On the challenges facing AIDS prevention workers in India

In 2002, when the Bill and Melinda Gates Foundation announced its HIV prevention programme in India with a grant of $100 million, the Health Ministry accused it of being alarmist. Yet, according to Naco’s estimate at the time, 4.8 million Indians were HIV positive. The number of AIDS orphans, at more than 2 million, was the largest in the world. A health crisis of epidemic proportions was being predicted. Yet, by 2009, there were concrete signs of reversal, and today India’s HIV positive population is estimated to have come down to 2.1 million.

This book by Ashok Alexander, in charge of the Gates’ Avahan programme, gives a sense of the challenges facing those working to contain the spread of HIV. The first part is a collection of impressions, largely from field trips he took to map and understand the risk groups. The vulnerable included injectable drug users, transgender persons, the group of MSM and truck drivers, but mostly the sizeable population of female sex workers.

The unorganised nature of sex work and their victimisation by the police, society, family and clients turned out to be a large hindrance in the HIV programme.

In India, only about 7% of sex work takes place from brothels; mostly, it is practised from homes and in the streets, these sex workers forming an “invisible majority” of those who had to be reached out to.

Hence, the Thai government’s successful intervention in the 1990s to create awareness about HIV prevention and stop unprotected sex work was difficult to replicate here; “large, well-regulated, legal brothels are a boon for HIV prevention,” Alexander finds out.

The other challenge came from sex workers themselves. Insisting on clients using condoms could deprive them of their meagre earnings and expose them to violence; in a daily struggle for survival, the risk of HIV was intangible.

Avahan funded NGOs across States with high HIV prevalence — Maharashtra, Andhra Pradesh, Karnataka, Tamil Nadu, Manipur and Nagaland. Where the work involved sex workers, the issue was to get these dispersed people together.

Alexander recounts the complexity through the experience of Ashodaya in Mysuru, which mobilised the sex worker community into running the programme. They had to first build trust by providing them what they needed most: security, and not just from physical violence and police harassment. Crucial was a safe place to meet, and a clinic of their own they could visit without being stigmatised. It was a successful experiment that still continues.

HIV prevention clearly requires a multi-faceted approach, and Alexander’s book recognises, above all, the contribution of sex workers in one of India’s biggest public health success.

A Stranger Truth: Lessons in Love, Leadership and Courage from India’s Sex Workers; Ashok Alexander, Juggernaut, ₹699.