HIV/STD Intervention Project
In 1992 WHO (GPA) funded National AIDS Control Organisation (NACO) to undertake a three month community based cross-sectional survey in Sonagachi, one of the oldest and largest red light areas of Calcutta, to assess the prevalence of STD (sexually transmitted diseases) and HIV among sex workers. The survey was conducted by All India Institute of Hygiene and Public Health (AIIH & PH), a Government of India institution in collaboration with local NGOs and Community Based Organisations (CBOs). The survey looked into issues of social demography of the locality, mapped the sexual behavioural practices among sex workers, their clients and partners and assessed the prevalence of STD and HIV among them.
Following the survey AIIH & PH initiated an intervention programme in the area with the objective of controlling spread of STD and HIV. The intervention programme started with three principal components:
- provision of health services including STD treatment;
- information, education and communication (IEC);
- and condom programming.
The programme was put into operation through a colloaborative network of government and non-government institutions. The conglomerate was constituted by AIIH & PH, in overall charge of the programme, some NGOs, providing the personnel and ancillary services, and several local CBOs, providing physical space and logistical support to run the health clinics and also helping in mobilising the community to participate in the programme. In 1994 Socio Legal Aid Research and Training Centre (SLARTC), a NGO, joined the conglomerate and helped in providing legal awareness training and legal aid for sex workers and the community. Durbar Mahila Samanwaya Committee (DMSC), a sex workers' forum which emerged with direct support of the Project, became an active participant in the programme from 1995.
There are various models of targeted STD/HIV intervention for sex workers, from mandatory screening to giving sex workers themselves an central role in health promotion.The design of SHIP's programme in Sonagachi was standard one, utilising sex workers as Peer Educators to disseminate information leading to behaviour change, distributing and promoting the use of condoms among sex workers, and referral to and provision of treatment of STD and general health problems. What however, is unique about the approach of SHIP is that it gave sex workers a central status within the aprogramme right from the beginning. The leadership of SHIP tried to imbue a genuine spirit of partnership between the Project team and the community of sex workers. From the start the profession of sex workers was accepted as a legitimate one and no attempt was made at discouraging them to practice prostitution and therefore at rescuing or rehabilitating them. Instead the emphasis was on improving the material condition within which they work and live. Risk of STD and HIV infection was seen as on occupational health problem for sex workers.
The basic approaches that SHIP adopted can be summed up as three 'R's: Respect, Reliance and Recognition. That is respect towards sex workers, reliance on them to run the programme and recognition of their professional and human rights. In practice the Project focused on translating this approach into a relationship of mutual trust and rapport between the community of sex workers and the staff members of the Project. As no move was made to disrupt the on-going sex trade or motivate the sex workers to switch to other occupations, the programme did not pose any immediate or ostensible threat to the local power-brokers of the sex industry who in turn therefore did not hinder the programme. With the local controllers of the sex trade negotiation and highlighting mutual benefits and shared interests was found to be an strategically effective approach. More importantly, the programme recognised and actively addressed the issue of 'empowering' the sex workers of every status within the industry, as an essential component for sexual behavioural change leading to improvement of the health status of these women.
Very early in the life of SHIP, the Peer Educators, with the empathetic support of the Project management, recognised that even to realise the very basic programme objectives of controlling transmission of HIV and STD it was crucial to view sex workers in their totality — as complete persons with a range of emotional and material needs, and not merely in terms of their sexual behaviour, as it was essential to address the range of issues that determine the quality of their lives and to locate these issues in the broader context within which they live.
While promoting the use of condoms, the Peer Educators soon realised that in order to change the sexual behaviour of sex workers it was not enough to enlighten them about the risks of unprotected sex or to improve their communication and negotiation skills. Sex workers first need to value themselves enough to think of taking steps to protect their health and their lives. Even when fully aware of the necessity of using condoms to prevent disease transmission, individual sex workers may feel compelled to jeopardise their health in fear of losing their clients to other sex workers in the area unless it was ensured that all sex workers may not even be in a position to try negotiating safer sex with a client as they may be too closely controlled by exploitative madams or pimps. Moreover, if a sex worker is starving, either because she does not have enough custom or because most of her income goes towards maintaining a room or meeting the demands of pimps, madams, local power-brokers or the police, she may not be in a position to refuse a client who can not be persuaded to use condoms.
