Two qualitative studies, investigating the implementation of a massive programme of HIV prevention through community mobilisation in India, have identified challenges to the rapid scale-up and roll-out of a programme in which grassroots action was meant to be central. While the programme was intended to empower sex workers to tackle the social conditions which made them more vulnerable to HIV, a more narrow focus on condoms and clinical services took over. This discouraged sex workers from getting involved in the programme.
Implemented in six Indian states with a high HIV burden, Avahan was one of the largest HIV prevention programmes ever delivered. It aimed to slow the transmission of HIV in the general population by raising the coverage of prevention interventions in high-risk groups such as female sex workers and men who have sex with men. Funded by the Bill & Melinda Gates Foundation, there was a strong emphasis on efficient delivery and scale-up of a defined package of interventions, in order to achieve saturation coverage. Monitoring and evaluation showed that this was achieved.
The core package of HIV prevention services included peer-led outreach and education; distribution of free condoms; community mobilisation initiatives to address structural and environmental barriers; and testing and treatment of sexually transmitted infections (STIs), tuberculosis and HIV.
An inspiration for the programme was the Sonagachi Project in Kolkata. It employed sex workers as peer educators and involved sex workers in all aspects of the project. As a result, the project moved from being focused only on health to empowering sex workers so that they could demand better working conditions and human rights protections. Sonagachi is credited with improving rates of condom use, STIs and experience of violence among sex workers.
The Avahan programme aimed to replicate this success. But what happened in practice? Separate qualitative studies of the delivery of Avahan’s sex worker programmes in Andhra Pradesh and Mumbai have recently been published in Global Public Health and PLOS One respectively.
Ethnographers studied the implementation of the programme in Andhra Pradesh (a state in southern India), between 2004 and 2012. Women sold sex both in urban and rural areas, soliciting in brothels, homes, agricultural fields and highways. While some publicly identified as sex workers, others were much more secretive, for example only doing this work away from their home village.
As well as observing meetings, the researchers had informal conversations and more structured interviews with sex workers, peer educators and leaders of community-based organisations.
During the first few years of the project, a community-led approach was implemented, as envisaged. Women who had leadership qualities and strong links with other sex workers were engaged as peer workers. They not only distributed condoms, brought sex workers to clinics and provided sexual health information, but acted as community organisers to change conditions which produce HIV risk.
They challenged police violence and harassment, met local government officials to oppose the proposed relocation of brothels to an outlying area and spoke to district officials to help individual sex workers with ration cards and housing.
The peer workers organised themselves and other sex workers into community-based organisations, structures which aimed to bring sex workers together and give them a collective voice. Within these organisations, peer workers participated in planning, implementing and monitoring all activities. For example, they organised a public rally to challenge stigma, reframing sex workers not as carriers of HIV (a widespread idea locally) but as public health workers combating it.
But the nature of the programme changed after 2008, when the funding and management of the programme was transferred – as planned – from the Gates Foundation to the Indian government. The programme began to focus more narrowly on easily measurable health-related outcomes. Observation of meetings showed that most time was devoted to holding peer workers to account for the number of sex workers they had brought to clinics or the number of condoms distributed.
Less attention was given to community mobilisation, collectivisation and the formation of community-based organisations. While responding to incidents of police violence had been retained as a programme activity, the nature of the response changed. Rather than sex workers mounting a collective response, they were encouraged to approach existing public institutions such as the legal aid authority. In the end, sex workers faced with police or partner violence stopped involving the community-based organisations that Avahan had helped set up.
Whereas meetings had previously helped sex workers forge a sense of collective identity, there were now fewer structured opportunities for peer workers to meet with other sex workers or peer workers. Previously, sex workers had been interested in engaging with the community-based organisations, but the organisations’ new narrower health-focused remit felt less relevant.
Peer workers struggled to convince other sex workers of the benefits of the community-based organisations. They made those managing the programme aware of the problem, but the information was not acted on. In contrast, in the earlier, community-led phase of the programme, grassroots feedback from sex workers and peer workers had frequently been the impetus for changes, for example setting up mobile clinics in more convenient locations.
Some of the same issues figure in the report from Mumbai, although the context is very different. Whereas the Andhra Pradesh projects were implemented in small cities with populations of less than a million people each, Mumbai has around 18 million residents and was expected to be a challenging environment for sex workers’ community mobilisation.
