Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India

Abstract

BackgroundThe period 2006–2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers’ risk environment is needed to explain this paradox.MethodsIn this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012.ResultsDramatic changes in Mumbai’s urban landscape dominated participants’ accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women’s decisions to compromise on condom use. Surveys monitoring HIV prevalence among ‘visible’ street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction.ConclusionsTargeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building ‘dark logic’ models to predict potential harms.

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India

“…This is consistent with findings that economic debt and more generally, economic vulnerability, contributes to HIV risk for sex workers [1,24]. Specifically, research indicates higher paid FSWs tend to frequent more controlled condom environments, with more formalized hierarchical structures [19,21,22].…”

“…First, low paid FSWs who solicit using traditional practices, such as brothels, street or brokers, may use mobile phones as a way to supplement their sex work income. For this group, mobile phone use may offer opportunities to earn sex work income without having to share profits to third party brokers and this may result in FSWs more willing to engage in high-risk sexual behavior with clients [1]. …”

“…This may result in less ability to screen out high-risk clients compared to FSWs who are using mobile phones exclusively. While these rationales require further study and confirmation, we believe they demonstrate a line of enquiry into understanding a new, more hidden sexual risk environment for FSWs that are not often captured with traditional FSW research and practice strategies [1,4]. …”

“…Emerging research indicates that the sophistication among sex workers, in respect to both mobile phone use and HIV/AIDS, requires moving beyond basic HIV/AIDS messaging to more substantive and empowering tools for sex workers [1,6]. In this paper, we identify a particular subset of FSWs, low paid FSWs who reported mobile phone and traditional solicitation strategies as most at risk for inconsistent condom practices.…”

“…While mobile phone use among Indian Female Sex Workers (FSWs) to connect with clients have consistently increased, strategies to integrate mobile phones into HIV/AIDS initiatives for FSWs have been limited, particularly in regard to HIV prevention [1–4]. The unique considerations required for sex work populations contribute to the challenge of designing effective strategies [5,6].…”