May #144 : Taking Care of Business - by Lucile Scott

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Table of Contents
 

HIV: Behind the Music

Taking Care of Business




Not by Meds Alone

No Viral Load=No Transmission?

The Stand

Staphing Up

Mixology

Heads of the Class

Heartburn Hotel

Protein Shakers

Mercury Rising

Britain: Hep C Rings Twice

Pill-Taking Tip

Cardio Risk Raiser

Cholesterol Downer




What's a Girl to Do?

Runaway Hit

The Mother of All HIV Tests

Lights! Camera! Bareback Action!

Prom Night Prep

Apply as Directed

Strong-arming HIV

Healing Fields

Jargon: DWI

Keeping Up With the Joneses

Melrose Place 2.0

Silence=Meth

Rock Out

Ladies First




Editor's Letter-May 2008

Mailbox-May 2008



 
Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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May 2008


Taking Care of Business

by Lucile Scott

HIV infections keep rising in India. But they have fallen drastically among one group: the country’s sex workers. These global prevention leaders are teaching squeamish governments—including America’s—how to get the job done.

Budhwar Peth, the largest red-light district in the Indian city of Pune, seems like any other neighborhood there. Vendors hawk everything from grain to knockoff designer handbags; they compete for space with an ever-moving mass of pedestrians, bicyclists, cars, carts, rickshaws and cows. But peer behind the bustle, and you’ll see dozens of women lining each block. They stand in front of ramshackle, two-story brothels with dirt floors and chipping pastel paint, a Hindu temple popping up above them. Men ranging from university students to soldiers and businessmen mill about and appraise the stationary women, who return their lingering glances. As the night wears on, music will blast, booze will flow and more and more women will emerge from the brothels. There they will earn from 10 rupees (40 RS equals $1) to, in a very few cases, 5,000 rupees a night, depending on their look and their employer.

This afternoon, one veteran of the sex trade, Shanti, 48, weaves through the dusty sidewalks. Wearing a sari of muted green, she makes her way to the neighborhood health clinic, where she works as a peer educator. Like many of India’s estimated 4 million female sex workers, Shanti arrived from a poor rural village. She was 18, her parents had just died and she had three young brothers to support. Facing a job market with few options for lower-class women, she turned to the brothels, where women without a good education can make far more than they can in other fields. She says her husband, whom she married as a teenager, “was of no use. He was a drunkard and he beat me up and we didn’t have enough food.”

Shanti shares another characteristic with many Indian sex workers: She is HIV positive. When she was diagnosed, in 2003, about 54 percent of female sex workers in the city of Pune (population: 5 million) were estimated to be positive. There were few programs designed to combat HIV in sex workers. What’s more, the failure of world governments—including those of India and the United States—to address the issue stigmatized the women of Budhwar Peth and sex workers around the globe, confining them to shadows of society. They had little knowledge of HIV or condoms as the epidemic spread not only through their community but to their clients, other sexual partners and the population at large. But all that has begun to change. The HIV rate among the area’s female sex workers has dropped to around 20 percent. “We didn’t know anything about condoms before,” says Shanti, with a grin. “And now there are too many.” Indeed, the country’s progress in combating HIV among sex workers is being recognized globally as a model for prevention among marginalized social groups. The sex workers of Budhwar Peth have much to teach the world about sexual safety and solidarity. And in that arena, their services are absolutely free.

Most Indians know and accept that prostitution and red-light districts exist, and about 15 percent of Indian men visit female sex workers regularly. Taking money for sex is not against the law, though aggressively soliciting clients is. This means prostitution is neither completely legal nor illegal, keeping regulation low and corruption and police harassment high. However, because the law does not force female sex work fully underground, as it does in other countries including the U.S., sex workers can be accessed, organized and educated, convenient facts when trying to fight HIV.

