Female sex worker HIV prevention projects:

Item

Title
Female sex worker HIV
prevention projects:
extracted text
Photographs by:
Smarajit Jana, Coordinator, Sonagachi Project
Joe Anang, Project Manager.Transex Project
Carol Jenkins, Travis Jenkins
AKM Mohsin, reprinted with permission from the Daily Star
Illustrations and author:
Carol Jenkins
Senior Scientist
Social and Behavioral HIV Prevention Research
DAIDS, National Institutes of Health. USA
Corer photo Hentto Sisters flnrint> u rocutionul training meeting at the project house,
irhere i'U C. i workers provided seirhi}> /essoiw.
Photo:.Joe Auans>. Project Manasier. Iranse.v Project.

Female sex worker HIV
prevention projects:
Lessons learnt from

UNAIDS/00.45E (English original, November 2000)
ISBN : 92-9173-014-9

© Joint United Nations Programme
on HIV/AIDS (UNAIDS) 2000.

All rights reserved. This document,
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(contact: UNAIDS Information Centre).

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Papua New Guinea,

India and Bangladesh

6
UNAIDS
Geneva, Switzerland
2000

Contents

Contents

Contents
Introduction
Background

..................................... ;
......... ................

Lessons in Best Practices in Sex Worker Interventions
The Individual vs. the Social
Formative Research
....................................

Courage and Clarity of Commitment
Measuring Effectiveness
Strategies for Strength and Replication
Efficiency and Management
Specific Points
Conclusions
................ .....................

..5
..7
..9
..9
10
11
12
15
16
17
18

Situational Background

Relevance
................................
Formative Stages
........................ ..........
Implementation.........................................................

Working strategies
Outreach, and peer education
Condoms .\
....................
Health care
Empowerment
Monitoring and Evaluation

.19
.19

Condom use and regular partners
Increasing knowledge.,
..................

2

Replicability .........................................

....51

Sustainability ...............................
Lessons Learnt.........................................................

....52
....52
....54

Acknowledgements...............................................
References ...............................................................

Red Light District of Calcutta, India

introduction

..............

Formative Stages
Implementation
Working strategies
Health care

.28
.29

Empowerment
Clients and lovers
Monitoring and Evaluation
Effectiveness

.30
.32
.35
36
42
44

46

:..:51

....55

Sonagachi: A Sex Worker Project in a

.20
.23
.25
.28

.33

Increasing condom use
Reducing line-ups

....47
....49
....50

Situational Background
Relevance

The Transex Project: Sex and Transport Workers,

Police and Security Men in Papua New Guinea...
Introduction

Condom and lubrication distribution
Resource materials................................
Efficiency..................................................
Ethical soundness..................................

Peer education
Condoms

.

Efficiency
Ethical soundness .>
.........
Replicability and sustainability
Lessons Learnt

Further Reading

.57
.57
.59
.62
.62
.66
.66
.67
.69
.70
.71
.75
76
77
83
84
85
86
88

Contents

introduction

SHAKTI: A Brothel and Street-Based

Sex Worker Project in Bangladesh...............................
Introduction...................................................................

i

Introduction

...91
T"he set of case studies in this collection emerged from a session
...91
I entitled Best Practices in Female Sex Worker Projects held at
Situational Background.......................................
...93
the Fourth International Congress on AIDS in Asia and the Pacific in
Tangail brothel..............................................
...93
Manila, October 1997. Preparation for the session began in May 1997
Street sex work in Dhaka...........................
...95
when UNAIDS sponsored an effort to learn about sex worker projects
Relevance................................................
...97
in the region. Lists of known potential projects were elicited from sex
Formative Stages.......................-......... ;......
...98
work networks, well-connected individuals and researchers. A call for
Brothel baseline studies,.............................
...98
responses was placed on the SEA-AIDS list server. After intensive com­
Street-based sex worker baseline studies
.100
munication with 25 sex worker projects in the Asia-Pacific region, five
Implementation............................................................
were selected that asserted they could produce data to document their
.101
Working strategies........................................
impact and effectiveness. It was decided to omit male and transgender
.101
sex worker projects, so as not to sideline them, and to place them in
Peer education..............................................
.101
their
own category for a future review. It was also decided to omit the
Health care ........................... ................... .
.103
national-sex
worker programme in Thailand as it was being docu­
Empowerment: in the brothel..... ......... .
.105
mented on its own as a successful best practice case study.
Empowerment: on the streets of Dhaka.
109
A turning point.............................................
110
The selected projects were requested to send a sex worker and a man­
Condoms.........................................................
111
ager to the Congress, able to discuss the nature of their projects, each
Clients, non-clients and lovers...................
114
from her own point of view. The session took place in several lan­
Monitoring and Evaluation.........................................
guages with translations, a time-consuming exercise, but because of
117
the
candid and forthright personalities of the sex workers involved,
Effectiveness...................................................
118
was
nonetheless very lively. Those attending felt the session was a suc­
Efficiency..........................................................
122
cess in demonstrating some of the effective strategies available and
Ethical soundness...........................................
122
showing the strength of sex workers themselves in bringing about the
Replicability and sustainability..................
123
success of their projects.
Lessons Learnt............................................................ .
123
References............................................
The presenters at the Congress were:
126