In-depth interviews and focus groups were conducted with people implementing the programme in 2012.
While the programme emphasised condom use, many sex workers were more concerned about poverty, extortion, stigma, harassment and other day-to-day challenges. Staff expressed frustration with the narrow focus:
HIV “is one of the hundred issues [that sex workers face]. We are so focused on HIV because of which quality gets suffered. We should think about other issues too but we are only about completing targets and not really having comprehensive approach.”
In some areas, the programme was implemented by newly created community-based organisations. These were seen as having superficial roots and thought unlikely to survive when Avahan funding came to an end.
But, in other areas, organisations which had a long-standing local presence implemented the Avahan intervention, using the additional funding to supplement their existing programmes. The services they provided to sex workers were comprehensive and holistic; in these cases, community mobilisation was more successful.
The Sonagachi Project, which provided the blueprint for the community mobilisation element, was developed with women working in brothels in a red-light district. The diversification of the sex industry in Mumbai made community mobilisation more challenging.
More women were now meeting clients over the phone or through their work in a bar. Many worked from their own home and only sold sex occasionally to supplement their income as a market seller, construction worker or housewife. Others travelled frequently, for example to community festivals, in order to temporarily work in a new area. These women were much harder to identify and to contact than women working in brothels or selling sex in the street.
Moreover, many of the women would deny that they were involved in sex work and did not identify with ‘female sex worker’ as a label. Some peer workers took a gradual approach with new contacts and were able to slowly build trust. But those evaluating the Avahan programme expected things to be clear cut, as one member of staff explained:
“Evaluators are trained to say “Are you a dhandewali [derogatory term for a sex worker]?” Women get offended. ‘Why should you call me a ‘dhandewali’? I am a woman first’. And so recently one evaluator at one site, in the evaluation recorded zero marks because women had said no, I am not a sex worker.”
Collective organisation around a shared identity as sex workers was therefore challenging. The problem was compounded by the great diversity of women selling sex in Mumbai. Many women were migrants from across India, from different cultural backgrounds, speaking different languages and with different forms of sexuality. Respondents reported that there was often mistrust and competition between different sex workers. There was not a pre-existing, cohesive ‘community’ of sex workers which could be mobilised.
“This thing will not happen within a year, two years of intervention. Getting all thousand women tested in a year two times is possible, but getting these thousand women to sit together and discussing the issue is a process. And that process is going to take time. And I don’t think that anybody have that patience, for that process is really long drawn.”
Peer educators attempted to liaise with the police, to prevent harassment and raids on brothels. This was generally unsuccessful. Many pimps and brothel owners were mistrustful of the programme, suspecting the peer educators of co-operating with the police on raids. As a result, these gatekeepers blocked access to ‘their sex workers’ and prevented community mobilisation.
The Avahan programme, as originally envisaged, “reflected the view that the risk of HIV was a result of power inequalities that constrained female sex workers’ ability to engage in safer sex practices,” the Andhra Pradesh researchers write. “Peer workers’ mobilisation of female sex workers to demand changes in contexts that promote risk was a means of challenging these power inequalities.”
In the second phase of the programme, community mobilisation was “diluted of its transformative dimensions”. It was used instrumentally to lend legitimacy and bring efficiency to the work of reaching sex workers and bringing them to clinical services.
The Mumbai researchers note the contradiction between the grassroots, bottom-up approach that was desired and the funder-driven, top-down way in which it had been planned. While the programme identified a wide range of needs that sex workers wanted to tackle, the evaluators were measuring targets that were pre-determined and relatively simple to measure. “Funding agencies have high and contradictory expectations from community-based organisations, demanding them to be both community-led and bureaucratically and managerially savvy,” they comment.
“Funders must be willing to provide services based on female sex workers’ actual needs, which far exceed STI/HIV screening and treatment,” they conclude.
George A et al. Sex workers in HIV prevention: From Social Change Agents to Peer Educators. Global Public Health 10: 28-40, 2015. (Abstract).
Kongelf A et al. Is Scale-Up of Community Mobilisation among Sex Workers Really Possible in Complex Urban Environments? The Case of Mumbai, India. PLOS ONE 10(3): e0121014. (Full text freely available).