Nongovernmental organizations (NGOs) such as the Mukta Project—which is part of Pathfinder International and sponsored by Avahan—and the Gates Foundation’s India AIDS Initiative began setting up shop in Budhwar Peth in 2003. Their main prevention strategy was not pushing for harsh regulation or giving patronizing lectures. Instead, they empowered sex workers, a highly stigmatized and abused population, to value and take charge of their own health. Shortly after testing positive, Shanti began doing HIV outreach for Pune’s Vanchit Vikas neighborhood clinic, which Mukta set up in a small stone building among the brothels. The clinic employs sex workers as peer educators who go out into the community to discuss HIV, the importance of condoms and how to negotiate with clients who refuse to use them. Other volunteer sex workers, known as paramedics, provide basic mobile health services. Sex workers best understand the issues other sex workers face, including mistrusting outsiders, who frequently ridicule or take advantage of them.

Before the efforts began proving successful, stigma against sex workers caused few to believe that the women would remain organized, interested and responsible enough to make it work. “Two years ago people thought of the sex workers as victims and that it would be difficult to have them participate in prevention, but they have made it their own,” says Ashok Alexander, Avahan’s director. Tejaswi Sevekari, project director of the Saheli HIV/AIDS Karyakarta Sangh, which was established in Budhwar Peth in response to HIV in the late ’90s by a collective of sex workers, adds, “At first local leaders and politicians were against the program and thought if sex workers had their own organization they would not be able to manage it properly and it would serve as a means of promoting sex work. Now we are an official government program.”*

Many HIV prevention advocates had accused the Indian government of ignoring HIV and the populations most affected because it was squeamish about discussing sex, which it often deemed immoral. But the country now is confronting the epidemic, which is estimated to have infected 2.5 million of the country’s more than 1 billion people. The third National AIDS Control Program (NACP-III), which launched in 2007, increased the amount of government AIDS funding to 40 times the amount pledged under NACP-II: $1.95 billion over five years. It also made community mobilization of high-risk populations a priority. “Until 2003 the government was in virtual denial. But the political will exists now in part because the successful programs have given higher visibility to these groups,” says Aparajita Ramakrishnan, team leader of the National AIDS Control Organization’s (NACO) Technical Support Unit. “They realized it is important to make the community part of the solution, not the problem.”

Not all governments agree. While the Bush administration and the President’s Emergency Plan for AIDS Relief (PEPFAR) have committed nearly $15 billion (and are discussing raising that figure to $50 billion) to combating the global epidemic, they have stipulated that one third of prevention funds go toward abstinence-based education—which is not an effective strategy when dealing with sex workers and other high-risk groups. They have further required that all organizations getting U.S. AIDS money sign a “loyalty oath” stating that they oppose prostitution— which makes operating organizations like Mukta difficult. In 2005, Pathfinder International and several other U.S.-based organizations sued, claiming the pledge violated their First Amendment rights. A U.S. district judge agreed and issued an injunction that the government could not reduce funding to the organizations participating in the suit until it was settled. The government appealed and the case was sent back to the district level, where it awaits retrial.

Defending and explaining the U.S. government’s position, Robert Clay, director of USAID’s Office of Population Health and Nutrition in India, says, “There is a lot of misperception. We can have money going to work with sex workers.” Clay’s office, for instance, gives money to NACO and Pathfinder. He adds, “Organizations just have to have a policy that they don’t support the legalization of prostitution.” Cara Hesse, director of public affairs at Pathfinder’s U.S. office, responds, “We wish USAID would be so clear in its court submissions and written guidance. The guidelines are vague and extraordinarily difficult to operate under. Without the protection of the court order we would have to censor our HIV prevention and outreach with sex workers [in India], and a lot of other organizations have had to,” she says. “There was an organization that was working with sex workers in Central America, and they developed a board game to educate the women about HIV since most of them were illiterate. A right-wing member of Congress started calling for the program to be defunded because he thought it was enabling sex workers to have fun and supporting prostitution.”

Though India’s government supports sex worker programs, much work remains to be done—work that increased funding from international donors like PEPFAR would facilitate. Avahan has projects in the six Indian states with the nation’s highest HIV rates, but India has 28 states, 23 official languages and nearly 10 popular religions, meaning HIV programs must not only be established but adapted to fit the varied culture. “The next five years is make or break, and we have to scale up the geographical areas covered and the intensity of programs that reach core high-risk groups,” says Ramakrishnan. “NACO is working to codify what began as a grassroots movement [among sex workers] into a model that can be implemented throughout the nation.”

