Mobilizing sex workers to stop HIV

Dr. James Blanchard, director of the University of Manitoba’s Centre for Global Public Health, spoke Oct. 21, 2013, about the importance of understanding communities when doing HIV prevention and protection work. He has worked in India on a major HIV prevention pilot program, since scaled up in an attempt the reverse the epidemic in a country of more than a billion people.

The first step was exploring transmission dynamics in order to prioritize interventions. What was driving this epidemic?

The team found sex work was their answer, due in part to the long history of prostitution in India. Sex work is much more common in India than it is in North America, with about 10 sex workers per 1,000 men. Around 1-1.5% of women in India are engaged in sex work. HIV prevalence is about 10 times higher in female sex workers than the rest of the population.

“This is rooted within the sex structure of India,” Blanchard said. Men significantly outnumber women in India and the result is a small population of women (sex workers) satisfying the sexual desires of men who do not have partners.

The project was funded through the Bill and Melinda Gates Foundation over 10 years. Locations in Karnataka and Southern Maharashtra were mapped for networks of sex workers, and then these locations were continuously monitored. The first component of the project was community mobilization and the second was building an enabling environment for a focused prevention program.

The basic program elements included outreach and peer education, basic health services, condom programs and vulnerability reduction. Peer educators designed the program with an individualized response to the needs of each sex worker. Each educator would look at the geographic location and decide how to approach the issue in that area. For example, what is the best way to distribute condoms in an area? Should condom boxes be placed in restrooms, or would it be best if peer educators placed condoms into the hands of sex workers? The teams also engaged in vulnerability reduction strategies involving crisis response teams for sex workers, police sensitivity training, skill building and economic empowerment for sex workers.

Over five years in districts where infection rates had been high, they dropped dramatically following the intervention. In one district, the researchers estimated that between 2004 and 2008, more than 3,000 potential HIV infections were averted through the program. That’s 55% of potential cases.

The program has now been scaled up, and is delivered by large collectives of sex workers, with funding from the Indian government.

Discussion:

Did you get any pushback from the clients of sex workers?

Not so much clients but we did get pushback from boyfriends and pimps. One misunderstanding that people have is that clients have power. The sex worker actually has power over clients. Clients don’t want to be seen visiting a sex worker, and the sex workers know where to go for privacy. I would say 80 per cent of clients that women have they have zero issues with, it’s the 20 per cent who are problematic. The question is how do we solve that? One of the big issues was with violent drunks and the solution to this problem was interesting. The sex workers in one area got together and collectively decided that they would not work after 8 p.m.

How could results of this research be applied in Canada?

We actually had an outreach conference in Montreal where we talked about this. However, the idea was met negatively from the community. Not knowing the Canadian situation as well, I let the issue drop. But since last year, we’ve been approached to see if we can start working in Canada, including with the Winnipeg Regional Health Authority, on mapping where sex workers are and how peer educators can be used.

What factors drive women to sex work?

This is very complex. Socio-economic factors are at play either in families or within groups. Generally, it is some kind of economic crisis in the family, or women have gone through a divorce and they need to be able to support themselves. What is the solution? The simplistic answer is to eliminate poverty. You could also discourage men from visiting sex workers, but you would have to focus on changing the culture in this approach.

Comments are closed