Advocating for Stigma-free Healthcare for Female Sex Workers

Advocacy coalitions under Koshish have successfully engaged with stakeholders to identify sexual and reproductive health needs of vulnerable populations like female sex workers. (Photo by Peter Caton for India HIV/AIDS Alliance)

Advocacy coalitions under Koshish have successfully engaged with stakeholders to identify sexual and reproductive health needs of vulnerable populations like female sex workers. (Photo by Peter Caton for India HIV/AIDS Alliance)

While conducting community consultations in East Godavari district of Andhra Pradesh, the Koshish programme team learned that female sex workers (FSWs) in the district faced numerous challenges in accessing healthcare services, including stigmatizing behaviour, discrimination, and apathy of service providers. A majority of FSWs who spoke at the consultations mentioned that counsellors at the Integrated Counselling and Testing Centre (ICTC) at the government hospital at Kakinada were highly insensitive and asked unnecessary questions while providing them services.

The advocacy coalitions set up under Koshish took note of the matter and decided to collect evidence from the community and flag the issue to relevant authorities. The team documented experiences of 50 community members and approached the Additional District Medical & Health Officer for redressal. After the initial briefing on the project and its activities, the community members shared their concerns. They narrated how clients were asked irrelevant questions by the counsellors and faced deliberate delays in testing and reports.

Appreciating the difficulties faced by FSWs, the official instructed his office to issue a circular to all ICTCs to remind them of their obligation to provide client-friendly services and not delay sample collection deliberately. He also facilitated the provision of other social security schemes and entitlements to these community members like Aadhar cards, Antyodaya cards, caste certificates and even voter registration. Later, the officer organized a review meeting with all counsellors in the district and invited Koshish partners. In the meeting, the official emphasized to the counsellors, “Key populations are to be given priority in availing health services.”

Supported by the European Union, Alliance India’s Koshish programme advocates for policies and strategies on sexual and reproductive health (SRH) and rights for people living with HIV (PLHIV) including key populations in India. The programme is implemented in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat. The advocacy coalitions under Koshish have successfully engaged with stakeholders and identified unfulfilled SRH needs of PLHIV. With these coalitions in place, Koshish makes sure that voices of communities affected by HIV/AIDS are heard by decision makers and the problems they face every day remain at the heart of the programme’s state-level advocacy agenda.

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India HIV/AIDS Alliance works closely with PLHIV in India through its Koshish programme which strengthens civil society organizations and networks that represent and work with PLHIV and other marginalized groups, such as MSM, transgenders, sex workers and IDUs, to effectively advocate for policies to improve the sexual and reproductive health and rights of PLHIV in India. This project is funded by the European Commission and is implemented in partnership with MAMTA, PWDS, VMM and CHETNA, along with state-level networks for PLHIV in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat.

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“Fearless”: Improving Sexual & Reproductive Health of Female Sex Workers

Targeted Interventions allow female sex workers to access services in a more supportive and less stigmatizing environment as compared to government hospitals. (Photo by Peter Caton for India HIV/AIDS Alliance)

Targeted Interventions allow female sex workers to access services in a more supportive and less stigmatizing environment as compared to government hospitals. (Photo by Peter Caton for India HIV/AIDS Alliance)

In India, as elsewhere, female sex workers (FSW) have considerable unmet sexual & reproductive health (SRH) needs due to their occupation and social marginalization. They shy away from accessing SRH services due to stigma and discrimination, negative attitudes of healthcare providers, and fear of law enforcement agencies, clients and people opposed to sex work.

Under the country’s National AIDS Control Program (NACP), targeted interventions (TIs) for FSWs are implemented to provide access to HIV prevention services. TIs allow FSWs to access services in a more supportive and less stigmatizing environment as compared to government hospitals. Unfortunately, TIs do not include SRH services in spite of the immediate relevance of these services.