Avahan’s Alexander also hopes it’s a model that, with proper international backing, can be replicated throughout the world. Governments in nations including Senegal and Thailand began mandating condom use in brothels in the early ’90s. But India was the first country where prevention among sex workers was not imposed; it came from within. The efforts began in 1992 in Songachi, a large red-light district in Calcutta, famous as the domain of Mother Teresa and for its revolutionary spirit. Reported usage of condoms in Songachi rose from 3 percent to 90 percent, while the HIV rate has remained around 5 percent, extremely low for a red-light district.

After the rapid success of their condom campaign, the women of Songachi determined that truly taking charge of their health required taking charge of other aspects of their lives, since sex workers are often denied access to health care services, subsidized food programs and bank loans. So the sex workers, with the guidance of some local NGOs, set up a literacy center, a nursery, schools, health clinics, a regulatory board that screens all new entrants into the brothels (to make sure they are of age and entering sex work willingly), and even a bank to dole out low-interest loans. Their efforts have been named a Best Practices Model by UNAIDS. They have 60,000 card-carrying union members who are demanding that sex work receive the same recognition and treatment as other professions. Most of the women pay dues out of their own earnings to support the efforts. “There is that much solidarity,” says Tripti Tandon of the Lawyer’s Collective HIV/AIDS Unit. “The city has a radical air that is not in other places, but it is a model that can be replicated in other communities in ways that work best there.”

However, none of this has decreased the larger population’s stigmatizing of the sex workers’ profession and HIV. Many doctors still refuse to treat positive people, and stories abound of people being harassed, shunned and expelled from villages after their status is revealed. Mass media campaigns organized by NACO and organizations like the American actor Richard Gere’s Heroes Project are aiming to reduce the stigma by normalizing HIV tests and condoms, which are often still considered a sign of immorality in a nation where the majority of marriages are arranged and premarital sex is taboo. “People in this country think the morality here is like an invisible condom that protects everyone,” says Avahan’s Alexander. “Indians don’t have shyness going to sex workers, just talking about sex.” However, like in most nations, it is the sex worker, not the client, who is disdained and shamed.

Positive sex workers face a double stigma, fearing reprisals both for their status and for their job. “The girls are accompanied by our paramedics the first few times they go to the government hospital to make sure the doctors don’t make them feel bad or deny them care,” says Dr. Laxmi, head of the Vanchit Vikas clinic, adding that at least in urban areas most positive women can access affordable, government-subsidized antiretrovirals, which are still hard to come by in the rural villages, where 72 percent of Indians live. The women are also frequently run out of brothels or their family homes and lose their clients, meaning even those who are aware that they have access to treatment and care may avoid testing in order to maintain their livelihood.

Outside the red-light district, on the outskirts of Pune, the John Paul Slum Development Project (JPSD) has set up headquarters for a program reaching out to non-brothel-based sex workers. It is dusk, so the office, which has no electricity, must close up, but three HIV-positive sex workers who serve as peer educators through JPSD have gathered on the roof. Manisha, 40, Pooja, 30, and Alka, 25, sit, wearing saris, cross-legged on a handwoven straw rug sipping chai and chatting, with the melodic chant of the evening Muslim call to prayer echoing in the background. “No one in my area has sex without a condom,” boasts Pooja. “Even if the client says, ‘I will give you 100 or 200 rupees less,’ we say, ‘OK.’ That way, if everyone says no, the client has nowhere else to go.” They then discuss why it is easier to push condom use than HIV testing. “It is a fearful message, because if you test positive, you will have to go to the government hospital and everyone will know,” says Manisha. “We just ask women who fall ill again and again or who we know don’t use a condom to get tested.” Alka chimes in, adding, “People see us taking meds and they go back and talk about us. I know a woman who was seen and she was thrown out of her brothel and abused by locals.”

