One of India’s most successful HIV interventions is currently facing a policy glitch it cannot easily overcome: love affairs.
In Sonagachi, the largest red-light district of South Asia, in the heart of Kolkata, sex is solicited for a price, and the odds of finding an empathetic lover also come with a rider: unprotected sex. For sex workers, the distinction is necessary for specific clients commonly referred to as ‘babus’ with whom they have an emotional connect. However, for health workers who are working hard to convince the women to insist on condom usage, this is turning out to be a nightmare.
The babu culture
As thing stand, the number of HIV positive workers and clients in Sonagachi is at an all-time low, with just over 2 per cent positive cases being reported in 2014, down from 10 per cent in 2005. There are approximately 8,000 commercial sex workers (CSW) here, according to figures put out by the Durbar Mahila Samanwaya Committee (DMSC) which has been working among them for more than two decades. But keeping the gains is proving to be uphill. “I have been informed about risks of unprotected sex by didi (peer educator). But I can’t say no to my lover. I also like to be with him without protection,” says Saheba Bibi, a 27-year-old CSW with a 10-year work experience as she nervously waited for the results of tests for Sexually Transmitted Diseases (STD).
Shalini, 30, says that she is scared of losing her lover if she uses does not engage with him without protection. “I am attached to him and there is nothing else that I can give him. Our conversations also matter… we talk for many hours some times. But sex is important too,” she says.
Among the counsellors at Sonagachi, these love affairs are known as the ‘babu culture’.
“It is common knowledge that while the sex workers do not solicit a client who does not use condoms any more, they engage with their lovers without protection. Most sex workers have a particular client with whom they engage regularly and they develop a strong feeling of attachment. However, most of these babus have sex with more than one woman, putting both of them at risk of contracting AIDS. We counsel them and encourage the use of condoms despite a love affair,” says the counsellor who works with the DMSC.
Peer educator model
At the heart of this success story is Dr. Smarajit Jana who, in 1992, initiated a radical intervention programme to control STDs and HIV in Sonagachi. He worked with the Department of Epidemiology, All India Institute of Hygiene and Public Health in Kolkata and realised that HIV control is not only about screening and providing condoms but also addressing wider socio-economic challenges. “We asked sex workers to not solicit anyone without use of condoms. But if all women of the red-light area did not agree to it, then the customers would go to those who did not press for condoms. This would put pressure on the others too to earn money. Community or social action had to be initiated,” he says. Thus, DMSC took shape in 1999. Through a model of “peer educators” where elder HIV-positive women counsel sex workers, the DMSC began group discussions and community monitoring.
“We regularly hold group discussions and educate sex workers about HIV and other STDs. Peer educators teach them the method of using condoms effectively. We emphasise community monitoring. When a sex worker is caught by her colleagues for soliciting without a condom, then it puts pressure on her not to do this again,” says Tapasi Kole, a peer educator in Sonagachi , who earlier worked with DMSC in West Medinipur district. The work of DMSC has spread across West Bengal and caters to many areas in Kolkatasuch as Ultadanga, Kalighat and Cossipore. DMSC, which had 20,000 members in 1997, boasts of 60,000 members today.
Crossing the money hurdle
Dr. Jana faced another hurdle — money.
“No bank allowed sex workers to open accounts due to lack of proper identity cards. It was a struggle for them to keep their money safe. It was common for them to lose money due to stealing, making them vulnerable to customers who paid more money for no condoms. We had to come up with a bank.” he says.
Usha Multipurpose Co-operative Society Limited was founded in 1995, and merged later with DMSC. It was registered under the Societies Act — which was also a battle fought and won. “Under the Act, people without moral character could not register an organisation as it was considered that sex workers did not have any moral character,” says Santanu Chaterjee, finance manager at Usha. “We met the then Co-operative Minister of State Saral Dev who said that ‘character’ is a relative term and allowed us to open the bank,” says Mr. Chaterjee. With 29,000 members, Usha is one of the biggest success stories in co-operative banking in South Asia. Its turnover last year was Rs.29 crore. “In 2015, nearly 7,000 members took a loan, out of which 48 per cent was for children’s education,” he says.
Reducing infection rates
Usha has played an important role in reducing HIV infection among sex workers of the State. “The bank provides financial backing to its members in the form of savings and loans. Their dependence on immediate cash from customers is now negligible; they are not vulnerable to customers asking for sex without condoms.
The hard work has borne fruit. The National AIDS Control Organization (NACO) annual report 2015-16 claims that HIV prevalence among sex workers in India is 2.2 per cent. But other studies have found the range in different cities to be between 2 per cent and 35 per cent. The figure for brothels in Kolkata are on the lower side.
Another addition is customer care centres, located at positions of entry to Sonagachi. Their aim is to increase a client’s risk perception. Every day, nearly 150-200 customers visit these kiosks. Involving babus and using them to counsel other customers has added another dimension to the work of DMSC , which was a pioneer in community monitoring and financial support to sex workers with a vision to reduce HIV infection. “Babus are vulnerable to infection and are major carriers. We ask them to be particular about use of condoms,” says the NACO counsellor.
As the HIV/AIDS Bill is discussed among health experts and lawmakers of India, examples of work by organisations such as DMSC show that the community has moved forward. It is no more about discussing only treatment but also helping prevention by extending help to target groups such as the acquaintances of sex workers.
HIV Bill
The current Bill has also borrowed some features from the Sonagachi project. Chapter II, which is against discrimination, and chapter VII, on welfare measures by the Central and State governments, have been influenced by DMSC’s work. The organisation was the first to raise concerns over dual discrimination against sex workers with HIV/AIDS. The Bill protects the rights of employment of HIV-positive people, which DMSC has worked on for the most vulnerable group in the country. Chapter VII has components of child welfare and the spread of HIV-related information without prejudice. These concepts too have been borrowed from DMSC’s work.
But the current Bill falls short of expectations of the HIV community; it betrays the movement that led to its drafting in the first place. Clause 14 (1) of the Bill says that treatment will be provided by the government only “as far as possible”. It’s a truncated position because the mandate of NACO right now is to provide universal treatment.
“We have been demanding that the Bill address problems of shortages and stock-outs of medicines. But in its current form, it will even take way the treatment that exists,” says Paul Lhungdim, president of Delhi Network of Positive People (DNP+).
But there is much more that the Bill needs to learn. Financial protection and extending counselling to social relations of affected population are just a few examples.
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