Evidence, both global and national, has shown that linking HIV and SRH services provide a valuable impetus to encourage uptake of prevention, treatment, and care and support services, especially by people living with HIV (PLHIV) and key populations, including FSWs. With this approach in mind, India HIV/AIDS Alliance with support from MAC AIDS Fund has initiated a pilot programme Abhaya – meaning ‘fearless’ in Hindi – for FSWs in Andhra Pradesh and Gujarat.

Within existing TIs for FSWs, Abhaya expands access to complementary SRH services. The project enables FSWs and their partners to reach to a broader range of services like SRH information, counselling, referral and linkages to facilities providing relevant services. Along with this, the intervention also builds the capacity of existing healthcare providers and other relevant stakeholders to ensure a responsive attitude towards FSWs. Abhaya will also engage in advocacy with the government to identify opportunities to adapt and scale-up these expanded services in a stigma-free environment as a part of the national strategy.

Abhaya gives a significant role to FSWs and their partners in the implementation of the programme at all stages to increase ownership and the potential for sustainability of the initiative. Over the pilot year, the programme will reach 3,000 FSWs, helping them to better identify their SRH needs and access quality services thus empowering them to protect their overall health and wellbeing.

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The author of this blog, Kumkum Pal, is Programme Officer: HIV & SRHR at India HIV/AIDS Alliance.

Supported by the MAC AIDS Fund, Abhaya expands access to sexual and reproductive health (SRH) services as part of HIV prevention interventions for female sex workers (FSWs) in Andhra Pradesh and Gujarat. The programme will complement the existing targeted intervention (TI) programme under the country’s National AIDS Control Program (NACP) by providing key SRH services and linkages and increase the desirability and value of the TIs for FSWs. Alliance India is implementing the programme with support from Sakhi Jyot in Gujarat and Prema Sangam Mahila Mandali in Andhra Pradesh.

‘Has anything changed?’ A Decade of International Day to End Violence Against Sex Workers

Community mobilisation and peer support can make a significant difference in the lives of female sex workers, helping to reduce the impact of criminalisation, social stigma and vulnerability to HIV. (Photo: Peter Caton for India HIV/AIDS Alliance)

Community mobilisation and peer support can make a significant difference in the lives of female sex workers, helping to reduce the impact of criminalisation, social stigma and vulnerability to HIV. (Photo: Peter Caton for India HIV/AIDS Alliance)

The International Day to End Violence Against Sex Workers was created to call attention to violence and other hate crimes committed against sex workers all over the world. Conceptualised by Dr. Annie Sprinkle, the first annual day was observed in 2003 by the Sex Workers Outreach Project USA (SWOP-USA) as a memorial and vigil for the victims of the Green River Killer in Seattle, Washington. On that day sex workers gathered to honour women and sex workers murdered by the serial killer Gary Ridgeway. In the killer’s own words: “I also picked prostitutes as victims because they were easy to pick up without being noticed. I knew they would not be reported missing right away and might never be reported missing. I picked prostitutes because I thought I could kill as many of them as I wanted without getting caught.”

Today, ten years from that first annual observation we should to pause and take stock. Has anything changed substantively in the last decade?

“Sex workers are subject to violence from the general community, who do not view us as deserving of protection. Sex workers are often rejected by family and peers, and for transgender and HIV-positive sex workers, the stigma can be even more intense.” (Friends Frangipani, Papua new Guinea, Asia-Pacific Regional Dialogue, 16–17 February 2011, quoted in Global Commission on HIV and the Law (GCHL) report “Risks, Rights & Health”)

In a public letter, Sprinkle states: “Violent crimes against sex workers go underreported, unaddressed and unpunished. There really are people who don’t care when prostitutes are victims of hate crimes, beaten, raped, and murdered. No matter what you think about sex workers and the politics surrounding them, sex workers are a part of our neighborhoods, communities and families.”

The GCHL report published in July 2012 highlights that more than 100 countries globally criminalise some aspect of sex work. Some countries, such as most of the United States, Cuba, People’s Republic of China, Iran, Vietnam and South Africa, outlaw sex work entirely. Some in Western Europe, Canada, Latin America, and South Asia prosecute activities related to sex work such as brothel-keeping or transporting sex workers, communicating for the purposes of prostitution, street soliciting and living off its profits. Norway and Sweden do not criminalise workers themselves, but paradoxically criminalise buying sex and arrest clients of sex workers.