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Dr. Smarajit Jana, Coordinator, Sonagachi Project, Calcutta, India

•

Anima Bannerj^e, Mohila Samanwaya Committee, a sex worker
organization developed as part of the Sonagachi Project

•

A.M. Quddus, Field Coordinator, SHAKTI Project, Bangladesh

IBI iifli
■■■

Introduction

•

Aklima Begum, Peer Educator, SHAKTI Project

•

Kim Yel. Outreach Worker, Svay Pak Project, Cambodia

•

Hong Chanta, brothel owner, Svay Pak Project

•

Joe Anang, Manager, Transex Project-Port Moresby,
Papua New Guinea

•

Alice Michaels, Peer Educator, Transex Project-Port Moresby

•

Candelaria Cantillo, Project Coordinator, Talikala, Davao City,
Philippines

•

Michele Valera, Lawig Bubai, a sex worker organization devel­
oped as part of the Talikala project

Carol Jenkins and Irene Fonacier-Fellizar were the facilitators.

The case studies that follow are constructed from information gath­
ered from those projects, both before, and for many months following
the session. With one exception, all project sites were visited. After vis­
its and attempts to secure adequate proof of effectiveness, two proj­
ects were omitted from the case study collection, Svay Pak and Talikala.
While screening projects, we recognized that some sex worker projects
might have been as effective as those selected, but because they
lacked good documentation, it would be difficult to defend their
approaches. Others appeared sound in some respects, but aimed at
removing sex workers from prostitution, which was rarely successful
and is not the principal aim of most HIV prevention projects. Others
were not considered simply because communicating with them was
very difficult, either due to the lack of (or poor) electronic communi­
cations, or because their managerial personnel were unable to com­
municate in English, or another accessible language to the reviewers.
These fell out of our network.

The evolving nature of UNAIDS best practices criteria also played a part
in the eventual selection of these case studies. These guidelines

■

■

. - -

«

1

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introductior

emphasize effectiveness and impact, but not entirely on criteria of an
epidemiological nature. Other factors, such as sustainability, ethical
soundness, relevance, efficiency, were also considered. At first it was
difficult to find any project which met all of these criteria. Eventually,
UNAIDS came to realize that documenting weaknesses can be just as
useful as showing success. None of the projects selected is a perfect
example of all criteria. It is doubtful that any such project exists. What
these case studies represent is a set of experiences and lessons that
might clarify for others the areas of strength and weakness typical in
successful female sex worker projects. To the greatest extent possible,
we have shown the real difficulties and triumphs of each of the proj­
ects. These case studies demonstrate how sincere organizations have
tried to deal with the complex problems presented to their projects in
different (and sometimes similar) ways: And they exemplify some of
the region's best efforts*at preventing HIV among a diversified and

highly vulnerable group of women.

Background
"The three projects selected for case studies represent a range
I of situations, geographical locations, problems and solutions.

Two of these, Sonagachi and SHAKTI, involve brothel-based sex work­
ers in South Asia. The Transex project works with club or street-based
sex workers in the Pacific nation of Papua New Guinea. SHAKTI
includes both brothel and street-based sex workers in Bangladesh. In
each case, situations differ considerably. Sonagachi is'a large, densely
populated red light district in the centre of Calcutta, housing 5,000 sex
workers, of whom two-thirds are Indian and one-third hail from
Bangladesh and Nepal. The project emanates from the All India’
Institute of Hygiene and Tropical Medicine, funded by WHO in its ear­
lier days and by the United Kingdom Department for International
Development (DfID) more recently. Although it began when HIV
prevalence was still quite low, prevalence has been increasing in West
Bengal. In other regions of India, HIV prevalence has risen very rapidly.
SHAKTI is the name of a project implemented by CARE, Bangladesh.

