HIV Prevention among Commercial Sex Workers-Sristi Sharma

Introduction

People who work in the commercial sex industry are more likely to be affected by HIV and AIDS, more so in the developing nations than in the developed nations. The very virtue of their work leads them to be exposed to HIV, as well as many other Sexually Transmitted Diseases. Once they are exposed to these diseases, apart from being ill themselves, they become a continuous source of infection for others. Public health interventions, directed towards sex workers, are mostly aimed at personal prevention as well as prevention of further spread of the disease (1).

Owing to the diverse range of backgrounds and cultures that different Commercial Sex Workers come from, as well as the different lifestyles they lead, it is difficult to generalize sex workers and the interventions that are applicable to them. The levels of risk that they face, in terms of HIV infection, can be vastly different, depending on the country that they live in, where they work (e.g., a brothel or ‘on the street’), and whether they have access to condoms, amongst other factors. So, what are the factors that put a sex worker at a higher risk for contracting and spreading the disease (1)?

1. Multiple partners, inconsistent condom use.

2. Social and economic factors: Sex workers are generally stigmatised and marginalised by the societies that they live in. Around the world there are not adequate laws that protect a sex worker, especially from actions of the client that can put them at an increased risk for diseases.

3. Injecting drug use: Possibly, because of the high stress levels related to the nature of the work that they do, many sex workers are injection drug users.

4. Migration, mobility and sex trafficking: The rise in sex tourism and trafficking, especially in countries in Asia and the Caribbean islands, is just an added factor to the spread of HIV and AIDS.

What are the aims of a successful education programme directed against HIV in Commercial Sex Workers? All the HIV Prevention programs directed against the Commercial Sex Workers, as well as large organizations like World Health Organization have agreed that the goal of a successful HIV program should be the following (1):

1. An increase in the use of condoms among Commercial Sex Workers and their clients.

2. An increase in involvement and control, by the sex workers, of their working environments.

3. A reduction in the number of sexually transmitted diseases in the sex workers.

4. Encouragement to live a healthy and dignified life.

The approach, by the public health workers, to achieve these goals, is through education of sex workers about HIV/AIDS and its prevention. This is done by (1) :

1. Education of the sex workers, by public health personnel.

2. Encouraging peer education (where sex workers inform one another about HIV).

3. Reducing the stigma that communities attach to sex work.

Though major efforts have been put into the education of sex workers for HIV prevention, HIV is still widely prevalent among Commercial Sex Workers in the developing nations, sometimes being as high as 20 times the national average (1). Commercial Sex Workers have been taught almost everything about safe sex practices. However, the use of condoms have not been at par with efforts, thus leading to persistent high levels of HIV and AIDS. This proves that education as a prevention strategy has been unsuccessful among the commercial sex workers in the developing nations.

Criticisms Against The Education Approach For Hiv Prevention Among Commertial Sex Workers

Hierarchy of needs

A Commercial Sex Worker in the Sonargachi Sex District in Kolkata makes about Rs.40, which amounts to less than a dollar. Out of this the sex workers gives half of it to her “owner”, some amount to the policeman as a bribe for letting her work, and some fee for her “room use”. By the time she is done paying off all, she is left with about Rs.10. This barely buys her a single meal. Now consider this. Suppose this lady has not had a single client the whole day and in the evening along comes a man who wants to have unprotected sex. Will she actually go ahead and say no to the client because she has heard and learnt all about AIDS prevention?

The Hierarchy of Needs is also known as Maslow’s Hierarchy of Needs. It’s a psychological model that largely explains, why humans behave the way they do. His model takes the shape of a pyramid, with the most fundamental needs of a human being at the bottom of the pyramid, and the need of self actualization at the top (2). Self actualization is a process by which one expresses oneself in his fullest capability (3).

