World AIDS Day 2017: Young female sex workers in Maharashtra, India: Why they have a higher vulnerability and risk behavior for HIV
Existing evidence showed that young female sex workers (FSWs) (<25 years) have an even greater HIV vulnerability and risk behaviour than older FSWs. However, only very few studies analysed differences in HIV vulnerability and risk behaviour based on age, which is why this study compares the vulnerability and risk behaviour of young FSWs and older FSWs, by conducting a descriptive exploratory analysis of secondary age-disaggregated data from Maharashtra (south Indian state). (Photo: AIDS:The Indian Epidemic/Benzene Aseel/flickr, CC BY-NC-ND 2.0)
By Mira Gardi
HIV Epidemic in India, Maharashtra
India has the third highest number of people living with HIV, with 2.1 million out of the 36.7 million people that are globally infected with HIV. The HIV epidemic in India is mainly concentrated among key populations: Female Sex Workers [FSWs], People Who Inject Drugs, Men who have Sex With Men, Transgender - and bridge populations (migrants and trucker) (1, 2). FSWs are highly vulnerable to HIV because of their risk behaviour (i.e., high number of clients, non-consistent condom use, drug use, anal sex), infection with other Sexually Transmitted Infections [STIs] and exposure to physical violence (3-9). Maharashtra, a south Indian state overall has one of the highest HIV burden in terms of absolute numbers (301’000 people living with HIV). In Maharashtra FSWs (7.4%) have the highest HIV prevalence compared to other key populations and a 20 times higher HIV prevalence than the adult population (0.37%). The megacity Mumbai, the capital of Maharashtra, is also known as the epicentre of the HIV epidemic in India (10-13).
The context of sex work: Policies and environment that cause harm
FSWs’ HIV vulnerability is shaped by the context in which sex work is embedded. India’s Immoral Traffic Prevention Act (1956) does not prohibit selling sex per se but it prohibits solicitation of sex work in public places, and it allows arresting sex workers who do not respect this principle. The law also criminalizes running of brothels (14). Studies from across India found that FSWs often face harassment and violence by the police, which was found to undermine HIV prevention efforts and increase experienced violence by clients (15-17).
Another factor increasing FSWs’ vulnerability is the changing urban landscape (gentrification): working class quarters get renovated in order to conform to middle-class taste. Consequently, brothels and their sex workers, as well as non-brothel-based FSWs are pushed from downtown locations to more scattered places across the city, complicating the delivery of prevention programmes (17).
Moreover, the changing nature of sex work, such as increasing number of FSWs using mobile phones for solicitation (70.9% in Maharashtra) makes FSWs more anonymous and difficult to reach with HIV prevention programmes (11, 17).
Photo: New Delhi/ Mira Gardi
Young FSWs’ risk behavior and HIV vulnerability
High HIV and STI prevalence among young FSWs
Young FSWs’ HIV prevalence was substantial with around every fifth young FSW being HIV positive. Despite overall young FSWs are much more vulnerable for HIV and have a higher risk behavior, it is not surprising that older FSWs had a higher HIV prevalence, as the probability of getting infected with HIV is correlated with the time spent in sex work.
In contrast to the HIV prevalence, the STI prevalence was overall higher among young FSWs compared to the older cohorts. Every 7th young FSW suffered from at least one STI (Syphilis, Chamydia, Gonorrhoea). This high STI prevalence among young FSWs increases their vulnerability for HIV, as being infected with STIs constitute a risk factor for the acquisition of HIV (9).
Young FSWs are of higher demand than older FSWs
The young age is per se already a risk factor: Young women have a higher level of cervical ectopy and genital inflammation – a risk factor for HIV and/or STI infection (18). My study found that young FSWs were even younger when entering into sex work compared to the older FSWs. Being young and new in sex work (i.e. short duration of sex work) makes young FSW more vulnerable to agree to risky practices, due to the lack of work experience and lower negotiation skills.
Photo: Indian sex workers/Ben Sutherlands/flickr, CC BY 2.0)
In line with earlier evidence, my study found that young FSWs had a higher client volume compared to older FSWs, which increases the vulnerability to HIV, i.e. due to repeated trauma of immature genital track (3, 4). The number of clients decreases with age as young FSWs are in greater demand (4, 19). Especially for young FSWs sold as “virgins” clients pay huge amounts of money (17). A higher client volume was observed in brothel settings, which might be due to young FSWs’ limited freedom in closed settings to choose and refuse clients, as decisions are made by gharwalis (brothel madams) (21). As an earlier study in India concluded that the mean age at trafficking was 17 years, it can be assumed that among the younger FSWs (< 25 years), there is a relatively large proportion of newly trafficked FSWs (20). Literature shows that FSWs having been trafficked tend to have more clients as they have to earn as much as possible to offset the cost of their acquisition (17, 21, 22).Being trafficked as well as having a larger client volume increases the risk for physical violence (22, 23).
