STRIVE Tackling the structural drivers of HIV

Since the early 2000s, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled up as part of India’s national response to the HIV epidemic. The National AIDS Control Programme (NACP) of India pronounced CM to be a central tenet of comprehensive sex worker programmes. However, there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments.

This study conducted semi-structured, in-depth interviews and focus group discussions with 63 participants to explore challenges of HIV prevention among FSWs in Mumbai. All participants were involved in programme implementation:

• 41 at grassroots level either as peer educators (PEs) or outreach workers (ORWs)
• 9 programme coordinators (PCs) at mid-level
• 11 senior staff in leadership positions

Themes

A thematic analysis identified six interlinking contextual themes that impact CM efforts among women who sell sex in Mumbai:

1. Diversification of buyers and sellers of sex
2. Stigma and identity
3. Management and control of sex work (which includes efforts to control and police sex work by madams/pimps/brokers, interventions and police/society)
4. Sex workers’ mobility
5. A heterogeneous sex worker population
6. The programme model and ownership

Findings

• Many women feel a strong motivation not to be identified as sex workers.
• Urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more ‘hidden’ forms of solicitation, further challenge outreach and collectivisation.
• Registration practices and programme monitoring were experienced as stigmatising.
• Persistent labelling seemed to have amplified the pre-existing stigma and made some women shun the programmes.
• Participants reported that brothel owners and ‘pimps’ continued to control FSWs’ workload, their exposure to interventions and their location, and to restrict researchers’ access to FSWs.
• The heterogeneous ‘community’ of FSWs remains fragmented with high levels of mobility.
• Stakeholder engagement was poor and mobilising around HIV prevention not compelling.

Large-scale interventions have been impacted by and have contributed to an increasingly complex sex work environment in the rapidly changing context of Mumbai. This challenges outreach and mobilisation efforts. There is an urgent need for sensitivity in both programming and monitoring as women who sell sex in Mumbai continue to have increased vulnerability and HIV risk.