Targeting commercial sex-workers in Goa, The Lancet. Vol. 364, No 9442. 09 Oct04

[Guest guest]

Targeting commercial sex-workers in Goa, India: time for a strategic

rethink?

am Shahmanesh, Sonali Wayal

The Lancet. Comment. Volume 364, Number 9442 09 October 2004

At 0700 h, June 14, 2004, bulldozers shattered our dream of an

evidence-based participatory intervention for HIV prevention with

sex-workers in Goa, India.1 Under the pretext of a High Court order

to rehabilitate commercial sex-workers (CSWs), the government of Goa

demolished the red-light area of Baina. The demolition occurred

during the monsoon rains and the government provided no

rehabilitation or relief for the thousands of people it rendered

homeless. A day's work demolished a decade of HIV prevention and

made the newly homeless, destitute women even more vulnerable to

HIV.

After a decade of HIV prevention efforts by non-governmental

organisations (NGOs), CSWs regularly turned to peer educators and

NGOs for condoms and treatment of sexually transmitted infections

(STIs). The CSWs' active participation invigorated the HIV

prevention programme. The authorities not only failed to appreciate

these efforts, but they ignored us when we reported that cordoning

off the red-light area before the demolition had forced women to

seek clients elsewhere. Those women reported rape, multiple

partners, reduced ability to negotiate condom use, increased

violence, and police raids. Condom distribution fell significantly,

probably increasing their vulnerability to HIV. The authorities also

ignored experts who warned that destroying the red-light area would

spread sex-work over a poorly defined area, isolating the CSWs and

exposing them to violence and infection. As anticipated, the

government's effort to eradicate prostitution has made it nearly

impossible to provide HIV prevention services to CSWs.

Was the eviction a result of the government's antimigrant ideology

(most CSWs had migrated from other States--eg, Karnataka and Andrah

Pradesh) or an antiprostitution ideology? Or did the government

evoke those sentiments to justify to the public an illegal and

inhuman demolition? Motivation aside, it was startling that this

event occurred in a country that boasts an internationally acclaimed

model of success: the empowered and collectivised CSWs of

Sonagachi.2

The demolition brought back vivid memories of the first author's

involvement in HIV prevention efforts in Burma, where sex-work is

illegal and the penalty of 10 years of hard labour almost invariably

leads to death. There, our programme's access to clandestine

brothels was sporadic; coverage was poor and the HIV epidemic was

unchecked.

There is mounting evidence that intervening with CSWs prevents HIV

spread. Using mathematical models, researchers have shown the

effectiveness of targeting people with a high rate of sex-partner

exchange in the early phases of an HIV epidemic.3 Investigators have

also shown the effectiveness of various HIV prevention strategies in

many published experimental and quasi-experimental studies of sex-

workers.4-11 A recent randomised trial found that rates of HIV

dropped 400-500% in both study arms after women changed their HIV

risk-taking habits.11 Thailand focused on sex-work in its

countrywide intervention,12 and it is one of the few countries to

see success in stemming the tide of HIV. Despite overwhelming

evidence, only a handful of countries have implemented national

interventions in the 10 years since the first reports were published

about the successful programmes in Zaire.10

We must answer some fundamental questions in HIV prevention

strategies. Can we continue to develop effective interventions and

see them not used on a large scale because of political and legal

barriers? The commercial interest vested in the intertwined tourist

and sex industries might have prompted Thailand's success. Can

public health afford to remain hostage to such political or economic

whims? Is it ethical to collect data that blames the spread of HIV

on people with a high rate of sex-partner exchange without

implementing the resulting intervention? Our community advisory

board's futile attempt to seek refuge in our research centre during

the demolition exemplifies researchers' inability to protect

participants in the face of governmental antagonism.

Instead of endlessly perfecting interventions in a tiny fraction of

CSWs, HIV/STI prevention efforts must have unfettered access to all

CSWs to succeed. To do that we must demand international political

and legal standards to protect the human rights of sex-workers.

These rights include the ability to self-organise and work without

fear of violence and arrest, and access to HIV/STI care and

prevention. Such rights might be established if access to HIV

prevention and treatment funding becomes contingent on adherence to

them.

Following this line of reasoning, clinicians, epidemiologists, and

academics would be forced to venture into the uncharted territory of

legislation for commercial sex. That would mean developing

interventions that attend to such diverse issues as economics,

migration, and gender inequalities, and their intersection with

policy.13 Despite logistical difficulties, we must evaluate the

effect on the HIV epidemic of interventions that address economic

injustice and gender inequalities.13 Perhaps we can start with large-

scale trials of the effect of changing policy on the spread of HIV

in commercial sex.

*am Shahmanesh, Sonali Wayal

________________________________________

Centre for Sexual Health & HIV Research, Royal Free and University

College Medical School, University College London, WCIE 6AU, UK

(MS): and Positive People, St Inez, Panjim, Goa, India (MS, SW)

________________________________________

bamaryjoon@...

Our research is funded by a Wellcome Trust training fellowship. We

have been working with the CSWs of Baina.

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