India has the second highest number of people living with HIV/AIDS (5.1 million in 2003). In India transmission is estimated to occur largely through heterosexual contact and is linked to sex work. In Andhra Pradesh, where a high percent of female sex workers are HIV positive, efforts to prevent HIV infection in sex workers need to be enhanced.

A large number of adult women in India may be involved in sex work and it is estimated that most of them are not based in brothels. At the same time, the majority of new HIV infections in Asia are linked with high risk groups, including sex workers and their clients. There is evidence that HIV prevention programmes targeting female sex workers – especially by encouraging the consistent use of condoms – can be highly effective in preventing the spread of HIV/AIDS.

Research led by the Centre for Human Development at the Administrative Staff College of India looked at when female sex workers in Andhra Pradesh did not use condoms during penetrative sex, and identified associated factors to be taken into account when planning HIV prevention.

Of the 6,648 female sex workers who took part in the study, 24 percent said they had never used condoms. The majority of the female sex workers were street workers (75.4 percent) compared with home-based workers (22.5 percent) and brothel-based workers (2.1 percent). Of these, 53.7, 30.2 and 13.3 percent respectively reported no or inconsistent use of condoms with their clients, placing them at a high risk of HIV infection.

The study also found that:

• Almost half of the female sex workers who had had penetrative sex with a client in the past 15 days had not used condoms consistently.
• The most significant predictors of female sex workers not using condoms were a lack of knowledge that HIV infection can be prevented, no access to free condoms, being street-based rather than brothel-based, and not participating in female sex worker support groups. 
• Other linked predictors were lower social support, lower income, illiteracy, being older than 24 years old, and living in rural areas or medium-sized urban cities.
• The majority (94 percent) of female sex workers who had had penetrative sex with their regular sex partners (38.8 percent of total) in the past seven days had not used a condom.
• Overall, 41.8 percent did not use condoms consistently with either their clients or partners.

The HIV epidemic in India has been given high priority by the national government. Significant HIV prevention interventions for female sex workers are currently on-going in India, and would continue to be expanded to increase the coverage of HIV prevention programmes.

Policy recommendations include:

• Significant differences in the HIV infection risk between brothel-based and non-brothel-based female sex workers suggest that HIV prevention efforts must expand their coverage of the latter in order to reduce this gap. 
• Knowledge that HIV transmission can be prevented and access to condoms should be central to promoting the use of condoms by non-brothel-based female sex workers in India.
• Sex workers who are older than 24 years, illiterate, with lower income and lack of participation in support groups should be targeted by intervention programmes.
• Social and legal context of sex work should be addressed to create an environment for sustained reduction of HIV risk in female sex workers.

Source(s):
‘High risk of HIV in non-brothel based female sex workers in India’, BMC Public Health 5:87, by R. Dandona et al, 2005 Full document.

Funded by: Bill and Melinda Gates Foundation (Frontiers Prevention Project – FPP)

id21 Research Highlight: 16 March 2006

Further Information:
Rakhi Dandona or Lalit Dandona
Health Studies Area
Centre for Human Development
Administrative Staff College of India
Raj Bhavan Road
Hyderabad
500 082
India

Tel: +91 40 2337 6958
Fax: +91 40 2331 2954
Contact the contributor: rakhi@asci.org.in, rakhi_dandona@hotmail.com or dandona@asci.org.in

Centre for Human Development, Administrative Staff College of India, Hyderabad

Juan Pablo Gutiérrez
Health Economics & Evaluation
National Institute of Public Health
Mexico

Tel: +52 777 329 3099
Fax: +52 777 311 1156
Contact the contributor: jpgutier@correo.insp.mx

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