The pyramid is as follows (12):

The above picture shows that self actualization, which involves problem solving and acceptance of facts, both of which are vital to the success of intervention programs, is high up in the pyramid. There are many levels in the pyramid that have to be achieved prior to reaching this level. A human being is not usually known to go to a higher level before fulfilling his lower level needs. He is going to take care of his basic needs, which are all the requirements of survival, before he moves to the next level. In the next level, the safety needs of a human being dictate his behaviour. “These needs have to do with people's yearning for a predictable orderly world in which perceived unfairness and inconsistency are under control, the familiar frequent and the unfamiliar rare”(2) . Though in this level we have health and well being, health here involves mostly acute diseases and events, as well as their adverse effects. For example, in the sex worker, fever and Urinary Tract Infections is going to take precedence over AIDS prevention even though AIDS is a health related matter. The perceived severity of a disease, that may not be evident at the moment, takes a back seat. In some ways, the health belief model comes to play here. The chronic nature of HIV and AIDS downplays the sex workers’ perception of severity as well as the perceived susceptibility. The thought of getting AIDS and dying from it is quite farfetched for the sex workers, especially when their daily lives are full of other life threatening situations. No amount of education or prevention programmes can change this perception.

So, in answer to the question in the beginning of the discussion, the sex worker is quietly going to agree to the demands of the client, even though she knows that doing so will put her and her unborn baby at risk for HIV and AIDS. Therefore, education approach for HIV prevention fails because the hierarchy of needs is clearly not addressed in these education programs.

Fundamental Attribution Error

An attribute is an inference about cause of behaviour. There are basically two sources for behaviour-those that are influenced by internal factors and those that are influenced by external factors. Internally caused behaviours are those that we believe are under the personal control of an individual, or those that are done deliberately by him. Externally caused behaviours are those that are seen as resulting from outside causes, that is, the person is seen as having been compelled to behave in a particular way by the force of a situation and not because of his own choice. When we make a fundamental attribution error, we tend to overestimate the internal factors while under estimating the external factors that can explain behaviour (4, 5).

In case of HIV prevention programs, we tend to make a fundamental attribution error when we do not consider the situation that caused a sex worker to choose this type of work. We fail to consider why the sex worker is not using preventive measures in spite of knowing all benefits of doing so. Fundamental attribution error has profound significance. The majority of the common population believe that these diseases, especially HIV and AIDS was “brought onto themselves” by the sex workers; that, it is a voluntary and controllable risk. The population fails to sympathize with their situation. And though this attitude is changing quickly, some work still needs to be done in this area because these social views continue to impact policies, practices for diagnoses, as well as the treatment and the prevention strategies. Social programs and policies that fail to recognize the complex interplay of individuals and social contexts may fail to resolve the problems they are intended to solve. In this situation, Fundamental Attribution Error can also be likened to context minimization error, which is something that eventually leads to the impoverished theory (6).

Fundamental attribution error is made in every level of the intervention for HIV prevention among the Commercial Sex Workers. Policy making, educating the workers, and showing them the harmful effects of risky behaviours; all of these interventions do not take into account the conditions under which a sex worker works. Because of this many of the education programs fail. Intense talks on HIV and AIDS as well as many related conditions may be given, groups of people may be gathered to participate in the education programs, pictures may be shown, even free condoms may be distributed; however at the end of the day it is what the client tells them and what the client pays them, that dictates the behaviour of the sex worker. As long as there is a failure to understand the situation under which the sex worker is working, there will a failure in making an impact at any level; right from the policy making level to the individual level.

Which brings us to the next criticism: What is it that makes the commercial sex worker disregard all warnings?

Theory of Social Stigma and associated Blaming Theory

Social stigma is a severe social disapproval of a person due to his beliefs or work, because they are perceived to be against cultural norms. Erving Goffman defined stigma as 'the process by which the reaction of others spoils normal identity' (7). The attributions of criminality to the work of commercial sex workers stigmatize what they do. Not only do people stigmatize the work that the sex workers do, there is known to be a stigma against HIV/AIDS too. HIV/AIDS related stigma means a real or imagined negative response to a person or persons by individuals, communities or societies that are due to the disease that they have (8).

The stigmas faced by the workers are seen at different levels:

v Among the general population. There is a poor understanding and discriminatory practices among the general population, against the sex workers. The general population are usually of the opinion that sex workers work is something that they chose for themselves and that they have the freedom to opt out of it anytime. Due to this, they believe that any health related issues that the sex workers have is because of the choices they have made..

v Among the sex workers: The society’s attitude towards them has a profound impact on the sex worker’s attitude about themselves. The workers tend to think of themselves as being inferior to the general population. The level of self esteem that these individuals have is quite low too. They feel suppressed and thus they rarely raise their voice against any of the injustice, including violence, which may be done to them. They usually have no say over their client’s demands, even if the demands put them at a risk for HIV/AIDS. If the sex worker is addicted to drugs, this compounds the problem because the worker will be more in need of money and she will be more easily exploited. Overall, because of this attitude, where the sex worker thinks of herself as a victim, , make them more vulnerable to diseases. However, do they hold themselves responsible for the disease when they actually get them? No. Their low self esteem always makes them think of themselves as a “victim” and thus the blame is put on the client.

