Is Scale-Up of Community Mobilisation among Sex Workers Really Possible in Complex Urban Environments? The Case of Mumbai, India

Abstract

BackgroundIn the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India’s national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation’s Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments.Methods and FindingsBetween March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as ‘sex workers’. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more ‘hidden’ ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and ‘pimps’ continued to restrict access to sex workers and the heterogeneous ‘community’ of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported.ConclusionLarge-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services.

Heterosexual men who patronise entertainment establishments versus brothels in an Asian urban setting – which group practises riskier sexual behaviours?

“…Programmatic recommendations to the EE settings are not so clear-cut, but there is a growing consensus that the interventions should be structural and targeting all key stakeholders, including the owners and management, for successful HIV/STI prevention [ 28 – 33 ]. In a study in the southern Philippines [ 28 ], female EE workers who received peer and establishment manager interventions, and establishment policies favouring condom use, reported more positive condom attitudes and fewer STIs than the peer-only intervention and the control group.…”

“…It was also reported that the recommended programmatic actions tried in different settings did not necessarily produce good results all the time [ 32 ]. This was particularly so when stakeholder engagement was poor, for example in the case when owners and pimps obstructed such preventive interventions to the sex workers [ 33 ].…”

Funding of community-based interventions for HIV prevention

“…Among these, the lack of adequate funding is only one. Other explanations found in the literature include: institutional disbursement and policy constraints (Oomman, Nandini;Bernstein & Rosenzweig, 2007); difficulties involved in scaling up community-based projects (Binswanger-mkhize, Regt, & Spector, 2010); difficulties in operationalizing the concept of community mobilization in different contexts (Cornish et al, 2014;Kongelf, Bandewar, Bharat, & Collumbien, 2015;Mburu, Iorpenda, & Muwanga, 2012); and insufficient attention given to social and structural factors (Auerbach, Parkhurst, & Caceres, 2011).…”

Competition is not necessarily a barrier to community mobilisation among sex workers: an intervention planning assessment from Zimbabwe

“…Community mobilization programmes focus on bringing women together for participatory activities to build trust, strengthen social networks, and enhance both individual and collective agency in addressing structural determinants of their vulnerability to HIV [ 6 , 7 ]. Perhaps the best documented successes in community mobilization among female SWs come from India, where the well-renowned Sonagachi programme [ 8 , 9 ] has been replicated and scaled-up across six states in India through the Avahan initiative [ 10 , 11 ]. Avahan works to transform SWs’ role in health interventions from mere participants to social change agents with collective agency, ownership, and eventual sustainability of local organisations [ 12 , 13 ].…”

“…Even within Avahan, some settings present greater challenges to the mobilization process than others. A qualitative study examining Avahan’s specific experience in Mumbai found that a much more challenging context for establishing an enabling environment for SWs’ collective action [ 11 ]. Greater control over SWs by brokers and pimps, and a fragmented, mobile and heterogeneous SW population weakened potential for women to come together and organise for mutual gain.…”