‘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.

International Human Rights Day 2013: Reflections on Rights Situation of PLHIV and Key Populations in India

HRD_blogSince the United Nations adopted the Universal Declaration of Human Rights in 1948, there has been a slow but steady expansion of international agreements that promote and protect the rights and dignity of all people everywhere. But even today, people living with HIV (PLHIV) and members of key population groups, such as men who have sex with men, transgenders, hijras, people who inject drugs and sex workers, continue to face violations to their basic rights. They are denied recognition in society, face barriers in accessing basic services like healthcare and education, and are often victims of violence and other forms of discrimination and marginalization.

Protection and fulfilment of the human rights of vulnerable communities are at the core of India HIV/AIDS Alliance’s work. Although the full enjoyment of their rights remains a dream for too many people, there are stories of hope and courage. This Human Rights Day take a look at some of the challenges facing India and how we’re responding:

The Other Epidemic: Gender-based Violence in India

Gender-based violence is an epidemic facing India and the world, and like AIDS, it will require a sustained and committed effort to overcome. Attitudes must change. We must never tolerate violence against women and girls. We must never be blind to gender’s diversity. Read more.

Fighting for the Right to Health for Women Living with HIV: A Success in Gujarat

Stigma and discrimination remain among the primary barriers to achieving universal access to HIV treatment, care, and prevention. As HIV treatment programmes become increasingly available, access to these lifesaving services depends on the degree to which all health facilities welcome PLHIV and respect their rights. Read more.

Confronting Quackery, Demanding Care: India’s Hijras Seek Access to Sex Reassignment Surgery Services

India’s hijra community routinely experiences mistreatment at the hands of doctors and the health system. Progress is slow and often only as a result of significant advocacy by community organisations. Hijras and transgenders have the same right to health as any other citizen, and the government must act to protect their lives. Read more.

Confidentiality: A Health and Human Rights Issue for PLHIV

There is nothing more angering than the thought of stigma faced by people living with HIV (PLHIV). Take, for example, the situation where numerous PLHIV had their HIV status published on the front page of their medical history records, making confidential information available to anyone who glanced at their files. Read more.  

The Pain of Being ‘the Other’: How Stigma Fuels HIV/AIDS among People Who Inject Drugs in India

The vulnerability of people who inject drugs (PWID) is further fuelled by the fact that society perceives drug users as criminals and a threat to society. This makes it difficult for people who want to reach out to them to build rapport and trust. This demonization further fuels the HIV epidemic in the country. Read more.

Shedding Light on Abuse: Alliance India study shows that almost 50% of women who inject drugs in Manipur report harassment and abuse from community members

A study conducted by Alliance India sheds light on the extent of the social discrimination and isolation experienced by women who inject drugs in Manipur. The lack of a support system in the lives of women who inject drugs significantly increases their isolation and likelihood of engaging in sex work as a means of earning a living. Read more.

A Beacon of Hope in the Fight Against Child Marriage: One Girl’s Story

The issue of child marriage is a very common problem in Allahabad in the conservative Indian state of Uttar Pradesh. Here, girls are married early and are expected to bear children soon after.  Issues such as contraception, sexually transmitted infections, and reproductive rights of young people are met with a wall of silence. Read more.

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.

Strengthening STI Services for Key Populations: Alliance India’s Mythri Mainstreaming Model

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Providing STI/HIV services in rural areas with fewer and scattered key populations (female sex workers, men who have sex with men, transgenders) is a challenge for HIV prevention programmes in India. In such scenarios, project-supported static clinics are not a sustainable option because of the limited availability of skilled health professionals and operational costs involved. Realising this need for sustainable approaches for providing STI services to key populations, India HIV/AIDS Alliance in collaboration with Andhra Pradesh State AIDS Control Society (APSACS) conceptualized the Mythri Mainstreaming Model in March 2007 as part of programming it supported under the Bill & Melinda Gates Foundation-funded Avahan India AIDS Initiative.

Alliance India initiated the model through a public-private partnership (PPP).The model used infrastructure and personnel of existing government healthcare facilities. Capacity building of staff, provision of STI drugs, and syphilis screening kits were provided by Alliance India to enable the provision of an essential package of STI services. STI services were provided after regular outpatient hours to female sex workers, men who have sex with men, and transgender communities. To address stigma and discrimination in accessing government facilities, doctors and staff were trained on issues faced by these clients.

The Mythri Mainstreaming Model achieved notable success. It resulted in improved utilisation of public healthcare facilities. Within the first year of initiating these clinics, more than 60% of targeted key populations had accessed these STI services. It successfully brought these groups to mainstream healthcare services. The Mythri model serves as a ‘one-stop’ centre for HIV/STI as well as other health care needs of key populations. Considerably greater understanding on health issues of key populations developed among medical staff, and these groups reported less stigma and discrimination while accessing services. Additionally, government healthcare facilities enjoyed improved infrastructure and staff capacities.

A study done by Alliance India to identify the most effective healthcare model for the delivery of STI services found that of the three models studied—project-owned clinics, private clinics, public private partnership (Mythri) clinics—the Mythri model was the most cost-effective. The model was also found to be the most effective in leveraging the strengths of the public and private sector and was the most sustainable of the three.

Due to lower operational costs and with better performance indicators, the Mythri Mainstreaming Model offers characteristics that make it preferable to other models of HIV/STI service delivery for scattered key population groups in rural areas. Similar models should be promoted in other resource-poor settings to improve HIV prevention and overall healthcare for vulnerable populations, such as female sex workers, men who have sex with men and transgenders.

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The author this post, Dr. M. Ravikanth, was Documentation & Communication Specialist with India HIV/AIDS Alliance in Andhra Pradesh.

The Avahan India AIDS Initiative (2003-2013) 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, specifically 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.

Community Collectivisation to Sustain HIV Prevention: Findings from Avahan in Andhra Pradesh

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Community collectivisation empowers key populations such as female sex workers, men who sex with men and transgenders to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes. Photo by Peter Caton for India HIV/AIDS Alliance

Community collectivisation can help develop a stronger sense of purpose and interconnectedness among key populations (KPs) such as female sex workers, men who sex with men and transgenders. Sometimes known as ‘community mobilisation’, community collectivisation enables these groups to utilise their experience of vulnerability to overcome barriers they face and realize reduced HIV vulnerabilty and greater self-reliance. Collective action by KPs also empowers them to voice their concerns and more confidently exercise their right to access healthcare and social welfare schemes.

With support from the Bill & Melinda Gates-funded Avahan programme, a recent study led by Niranjan Saggurti of Population Council in collaboration with India HIV/AIDS Alliance was designed to demonstrate if community collectivisation is associated with consistent condom use and STI treatment seeking behaviours among female sex workers (n= 3,557) and high-risk men who have sex with men/transgenders (n=2,399) in Andhra Pradesh. Recently published in the journal AIDS Care, the study generated significant positive findings.

Entitled ‘Community collectivization and its association with consistent condom use and STI treatment seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India’, the study showed that high levels  of collective action and participation in public events by both populations led to higher levels of consistent condom use, increased STI treatment seeking from government facilities, and improved ability to negotiate condom use.

The findings confirm the value of sustained community system strengthening to empower communities to meaningfully engage in national HIV prevention efforts and show the key role played by community collectivisation as an essential strategy to encourage consistent condom use and health seeking behaviours among KPs.

Read the complete study here.

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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.