i

Introduction

IntrodL

It began at a brothel in Tangail, a medium-sized city in Bangladesh, and
expanded to include street-based women in the capital city of Dhaka.
DfID provided funding. The brothel at Tangail houses about 600 sex
workers and the street-based intervention targets about 3000 workers.
SHAKTI began when HIV was only sporadically found in returning
migrants and a few other groups of people in Bangladesh. As of 1998,
HIV prevalence remained fairly low in Bangladesh, but appeared to be
increasing slowly. The Transex project, implemented by the Papua New
Guinea Institute of Medical Research, has two branches in the two major
cities of Papua New Guinea, Lae and Port Moresby. In both cities, the
project works with independent, street-level sex workers. The project is
mainly funded by AusAID and, to a smaller extent, had funding from
UNAIDS for a single year. It is named Transex because it focuses on trans­
port workers, i.e. sailors, truckers and dock workers, as well as police and
security men, in addition to the women who sell them sex. HIV preva­
lence was rising rapidly as the project started and continues to do so.

the reader will glean useful insights from the strengths and weak­
nesses these projects demonstrate.

ion

Lessons in Best Practices in Sex Worker
Interventions
T“he efforts made to document and analyse five female sex
I worker projects selected for the session at the conference in
Manila in 1997 have resulted in three best practice case studies. Two
have been set aside because of inadequate documentation and lack of
sound data to support claims of success. The other three illustrate var­
ious aspects of good practice and some not quite so good. There are
lessons to be learned from all. In fact, it might be easier for most of us
to see why some action fails than how an activity succeeds in bringing
about change in complex and difficult situations. This section will
address several broad issues, illustrated by discussions of the case stud­
ies. Other more specific points will be listed below more briefly. The
interested reader can refer to the full case studies for a more complete
discussion.

The process by which these projects have been documented requires
some mention. All projects were visited and documents reviewed.
Taped interviews were conducted with some managers. Mid-term or
final evaluations were carefully examined where available. Raw data
were accessed for several projects and analysed. Sex workers from
three projects were especially helpful, as were outreach or field work­
ers. The first drafts of the case studies were examined by each project
manager and then sent for review and comments to persons uncon­
nected with the project in the same country as well as to persons out­
side each country. Each reviewer was a person closely involved with
HIV prevention activities, including several known authors of pub­
lished AIDS-related materials. After their comments were received,
project managers were asked to respond, and then a full review of all
materials took place in Geneva with UNAIDS representatives. As this
process extended over a year, updated information was sought from
each project just before the completion of the last draft. Therefore, it
is hoped that this document is a fair and honest representation of the
realities faced by the selected projects and their participants and that

I n nearly ail settings, female sex workers are a stigmatized group
■ of peopie. Their very existence challenges the standard family
and reproduction-oriented sexual morality found in most societies. Yet
they exist near!', everywhere, clearly indicating that they fulfil a func­
tion for society Hypocritically, most mainstream societies have rele­
gated them to the margins, abused them, exploited them and
restricted their nghts as citizens. As women (in contrast to male sex
workers), they are doubly powerless. With the advent of the HIV pan­
demic, they have beerrthe first group in many nations to be targeted
as vectors and seen as dangerous to the general population. They are
seen as the agents of infection and their clients as unwitting victims.
Usually the sex fade or industry itself is left untouched. The contrast­
ing perspective s that the sex worker is a person whose livelihood

£

a

The Individual vs. the Social

Introduction

introdu'ction

places her in a highly vulnerable situation for acquiring HIV. That liveli­
hood, being illegal, is surrounded by layers of uncontrolled and there­
fore abusive persons. Sex worker projects must grapple with these vari­
ant perspectives, both in the society at large surrounding the sex
worker and in the views of project personnel. Sometimes sex workers
themselves are ambivalent about their position in the epidemic, at
times seeing themselves as actors, and at other times as victims. The
strategies taken by HIV prevention projects for female sex workers
reflect these perspectives and set the tone for the way in which the
project is implemented.

sex workers' children's needs, gradually adding each piece of research,
as issues become clearer. More qualitative information was gathered
somewhat informally, but was reflected repeatedly in the published
documents on the project. SHAKTI conducted a formative survey, but
it was not designed to uncover the power structure of the brothel. This
information was gathered in a less formal and less organized fashion,
leaving project implementers somewhat confused about how to pro­
ceed. The force of events, however, in Bangladesh, moved the project
forward.

Most projects seem to address high-risk behaviour on the level of the
individual, with persuasive methods, such as advice, counselling, and
peer education; enabling approaches that remove social constraints to
safer sex (or conversely, put barriers to unsafe sex in place) demon­
strate greater success. These enabling approaches are exemplified by
the projects documented here in various ways, which illustrate the way
they function.

