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

Bandewar SV, Bharat S, Kongelf A, Pisal H, Collumbien M. BMC Public Health, 2016; Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India

The period 2006-09 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.

To get a better understanding of sex workers' risk environment and to explain this paradox, researchers conducted a qualitative study including 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012.

Dramatic changes in Mumbai's urban landscape dominated participants' accounts.

  • The number of sex workers in traditional brothel areas dwindled; this was attributed to urban restructuring.
  • Gentrification and anti-trafficking efforts explained an escalation in police raids.
  • With the dispersal of sex work, the sex-trade management adapted by becoming more hidden and mobile, leading to increased vulnerability.
  • Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways, leading to an increased dependence on lovers for support.

The study found that 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 and power structures in the sex trade. This continues 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-based 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.

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.

Targeted 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.

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