Most countries use other laws against civil and administrative offences such as “loitering without purpose”, “public nuisance”, and “public morality” to penalise sex workers. Often anti-human trafficking laws are targeted against adults involved in consensual sex work rather than ensuring that the enforcement of those laws identify and punish those who use force, dishonesty or coercion to procure people into commercial sex, or who abuse migrant sex workers through debt bondage, violence or by deprivation of liberty.

The report goes on to say that for sex workers, the threat of violence – from both police and other actors – is a daily reality. Criminalisation, in collusion with social stigma makes sex workers’ lives more unstable, less safe and far riskier in terms of HIV. There is no legal protection from discrimination and abuse when sex work is criminalised. These kinds of laws invite police harassment and violence and push sex work underground, where it is harder to negotiate safer conditions and consistent condom use. Some sex workers fear carrying condoms, which are used as evidence against them, sometimes as an explicit provision of law. Police violence prevents sex workers from seeking their assistance, which ingrains a culture of more client and police violence.

Stigmatised, criminalised sex workers are unable to access programmes of HIV prevention and care. Police, criminals and clients deploy the threat of criminal sanctions to control and exploit sex workers. Rape and assault are difficult to report when the sex worker fears that she will be arrested, and sexual violence heightens exposure to HIV. Working in the informal sector reduces sex workers’ access to education and housing, thus increasing their dependence on others, including pimps.

Today, to make the observation of the International Day to End Violence Against Sex Workers meaningful, we must join the demands of sex workers, and their friends and allies to address the structural factors that continues to perpetrate, condone, and justify persistent violence against sex workers world-wide. Given this unsupportive legal environment around the world and the stigma against sex work, sex workers, and their clients, the critical first step towards ending violence against female, male, or transgender sex workers would be to repeal laws that prohibit consenting adults to buy or sell sex, as well as laws that otherwise prohibit commercial sex, such as laws against “immoral” earnings, “living off the earnings” of prostitution and brothel-keeping. Moreover, sex workers must have access to justice to ensure safe working conditions and security against violence from state and non-state actors.

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The author of this blog, Nandinee Bandyopadhyay, is an independent consultant. She has been working on issues of class, gender, and sexuality for over thirty years. She has worked extensively with sex workers’ movements in India and internationally. 

Keeping Violence at Bay in Andhra Pradesh: International Day to End Violence against Sex Workers 2013

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

Violence, stigma and discrimination decrease the capacity of sex workers to access health care and other social services. (Photo by Peter Caton for India HIV/AIDS Alliance)

“I filed an application for a ration card in the mandal (block) administrative office. The clerk made me come to office 15 times, and every time he slept with me,” rues Meena  (name changed), a sex worker from Andhra Pradesh. “Wherever we go – offices, schools, hospitals or banks – we are sexually exploited and discriminated against.”

Sex workers across the world are easy targets for violence and discrimination at work, at home and in society at large. Data show that violence faced by sex workers ranges from slapping to sexual assault, physical and psychological torture, and sometimes even murder. HIV programmes across the world are grappling with this reality of sex workers facing high levels of stigma, discrimination, gender-based violence and other human rights violations, which prevent them from accessing HIV information, health care and needed social services.

To tackle the problem, India HIV/AIDS Alliance has worked through our Avahan programme to develop community-led strategies for prevention and mitigation of violence among female sex workers and other sexual minorities. Working in a total of six states, the Avahan India AIDS Initiative is funded by the Bill & Melinda Gates Foundation. In Andhra Pradesh, our programme covered over 40,000 sex workers in 14 districts. Programme strategies on violence include: community mobilisation and empowerment, crisis response systems and teams; and sensitisation of police and other law enforcement agencies, media personnel and service professionals. The crisis response teams respond within 24 hours to any violence reported by liaising with legal services in the event of unlawful arrests, sexual assault, violence and other rights violations against sex workers.

