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http://www.thelancet.com/journal/vol364/iss9442/full/llan.364.9442.ana lysis_and_interpretation.30939.1
Comment
Targeting commercial sex-workers in Goa, India: time for a strategic rethink?
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. *Maryam 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)
---------------------------------------------------------------------- [EMAIL PROTECTED]
Our research is funded by a Wellcome Trust training fellowship. We have been working with the CSWs of Baina.
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