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print versionby Kevin EG Perry
Damanjodi is a small mining town nestled in the verdant hills of Orissa, in the east of India. The skyline is dominated by a sprawling network of mines, refineries and factory buildings. They are owned and run by Nalco, Asia’s largest aluminium producer. Men come from all over the country to seek employment, creating a large migrant workforce with money to spend and time on their hands. In their wake, women come too, seeking work of a different kind. There are more than 500 women engaged in prostitution in Damanjodi and its satellite towns. Their poverty drives them to sex work out of desperation and in the terrible knowledge that the risk of contracting HIV goes with the territory.
The slums in the centre of town are clean, orderly and vibrant with colour. Ambica Das, an energetic woman with a commanding presence, is hosting a women’s meeting. The meetings are an open forum, and today the women are discussing how to find a boarding school for a girl who has been recently orphaned. They do not - and cannot - discuss openly the main reason why Das organises these meetings. Das is employed as a peer educator by a targeted intervention programme funded by the Orissa state Aids Control Society and run by Ekta, a local non-governmental organisation (NGO).
Although not all of the women present are sex workers, many are. Das’s job is to distribute condoms and educate the women about safe sex practices, but in reality she does much more – from arranging safe places where they can find some refuge from harassment, to suggesting alternative ways of earning a living. In a world without social workers and where the police can cause as much trouble as the customers, she is often the only friend the women can turn to.
Away from the public meetings, Das visits the women who are most at risk each week. It has taken a long time, but she has earned their trust. The stories she tells me are as harrowing as they are commonplace – a girl of 15, the daughter of a sex worker, recently came to her after being persuaded to work as a prostitute. Her mother had not known of their shared profession until the girl became pregnant. They do not know who the father is.
Her mother disowned her, and the girl faces raising her baby alone with no other means of income except returning to prostitution. Other women come to Das after contracting HIV from unprotected sex. Despite her best efforts to promote condom use, the offer of a little extra money is often enough to persuade the women to go without. By western standards, it really is a little extra money. Das says that women receive 200 to 500 rupees (£3 to £7) for sex, but encounters can cost as little as 50 rupees (70p). In the local context, these are significant sums. A month’s wage for a woman working as a maid is just 300 to 400 rupees (£4 to £5).
Although India remains a stratified society in many ways, caste is no bar to sex work. In a country where women are rarely in control of their own finances, all classes can find themselves forced to turn to prostitution. Many of the women have been widowed or divorced and find themselves barred from other forms of employment. Others may be single or married, but work in secret to supplement their family’s meagre income.
Nirmala (not her real name) explains: "I see four to five men each week, so I can earn up to 2,500 rupees. My husband doesn’t know what I do. A couple of the other women have husbands who know, and it is them who contact customers for them, but most of our husbands don’t know what we do. The men go out to find work so they are not always at home. When men have 10 rupees in their pocket, they have 10 other entertainments for themselves. They need to chew betel nuts, they need to eat paan, they need to play cards, they need to drink, so there is always less money for us."
She adds: "I want to pay for my children’s education. The school run by the government is not a quality school. Once I have a better income I can try to put them in a quality school, where they can learn English. That is one of my aspirations. I want them to get a quality education so that they can gain merit and get selected for a good job.
"Our forefathers were illiterate. They never went to school. But now we have started sending our children to school so they don’t need to work like us, they are smart now."
Money for marriage
Raising money for a dowry, either for themselves or for their daughters, is a common reason for entering the industry and marriage represents one of the few realistic escape routes.
As Shila (not her real name) says: "I want to get married, but my family has no money for a dowry. Here, your most important priority is to get married and then to produce children, not getting educated and standing on your own feet."
The risk of HIV infection is ever-present. There are more than 18,000 people living with HIV in Orissa. Some 88% of new infections are a result of sexual contact, and a further 7% are a result of mother-to-child transmission. Marriage is no safeguard. According to Unifem, the United Nations Development Fund for Women, within Indian marriages condom use is extremely rare, wives have little negotiating power about sexual matters and conversely men who suggest using protection are usually accused of infidelity. A Unifem study at a clinic in Pune found that of 400 women, 93% of whom were married, 25% had sexually transmitted infections and 14% were HIV positive. More than 90% of them had never had sex with anyone but their husbands.
Near to Damanjodi, the Indian health department runs an integrated counselling and testing centre (ICT). Das says that referring people is one of the hardest parts of her job. "Sometimes we are put in embarrassing situations," she says. "People are scared to be referred to ICT and take offence if they think that we are accusing them of being HIV positive."
Despite the hardships that Das encounters on a daily basis, the good news is that targeted interventions such as these are working. In Orissa, the HIV infection rate for sex workers remains below 1%. The contrast with other areas is marked. In neighbouring Andhra Pradesh, nearly 10% of sex workers have HIV positive. In much of the country, and much of the world, stigma and an institutional squeamishness about dealing directly with sex workers puts lives at risk. According to UNAids, globally fewer than one in five sex workers receive adequate HIV prevention services and less than 1% of HIV funding is spent on sex work.
The reason why targeted interventions work is because people such as Das treat sex workers as human beings. UNAids’ own case studies of sex workers conclude that "one of the clearest public health lessons emerging from the HIV pandemic is that protecting the human rights of sex workers is one of the best ways to protect the rest of society from HIV".
Likewise, the Global Network of Sex Work Projects is calling for a number of reforms – including the decriminalisation of sex work and universal access to HIV testing and other health services – all of which the organisation identify as falling under the umbrella of better protection for the human rights of sex workers.
At the root of the problem is poverty. Arguably the best way to protect sex workers from contracting HIV would be to give them alternative employment options in the first place.
However, for those women who do end up in this riskiest of trades, Das’s work is evidence that taking the time to build a connection can have a lasting impact far beyond simply keeping them free from HIV.
"Earlier the women were ignorant," she says, "but now they are learning. At first it was difficult for them to interact, to talk about their issues, but now they approach us. They know about the importance of condoms and they are open with me about their problems. They want to be healthy."