Since 2006, our team has successfully sensitized around 7,000 police officials at state, district and block level. Over 700 community members have received training on law and human rights and have been recognized by the District Legal Cell Authority as para-legal volunteers (PLVs). PLVs from sex-worker communities provide support to those in need. In addition, community collectivization and legal education has empowered sex workers to recognize and address cases of violence against them.

Routine monitoring on violence and crisis response including data collected from Targeted Interventions for HIV prevention and from special Behavioural Tracking Surveys (BTS) among 2,000 female sex workers in five districts in Andhra Pradesh between 2009 and 2012 showed an improved response to violence in sex worker communities. The number of cases of violence against sex workers has declined by 68 percent, from 900 cases in 2009 to 288 cases in 2011. The BTS data indicate that there has also been a reduction in violence by police (from 29% in 2009 to 19% in 2011-12). The perception of fair treatment by police has increased from 14% (2009) to 29% (2011-12), and around 70 percent of sex workers now experience what they consider to be fair treatment at public institutions.

“Earlier we shuddered at the sight of police. Not anymore. We now know our rights and what to do in a crisis,” says Meena with confidence.

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The author of this post, Dr. Parimi Prabhakar, is Director of Alliance India’s Regional Office in Hyderabad.

The Avahan India AIDS Initiative (2003-2014) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, notably female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

A Long Way to Zero… | World AIDS Day 2013

(Photo by Peter Caton for India HIV/AIDS Alliance)

(Photo by Peter Caton for India HIV/AIDS Alliance)

“Getting to zero” is the theme of this year’s World AIDS Day. It is an ambitious goal, to be sure. Three goals, in fact. Three zeros. Zero new HIV infections. Zero AIDS deaths. Zero stigma and discrimination. Are we now so close to declaring victory? Are we really on a path to an AIDS-free world? Is the end of AIDS on the horizon?

On one hand, we have never been better positioned to achieve such goals. We have good epidemiological data. We know where the epidemic thrives. We know who are most at risk, and we have the tools to reduce their vulnerability. For those infected, we have treatment.

Yet mastering this epidemic remains elusive. Why does there still seem to be zero chance that we will achieve any of UNAIDS’ zero targets anytime soon? Although it’s no longer popular to say so, AIDS remains exceptional. As a virus, it has proved remarkably resourceful, outwitting scientists and keeping a vaccine or cure out of reach.

But for all its microscopic muscularity, HIV is still winning because we’re letting it win. Those most at risk — sex workers, men who have sex with men, people who inject drugs, transgenders and hijras — remain on the margins, socially stigmatized and victimized by legal discrimination. People living with HIV bear a daily burden of society’s cruelty and inaction.

Don’t get me wrong. Things are better than they’ve ever been, but better isn’t good enough. Our tools and knowledge can only stifle this epidemic if they are marshaled to the task. Government coordination must be matched with community mobilization and sustained in collaboration with civil society. National treasuries, donor governments, corporate houses and private citizens alike need to pitch in to support these efforts.

This World AIDS Day, even as we appreciate progress in India and elsewhere, we should not lose our momentum or let crumble the foundation that has been built in the quarter century since the first World AIDS Day in 1988. The path to zero is still long, even if the destination is clear.

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The author of this blog, James Robertson, is Executive Director of India HIV/AIDS Alliance in New Delhi.

This blog was republished on One World South Asia on 2nd December 2013. 

What Difference Does Discrimination Make? Reflections for World AIDS Day 2013

Lord Fowler during his visit to Lakshya Trust in Surat, Gujarat. (Photo: India HIV/AIDS Alliance)

Lord Fowler during his visit to Lakshya Trust in Surat, Gujarat. (Photo: India HIV/AIDS Alliance)

I have just returned from a visit to India to see what is being done in tackling HIV and AIDS. Back at the start of the epidemic in 1986 I was health minister in Britain. We carried out a very high profile public education campaign using television, radio, poster sites to get the message through. We sent leaflets to every home in the country. Remember at this time there was no treatment. If you contracted HIV it was so often a death sentence.