v Among the “clients”: Clients usually thinks of a sex worker to be someone whom he has complete power over. They are looked upon by the clients as someone they go to when they have to escape the realities and responsibilities of life, just like people using alcohol and drugs. These are beliefs that are quite deeply embedded and are difficult to change. The health of the sex workers is usually the last thing on a man’s mind when he uses her “services” (9). However, in event of a disease which they get from their risky sexual behaviour, they usually blame the sex worker.

How does all this fit into the education against HIV/AIDS approach? The social stigma attached to the work that the commercial sex workers do is so strong, that no amount of education of the sex workers will change the attitudes of people, clients as well as the workers themselves. As mentioned above, the illusion of control that a client has over a sex worker can lead him to demand unsafe sexual practices from the sex worker. The illusion of being “inferior to the common man” makes the sex worker agree to the demands that their clients make on them and finally the very fact that the entire society looks down on the work that the sex workers do, makes the society opposed to the idea of supporting the interventions that could make a difference. The education approach does not take the social stigma and the blame theory into account. The stigma makes it look like the “nice” and “decent” people of the society preaching the sex workers who are looked down upon. And the very fact that none take responsibility to their actions and the resulting consequences, makes them non responsive to the messages that we give the workers or their clients.

The above 3 reasons could be among the many others that this approach to reducing HIV and AIDS among sexual workers has failed. This in turn has lead to the failure of prevention of spread of the disease, not just among the clients and their networks, but also among the children of the sex workers themselves. The HIV/AIDS situation among the sex workers have been subtly acknowledged as one of the reasons of the pandemic that is taking over the world. Unless some major changes are undertaken to improve the methods of education of the sex workers, there will not be a significant difference in the way HIV and AIDS is spreading around the world.

Interventions Proposed To Counteract The Above Criticisms.

The biggest criticism to the education theory is that the public health workers preach and then expect the sex workers to follow their advice because “that would bring them good health”. The hierarchy of needs is largely ignored. Before the health problems of the sex workers are addressed, their basic needs need to be addressed. This could be done by making them self sufficient. Vocational programs would be one of the most effective interventions here. These programs would teach the sex workers some work that they are capable of doing. As I mentioned earlier, the sex workers live a secluded life in their districts. Though these districts are quite self-sufficient, much work needs to be done here. So, right from simple things like tailoring and knitting, to something as important as the education of children of the sex workers, could “jobs” that the sex workers do to feed themselves. Of course, the job would be based on the skills that the sex workers possess. The fact that they have the financial support to address their basic requirements of food and water, among others, would then make the workers think of the higher level of needs in the hierarchy. The next level is related to security. Security is a big issue with the sex workers. They are often victims of abuse, from the clients as well as the society. At the most basic level, this can be addressed by teaching the workers basic methods of self defence. Special laws that would cater just to the protection of sex workers could be passed. Then there is the next level of the need, where a human needs social support. Fulfilment of this requirement needs participation of the sex workers themselves. Forming peer groups, counselling groups as well as close circle of friends would be one way of addressing this need. The groups would be effective in providing support to those who are victims of abuse, addiction or just stress. Something as simple as having someone to talk to, can be a huge support to these women. Project Saheli (10), based in India, has a hugely successful counselling program for the sex workers in Mumbai. The program addressed the social level of hierarchy.

