Damanjodi is a mining town nestled in the verdant hills of Orissa, in the east of India. The skyline is dominated by a sprawling network of mines and refineries owned and run by NALCO, Asia’s largest aluminium producer. Men come here from all over the country, creating a migrant workforce with money to spend and time on their hands. In their wake, women come too, seeking work of a different kind. Over 500 women are engaged in prostitution in Damanjodi and surrounding 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 in an orange sari, is hosting a women’s meeting. The meetings are an open forum, and today they discuss finding a boarding school for a recently orphaned girl. They do not, they cannot, discuss their main purpose openly. Ambica is employed by a targeted intervention programme funded by the Orissa State AIDS Control Society and run by Ekta, a local NGO. Although not all of the women present are sex workers, many are. Ambica’s job is to distribute condoms and encourage safe sex, but in reality she does much more – from arranging refuges to suggesting alternative means 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.
Privately, Ambica visits the women who are most at risk each week. Over time 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 prostitute, recently came to her after starting sex work herself. Her mother had not known of their shared profession until the girl fell pregnant. They do not know who the father is. Her mother disowned her, and the girl, just a child herself, faces raising her baby alone with no other means of income except returning to prostitution. Other women come to her after contracting HIV from unprotected sex. Despite Ambica’s best efforts to promote condom use, the offer of a little extra money is often enough to persuade them to go without. By Western standards, it really is a little extra money. Women receive 200 to 500 Rs. (US$4-11) for sex, but encounters can start from as little as 50Rs. ($1). To put that in context, a month’s wage for a woman working as a maid is 300 to 400 Rs. ($6-9).
Many of the women are widows or divorcees, and caste is no bar to sex work. Raising money for dowry, either for themselves or for their daughters, is another common reason for entering sex work and marriage represents one of the few realistic escape routes. The irony of women needing to appear chaste for their future husbands while being forced into sex work to afford their marriage is not lost on Ambica.
The risk of HIV looms over them. Over 18,000 people live with HIV in Orissa. Eighty-eight per cent of new infections are a result of sexual contact and a further 7 per cent are a result of mother-to-child transmission(1). The Indian health department runs integrated counselling and testing centres (ICT). Ambica says that referring people is one of the hardest parts of her job. ‘It’s an embarrassing situation,’ 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 Ambica encounters on a daily basis, the good news is that targeted interventions work. In Orissa, the HIV infection rate for sex workers remains below 1 per cent. By comparison, in neighbouring Andhra Pradesh nearly 10 per cent of sex workers have HIV (2). In much of the country, and much of the world, stigma and an institutional squeamishness about dealing directly with prostitutes puts lives at risk. According to UNAIDS, globally fewer than one in five sex workers receive adequate HIV prevention services and less than 1 per cent of HIV funding is spent on sex work (3).
Targeted interventions work because people like Ambica treat sex workers as human beings. A UNAIDS case study concluded 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 (4).
Poverty is the greatest risk factor. Arguably the best way to protect sex workers from contracting HIV would be to give them alternatives to becoming sex workers in the first place. However, for those women who do end up in this riskiest of professions, Ambica’s work shows that taking the time to build a connection can have an impact that goes beyond keeping them free from HIV. ‘Earlier the women were ignorant,’ she tells me, ‘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.’
1 District AIDS Prevention & Control Unit, Koraput