But of course we were a relatively small country. India has a massive population of well over a billion and a vast area to cover. It is enormous credit to those early public health activists and to their successors on what has been accomplished. The creation of the National AIDS Control Organisation in itself was a massive achievement. Unlike some countries I have visited over the last 18 months there has been close cooperation with civil society organisations like India HIV/AIDS Alliance and many others. India put prevention first and the figures tell the story.

There has not been the explosion we have seen in Sub Saharan Africa where in one country almost a quarter of the population are infected. There may be two million people in India with HIV but compared with the population, prevalence is remarkably low. If you take injecting drug users then India has followed the sensible policy of providing clean needles. This should eliminate the spread of the infection by dirty needles being shared.

Does this mean then that all the problems in India have been solved? Of course not. No country can claim that. We still have a major problem of discrimination and stigma when it comes to  sexual minorities. Drug users are often treated with contempt as are transgender people who face particular prejudice. Sex workers continue to be exploited – although HIV transmission has fallen due to the vastly increased use of condoms. Men who have sex with men are still widely condemned.

And what difference does such discrimination make? It means that many men and women are unwilling to come forward for testing. They fear what the impact may be on their lives if it is known that they are positive. They fear the reaction in their families, in their communities and at work. And the effect is this: They are undiagnosed and continue to spread the virus. HIV and AIDS continue to increase. Deaths mount.

Of course this is not just a problem in India. It is a problem in every country in the world that I have visited. On this World AIDS Day we should vow to fight the discrimination and the stigma – and make a new effort to get people to test and get on treatment as it becomes more and more available. HIV is no longer a death sentence but the earlier a man or woman goes into treatment the longer life will be.

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The author of this blog, Lord Norman Fowler, was a member of Margaret Thatcher’s Cabinet and served as chairman of the Conservative Party under John Major between 1992 and 1994. He was instrumental in drawing public attention to the dangers of AIDS in Britain. He is the author of A Political Suicide: The Conservatives’ Voyage into the Wilderness and is currently writing a book on the global AIDS epidemic. Hosted by Alliance India, Lord Fowler recently visited New Delhi and Surat, Gujarat, to learn more about how this country has risen to the challenge of HIV.

“11 for ICAAP 11”: A Selection of Alliance India Posters at ICAAP (November 17-22, 2013, Bangkok, Thailand)

Alliance India is presenting a total of 31 posters at the 11th International Congress on AIDS in Asia and the Pacific (ICAAP 11) in Bangkok, Thailand, 17-22 November 2013. To mark the 11th ICAAP, below are a selection of 11 of our posters displayed in Bangkok that detail our work supporting community-based programming for people living with HIV (PLHIV), men who have sex with men (MSM), transgenders, hijras, sex workers and people who inject drugs (PWID), all key priorities to addressing India’s complex epidemic.

Paving the Pathway: PLHIV community consultations enhance national care and support programme in India

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Factors Influencing SRH Service Uptake by PLHIV: Findings from the Koshish baseline study in India  

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An Emergent Crisis: Addressing the Hepatitis C Epidemic in People Who Inject Drugs (PWID) in India

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By the Community, For the Community: Involving PWID in Assessment of Drug-using Patterns Assessments

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Identifying Access Barriers for Transgenders Seeking Gender Transition Services in India

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Community-led Advocacy to Address SRH Needs of PLHIV: Experience from the Koshish programme in India

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Service without a Smile: Pehchan study of the friendliness of HIV services to sexual minorities in India

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Positive Rights and Sexual Health: A review of SRH laws and policies for PLHIV in India

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Tracking Organisational Development of Sexual Minority CBOs in India Using Pehchan’s ‘CBO CyclePoster_Page_10

Power in Our Hands: Increasing involvement by sexual minorities in HIV programme oversight in India 

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Promoting Entrepreneurship among Sex Workers to Reduce HIV Vulnerability in Andhra Pradesh

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