The next level of hierarchy is according to me, the level that public health workers and the community as a whole can make the most difference. At this level not only do is the next level of need in the hierarchy pyramid addressed, the problem of social segregation is also addressed simultaneously. Respect is important for anyone, most importantly the sex workers. Dignity and acknowledgement of the work that they are doing is important. Once the sex workers are looked upon as someone who is not an outcast, they will know that they don’t have to agree to everything that the client demands. The power will be in their hands, and we know from various social and behavioural studies that restoring power in the hands would have the most impact on any intervention and approach that we may undertake. The attitude of entire society should be changed. The education programs should be directed not just to the commercial sex workers but also to the population at large. This can be done through media like television and radios, print media as well as something more cultural like street theatre. Programs like the RHANI program utilize the local forms of communication to get the message across to the population in question (11). Similar approaches can be used. Though, in many parts of the world, sex and sexuality is not a taboo subject any more, however there are many regions where the subject is still a source of embarrassment. Education of the society through the means mentioned above, is known to have a positive impact. In countries, like Brazil, which has much lower prevalence of HIV and AIDS among sex workers, sex and sexuality is such a “taboo-less” subject that not just is the topic freely discussed, but even sex work is legal. The government, by legalising the industry, has put the power right back into the hands of the sex workers. Many projects in Brazil have emphasized the self esteem and dignity of the sex workers. An excerpt “Sex work is not illegal in Brazil and the government has taken an unprejudiced approach to preventing HIV infection among this group. A number of schemes have been carried out, including a high profile campaign based around a cartoon character called ‘Maria without Shame’. Advertised on posters, leaflets and stickers placed in women’s toilets, this character was shown with the message “You need have no shame, girl. You have a profession”. A radio advert featuring a famous Brazilian singer was also broadcast. The aim of this campaign was to improve the self-esteem of sex workers and to encourage them to take care of their health, with an emphasis on using condoms. It was found, in a 2009 study, that almost half of sex workers are reached by prevention programmes and 60 percent know where they can take a free HIV test” (12) . There are many lessons to be learnt from Brazil’s approach to the problem:

· A strong relationship between the government, civil society groups and NGOs to fight against discrimination of the sex workers is usually the first step in any HIV/AIDS related program targeted at the commercial sex workers.

• The educators and the teaching methods should be non judgemental and tolerant while educating the sex workers about HIV and AIDS and their prevention.
• A strong focus on condom promotion.
• A commitment to fighting stigma and discrimination, and encouraging a culture where people who are sex workers are not looked down upon, but instead they themselves are actively involved in helping respond to the epidemic and promote the prevention methods.

This is one of the biggest methods which can impact the education for prevention approach. Recognising the fact that the work sex workers do is nothing for them to be ashamed of, legalising sex work and treating sex workers with dignity is very important in making sure that the stigma faced by them is erased. This way they will gain self esteem and confidence. This in turn will help them move to the next level of hierarchy where they will be more responsive to acceptance of facts, about themselves and their health, and thus will be an integral part in the problem solving process.

The next problem that needs to be addressed is the problem of fundamental attribution error. The circumstance under which the sex worker is working is never taken into account. We just assume that they are not responsive to our messages because they have a choice and they choose not to. But that is not always the case. Here individual approach to the problem is necessary. Each sex worker’s situation must be understood. This can be done by getting someone from the community or some public health worker who is close to the community to visit the workers regularly and to see what conditions that the worker works in. If this is not possible, then the members of the community themselves could themselves be involved in the lives of the workers and then could come back to the public health workers to learn to deal with the situation and teach the other members to deal with it too. Another way of dealing with fundamental attribution is by putting the power right back to the hand of someone who knows the situation and deals with it daily, i.e., the sex workers themselves. Engaging the members of the community, right from research to policy making, gives the members the power to control and modify their situation. For example, if we want to make a rule where all sex workers are required to use condoms, then instead of ordering them, we could involve them in the law making process so that they are more acceptable to the law. This way, not only do the policymakers understand the situation from the sex workers’ perspective, but the workers themselves will become more involved with the implementation. Also, the laws should not just apply to the sex workers. It should also monitor the clients. The creation of a situation where the sex worker is cornered into accepting “demands” from the clients should be avoided. The client himself should feel responsible, or should be “forced” by the law to use protective methods. He should also be instructed about the health benefits of practicing sex safe. He should be taught about the dignity of the sex workers. Another very important step in avoiding fundamental attribution error by the health workers is by periodic training sessions in which the tendency to "blame the victim" and the tendency to commit the fundamental attribution error are openly discussed. This can lead to the better acceptance and better understanding among the healthcare workers themselves.

Conclusion

HIV/ AIDS among the commercial sex workers are a major issue that needs to be tackled by the health care professionals. Not only are the sex workers one of the largest continual sources of infection, they are also the most disregarded source. The public health interventions that are directed towards the sex workers are mainly aimed at educating the sex workers about HIV and AIDS and how to prevent it. The education approach to the problem, is flawed in many ways. However some changes can be made and incorporated into the approach, so that maximum impact is seen from the interventions.

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