With her hair pulled into a loose ponytail at the nape of her neck and no makeup, Alka, who has soft, pretty features, looks younger than her 25 years. At 13 she married a 20-year-old man who visited sex workers throughout their marriage. “He knew he had HIV, but he didn’t tell me,” she says of her surprise when she tested positive seven years ago while pregnant with her third child, who was born infected and died of pneumonia. “After that I got sterilized,” she says. She took her two surviving children, now 10 and 13, and ran away from her husband, who then threatened to murder her mother and siblings if she didn’t return. “I left all hope of having a nice life and came back.” He died several years ago, but not before the family had racked up serious debt paying for his health care. “I had to repay the loans, but I couldn’t and the interest was rising,” she says. “So I left work washing dishes and became a sex worker.”

While female sex workers can be tricky to find and target with HIV messaging, it is even more difficult to reach most male sex workers. Homosexuality is against the law, and male sex work is largely hidden. Most men who have sex with men (MSM), including sex workers, are married and deeply closeted. Hanif, 29, began working as a male sex worker at age 18. “I wasn’t in contact with a person or organization who could tell me about HIV when I was a young, brash sex worker,” he says. “And I didn’t use a condom at all unless a client insisted.” Hanif is HIV negative but now visits hot soliciting spots near bus stops and beneath bridges to reach out to other men through Udaan, a community-based organization for MSM in Pune, to get them the education he did not receive when he was younger.

The community-based efforts are also now being extended to the most-high risk clients. An estimated 90 percent of India’s long-distance truck drivers, who are away from their homes and wives for months at a time, visit sex workers. Nearly one fifth of the country’s HIV cases are estimated to be among married women infected by their husbands, with wives of men in the transport industry showing the highest rates. “They think, ‘We have a meaningless life and one day we will die, so why not enjoy ourselves while we are alive,” says Uttamrao Zagade, project director of Sevadham Trust, which has set up a clinic and network of peer educators at Pune’s largest truck stop. “We teach them about [safer sex] and try to convince them that they are an important part of society.” However, most acknowledge that it is not the clients who are responsible for increases in condom use. Mahenatra Singh, 34, an HIV-positive truck driver who was infected through unprotected sex with sex workers, says, “Now the sex workers just refuse you point blank if you don’t want to use a condom.”

As with the truck driver campaign, Avahan’s self-empowerment model is designed not just to get information out to sex workers but to give them the community and self-esteem necessary to demand condom use and stand up for their rights. “All the sex workers have mobile phones now,” says Alexander, “so if they are wrongfully arrested, they can call a hotline and 10 or 20 sex workers will show up with a lawyer saying they will call the media or the UN.” They have also organized workshops to sensitize police officers to issues surrounding sex work. “Before, they faced violence from clients, police, madams and primary partners and were afraid to talk to anyone,” says Mukta’s T.K. Jayarajan. “They looked on themselves as worthless and good for nothing. Now they will stand in front of the deputy commissioner of police.”

This year the legality of the U.S. loyalty oath will again hit the courts and will also be scrutinized when Congress votes to renew PEPFAR in late spring or summer. The policy not only decreases funding for projects like Mukta, it also helps maintain the stigma and marginalization of sex workers, driving unsafe sex and HIV infections that Mukta combats. “You can’t just shut your eyes to something and think it will be fine,” says Mukta’s Sonia Singh. But regardless of U.S. policy, Mukta will continue. “Now there are such good health care facilities. Everyone should take care of themselves, and the younger women really are,” says Shanti, her mischievously cheerful voice cracking as she adds of her work with Vanchit Vikas, “My husband still comes and goes, but I have taken him out of my heart. The people at the clinic are my family now, and they help me in every way possible. I am happy.” With that she takes her leave, blending back into the noisy, darkening street, where little piles of condom wrappers can be glimpsed among the litter.

* Correction: The asterisked sentence above has been updated from the original version, which misspelled the first name of the person quoted and her organization.


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Martin Falk, New York, 2009-08-22 10:56:41
The Female Health Company, located in Chicago, Il. USA, manufactures and distributes a female condom. The company sells to public health clinics and not for profit organizations. The condom protects against unintended pregnancy and sexually transmitted diseases, including HIV/AIDS.

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