In order to motivate the larger body of sex workers to change their sexual behaviour and also to enable and encourage them to participate in Project activities and take best advantage of the services provided by it, the Peer Educators had to ensure that the entire body of sex workers in the locality developed a positive self image, had self-esteem and confidence and had an increased access to power so that they can articulate their needs and have an interest in investing in and planning for their future. They also realised that given the asymmetrical power relations within the sex industry and their social exclusion, the only way the sex workers could gain greater control over their own bodies, sexuality, income, health or life was through mutual support, collective bargaining and united action.
Thus the Project by its very design, went beyond the 'behavioural change model' and instead concentrated on the broader and more fundamental issue of social power relations which shape peoples' 'behaviour' and adopted strategies for empowerment of sex workers.
The most important direct fall-out of SHIP's activities has been the establishment of Durbar Mahila Samanwaya Committee (DMSC), a forum of sex workers. DMSC has been recurring brothel based as well as floating sex workers from all red light districts of Calcutta and other parts of West Bengal and has started its branches in all areas where there are sex workers, in order to reach out their services to as many sex workers as possible. Recently, the Peer Educators who formed DMSC, have started operating a HIV help-line, with the help of SHIP, mainly for helping serum positive sex workers and their families to cope with the social and psychological traumas associated with being HIV positive. When they come to know of sex workers who have contracted HIV, teams from the Committee visit them in there locality to extend moral and material support and also to sensitise the local community. The significance of this service is not restricted to affected sex workers alone but has broader implications. The thrust of this initiative is to challenge social constructions of AIDS patients in general and the misconceptions and apathy among the health professionals. In 1995 Peer Educators carried out a rapid assessment of the Sex Trade in West Bengal under the supervision of SHIP in order to map out a state level intervention programme. They indentified 254 red light districts and spots in the state. DMSC has started intervention initiatives in some of the selected red light areas since then.
The most recent development is perhaps the strongest indicator of how the strategy of empowering that SHIP followed has far reaching effect. A group of male sex workers operating in and around the red light areas of Central Calcutta approached DMSC and SHIP representatives with a written petition demanding that they too be included in the Committee and the programme. SHIP and DMSC members responded positively and promtly, as plight of the male sex workers are no less than the women involved in the trade, moreover their legal status is even more precarious as the sodomy Act of the Indian law penalises male homosexual act. Since then SHIP and DMSC have extended their work among a large group of male sex workers.
A programme of this kind, working towards reaching STD/HIV services and empowering one of the most deprived sections of the society obviously encountered various obstacles — both from within the sex industry and more critically from among the elite groups of the society who feel threatened by any change in the status quo and the existing socialj and political power equations.
From within the trade the greatest challenge was to instil a spirit of community among the sex workers themselves. However, the principal philosophy and strategy of SHIP of treating sex workers as responsible workers — both in society and within the Project, and later the formation of DMSC, meant that this issue was adequately addressed right from the beginning. The greatest obstacle however was posed by the dominant discourses on prostitution to be one which threatens the very core of 'respectable society'. As far as people with this point of view are concerned, be they the members of the police force, or social workers or intellectuals, sex workers can be pitied and rescued, but can not be given respect as 'workers'. To control disease among them, they have to be bullied and coerced but can not be given the autonomy or power to take control of their bodies and health. SHIP still has a long way to go and many a battles to fight, before it can shift this deeply entrenched dominant ideology of sexuality and sexual morality and establish the right of sex workers' to quality STD/HIV services and safe sexual health.
The most important lesson learnt from the Project is that to improve the health status of and control STD/HIV infection among an economically deprived, politically marginalised and socially stigmatised group like sex workers it is not enough to design a technically sound and efficient intervention programme. What is crucial for the success of any such intervention is to contest the social and structural power relations and ideologies that put such communities in such vulnerable position in the first place. Unless these structural obstacles are challenged at a much broader level, any micro intervention can not hope to bring about behavioural changes which will result in disease prevention. While working on STD/HIV with sex workers it is of crucial importance to keep in mind that the issues of class and gender have significant bearing on their ability to access the intervention services and take preventive measures. SHIP's experience of the Project shows that for a marginalised group to achieve the smallest of gains, it becomes imperative to challenge an all encompassing material and symbolic order that not only shapes the dominant discourses outside but, and perhaps more importantly, historically conditions the way the participants negotiate their own locations. The significance and historical importance of SHIP lies in the fact that through its innovative and flexible approach it has been able to create the real possibility of such negotiation, which is bound to have far reaching impact not only in the lives of sex workers but on the society in general.
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