for adopting safe behaviors. These have to be removed at local,
state and national levels, NACP III will evolve appropriate strategies in
partnership with affected communities, civil rights activists, law-enforcement
agencies the judiciary and opinion leaders. “It has been decided to constitute a
state level coordination group/task force with due representation of community members
to promote an enabling environment. The document further elaborates that a
national level Task Force will be set up to review and suggest reforms of
existing laws that influence risks and impede HIV prevention, care and support
services.” NACP 111 has also decided to assess the progress in this direction
choosing a simple indicator i.e. Number of people seeking redressal of
violation of rights.
THE ESSENTIAL FEATURES OF FOCUSED INTERVENTIONS FOR SEX WORKERS
As
explained in this document that the critical element of success in HIV intervention
program will depend on how an individual sex worker can gain control over her
body and exert her agency. This requires the mobilization of the ‘community’ of
sex workers to change the unwritten rules and practices that govern sex work.
Thus the significance of collectivization and role of collective bargaining can
not be overemphasized.
The
process of giving visibility to a community that has historically remained on
the fringes of the society requires adequate attention. Sex worker must be
treated with respect and dignity and there is a need to recognize sex work as a
livelihood option. Intervention programs must respect the perceived needs of
the community and respond appropriately. This could be done through
establishing linkages with education, reduction of economic vulnerability
through micro finance systems, creating spaces for cultural expressions and the
development of an enabling environment at micro, mesa and macro levels.
The
creation of an enabling environment in the existing social milieu requires
influencing gatekeepers of the sex trade, building broader alliances with
mainstream society, open dialogue, negotiation and conflict resolution with
different power brokers.
Interventions that have factored in
these programmatic principles have been able to provide communities the space
to transcend from beneficiaries to ‘owners’ of interventions and have created a
significant impact both in terms of quality and coverage. An outstanding
example of this is the Durbar Mahila Samanwaya Committee, an organization of
sex workers and has played a pioneering role in bringing to the fore the
problems of the individual sex worker and taking collective action to address them.
They were able to increase condom use rate as reflected from sells of condoms
by the community base organization [from almost nothing to 2 million pieces per
annum] significant reduction of STIs and stabilization of HIV. A single
intervention program called Sonagachi steered by the sex workers community
could expand to 50 other areas covering no less than 40000 sex workers over a
period of just two and half years based on the strategy of collectivization and
ownership development of key population. This could be a unique example of
scaling up of program. The ownership building process can be even more
rewarding as the very example highlights its far reaching impact within the sex
workers community. Spanning from a few months to four years, this organization
initiated and continued an HIV program in over 26 areas with their own resource
before any donor came to support their venture. This is a glaring example to
show how to shift a program from a service delivery mode to a demand driven
phase. Durbar has also been a pioneer in the creation of a self regulatory
system constituted by sex workers along with representation from various
government departments as a reddressal mechanism for various issues including
anti trafficking and other emerging conflicts and problems faced by the community
members. A significant lesson from these examples is that while designing
intervention one needs to consider both the practical needs as well as implicit
rights of the community.
WHAT IS NEW IN THE PROGRAMMING?
- Availability of comprehensive health care services with special emphasis to quality sexually transmitted infection treatment looking from the standpoint of occupational hazards.
- Integrate violence reduction [both social and structural]in the sex work settings and engage sex workers in enforcing child protection policies and regulations.
- Help collectivization and self help group formation of key population to empower and to enable the community to own , control and monitor quality and effective utilization of services Promote consistent and proper use of condoms to achieve 90% use at last sex with non-regular partner and ensure consistent condom supplies(reproductive age group).
- Active participation and involvement of key population at every stage of planning, designing and implementation of the program is important to reach out community members and to make services accessible and acceptable to them
- Address compromised social position [based on stigma and discrimination and criminalization] of sex workers what makes them vulnerable to HIV/STIs
- Protection and restoration of basic human rights played a crucial role in helping key population to exert their agency in ensuring safer sex practices.
- Address structural barriers including policies, legislation and customary practices - what prevent, access and utilization of appropriate prevention and care services
- Move to decriminalize sex work as it ensures sex workers’ ability to protect her and to promote safer sex practices by their clients.
- Address perceptive needs of the key population through linking HIV prevention program with all relevant welfare services including establishment of social support mechanism for sex workers and their families.
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