High levels of violence
My study found that younger, inexperienced FSWs were more frequently victims of violence and forced sex compared to older ones. Having been trafficked, having little choice to refuse clients and working in a coerced setting under control of a brothel madam are important determinants of violence and HIV risk, as shown by another study from a neighboring state (24). However, especially in non-brothel settings young FSWs face higher levels of violence and forced sex. This group is highly vulnerable because of the risk of police arrest as solicitation in public places is illegal in India, as well as due to the fact that sex work takes place in a hidden context.
Photo: Condom distribution in the red light district of Sangli, India/International Women's Health Coalition/flickr, CC BY-NC-ND 2.0)
Self-reported consistent condom use and social desirability
In order to assess the risk behavior and the way of how HIV can be transmitted, it is crucial to look at the consistent condom use (CCU) of young FSWs with their paying clients and non-paying partners. CCU with non-paying partners was low across all age groups (around 13%), while CCU with paying clients was reported quite high (above 90%). However, this self-reported CCU with paying clients might be lower in reality, as respondents are likely to answer sensitive questions with what is socially more accepted (i.e., social desirability bias) (25). Especially young FSWs that feel under pressure of brothel madams or that are newly trafficked might be more likely to over report CCU. Moreover, violence – which was found to be especially high among the younger FSWs – is highly associated with lower CCU (7, 23). Similarly the high prevalence of HIV and STIs among young FSWs make it hard to believe that such a high percentage of young FSWs is using condoms consistently with their clients and the way of infection is through their non-paying partners.
Young female sex workers are often hidden
In brothel settings, young FSWs had a considerably lower exposure to HIV prevention programmes (condom distribution, contact with peer educator, condom distribution, clinic visit) than older FSWs. Despite the fact that HIV prevention may have been higher in brothels (e.g. easier to identify sites), evidence and key informants suggest that especially young FSWs in brothels are often hidden by gharwalis (brothel madams) and not allowed to go out, which hinders them from accessing HIV programmes outside brothels. In addition, programme staff are often are not allowed into brothels as “outreach workers are bad for business” and thus young FSWs are not reached (17, 21). Therefore, close collaboration with stakeholders (e.g. gharwalis, community members) is crucial while implementing HIV prevention programmes, as also highlighted by a key informant. In non-brothel settings the challenge to reach out with programs are mainly that sites are unknown and hidden: an increasing number of sex workers entertain clients in private homes and uses apps or mobile phones for solicitation, which is partly also a result of empowering FSWs. Another factor hindering prevention work in non-brothel settings is that women selling sex may not identify themselves as sex workers (e.g. college students that sell sex occasionally). As challenges of each setting are different, it is also important to tailor further prevention programmes to their respective settings (brothel or non-brothel).
Evidence showed that lower awareness and trust in NGOs among young FSWs resulted in reduced access to services (26). A key informant from an NGO working with FSWs, who was interviewed in this study, argued – young FSWs often have a lack of interest in using and adhering to HIV prevention programmes as they feel healthy and do not want to know their status. They fear to be stigmatized if found to be HIV positive. Consequently, reaching out to young FSWs as well as keeping young FSWs in the programme is difficult, as their interest in the program might be low. For an effective HIV prevention, it is rather important that young FSWs are not only exposed once to interventions but that they stay in the programme.
Photo: Steve Evans/flickr, CC BY-NC 2.0)
Recommendations - New strategies are urgently needed
Key informants and evidence have shown success to make HIV prevention programmes more attractive for young FSWs using beauty parlors, where along free or cheap beauty services, HIV testing, education and empowerment are provided (27). To effectively work with young FSWs and encourage programme adherence, younger peer educators that can build a trustful relationship with young FSWs should be involved (26). To overcome the challenge with self-identification and stigma, an approach that focuses on risks rather than on key populations might be crucial. Information, communication and education (IEC) and Behaviour Change Communication (BCC) strategies need to be tailored specifically to this group. Strategies should also make use of new information technology (e.g. use of Whatsapp and other apps) to adapt to changing face of sex work. This is proposed in the newly designed National Strategic Plan for HIV/AIDS and STI 2017-24. As of now, this is proposed only on a policy level, further development of implementation strategies is crucial in order to ensure that young FSWs are reached effectively by HIV prevention programmes. In this regard also the involvement of civil society organizations is important, to understand what is actually happening in the field and what challenges they face. In India the civil society is very strong and was also present during the stakeholder meetings where the national AIDS strategy was discussed. UNAIDS plays an active role in civil society mobilization.
Reducing new infections among young FSWs is crucial, as young FSWs that are HIV positive may be more likely to spread the virus further, due to their higher client volume, as well as the longer duration they will still stay in sex work. Therefore, tackling the epidemic among young FSWs is crucial in order to end the HIV/AIDS epidemic by 2030 and reach SDG target 3.3.
Author: Mira Gardi, MMS intern and project leader, has examined the situation of young female sex workers in India with UNAIDS India as part of her master thesis (Master of Science in Global Health).
For more information and details on the study please contact mgardi@medicusmundi.ch
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