Formative Research
Qirst, one must understand the structure of the sex industry, the
I position of women in it, who has power over them and who
does not, and what the sex worker lacks to be able to live and work in
a healthier setting. Baseline quantitative survey research, while usually
required, is not able to supply the in-depth information needed to
design strategies for change.

i

Courage and Clarity of Commitment
O ut there is more. It also takes courage to face powerful politDical and social structures once these are delineated in the
formative phase. The Sonagachi project is hailed globally by sex
worker organizations and AIDS activists alike for its integral involve­
ment of sex workers. This could not have taken place without a palpa­
ble demonstration of courage and commitment on the part of project
personnel. In this case, several community-based groups had been
working in the Sonagachi area prior to the HIV intervention. They had
themselves confronted the local gangs, a portion of the power struc­
ture, and had developed understanding of the social scene and the
strength to stand up to it. As the HIV intervention began, they partic­
ipated and helped intervention personnel to develop the strategy of
empowerment that has been so successful. Gradually, women's groups,
legal rights organizations, and even government agencies have joined
the sex workers' efforts to reform the social system around prostitu­
tion in Calcutta.

The Transex project was based on an optimal use of qualitative situa­
tional assessments and formative research. This enabled the project to
tailor the activities to local contexts and to be able to adjust to the
realities in different sub-populations and cities. Sex workers them­
selves were involved in the project design and made their priorities
clear: they wanted help against police harassment. The Sonagachi proj­
ect conducted extensive surveys of sex workers, clients, boyfriends, and

The Transex project in Papua New Guinea (PNG) operates in quite a
different social setting. There are far fewer layers of control over the
sex worker than found in the Indian sub-continent. The one salient
power broker is the police force and the project took them on
directly, addressing the highly sensitive issues of group rape or line­
ups. This has been one of the most important aspects of the project,

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Introduction

Introduction

empowering the women through confronting police practices, sexual
violence and issues of social marginalization. Gradually, the commit­
ment of the project and its staff has become apparent to sex workers,
who appear to be beginning to bond in a self-run organization. Both
of these projects created a precedent by addressing social and sexual
norms.

SHAKTI, such a skilled person was available during the design phase
and good indicators were set up, but for a period in the project's life,
those skills were not replaced. A similar skills gap occurred in the
Transex project.

The SHAKTI project has attempted to bring about improved condom
usage without confronting the power structures and, in some ways,
has been less successful than the other projects. Its original model of
conflict resolution did not resolve the major conflicts surrounding the
sex worker and hence, she has remained relatively isolated in her
efforts to induce safer sex in her trade, one that remains highly stig­
matized in Bangladesh. Nonetheless, the participation of SHAKTI's sex
workers, particularly those who led in a fight against the closure of
brothels in 1999, has been critical in bringing about a court decision
citing prostitution as a legal way to make a living. While it is under­
stood that all constraints in the social arena are not amenable to rapid
change, the SHAKTI and Sonagachi projects demonstrate with clarity
that, even in highly repressive and abusive environments, the rights of
sex workers can be addressed and sex workers themselves can be
enabled to act.

Measuring Effectiveness

The types of indicators used must fit what the project is trying to
accomplish and must accommodate all its major effects. While all of
the projects discussed aim at the control of HIV transmission, preva­
lence levels of HIV do not demonstrate impact very well. Incidence lev­
els would be an improvement but require a cohort study, which
becomes a major investment in research and is not feasible for most
intervention projects. Levels of other STDs are considerably more use­
ful in demonstrating improved sexual health, but are not specific to
project components. It is not possible to separate out the effect of
improved recognition of symptoms, improved access to treatment,improved diagnosis and treatment, or improved condom use from
such data. Further, some STDs, such as chlamydia, are very often
asymptomatic and not a good indicator in women. Results of STD sur­
veys are very sensitive to modes of sample collection (e.g. how well a
vaginal or cervical swab is taken), modes of laboratory testing (espe­
cially where cultures are required), and modes of sampling. Unless
well-trained persons are in place to carry out such surveys, they are fre­
quently subject to failure, or at least, to questionable results.

jectively thought to be successful. When screening numerous projects
in the Asia-Pacific region, this issue loomed largest. Most projects are
quite capable of maintaining process indicators, i.e. the number of
condoms given out, the number of meetings held or peer educators
trained. Measures of impact or effectiveness, however, are often less
well developed. In some cases, data are collected which could be used
to demonstrate impact, but there are no project personnel available
with the skills to analyse and disseminate the results. In the case of

In the case of Sonagachi, STD indicators produced a problem for sev­
eral of the above-mentioned reasons. Eventually, the laboratory meth­
ods were improved. In the case of SHAKTI, laboratory methods were
apparently well controlled, although some confusion resulted over the
interpretation of negative controls on the PCR chlamydia results:
Unfortunately, those with the clearest results, i.e. PCR-tested gonor­
rhoea and current syphilis (via VDRL at dilutions >1:8), showed no
improvement over time. The Transex project vyas not able to develop
its STD indicators at the beginning of the project due to difficulties
with availability of personnel as well as with the government. This
work has begun but will require several years before an assessment of

12

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I I nless a project creates sound modes of measuring its success,
kJ it is very difficult to defend its practices, even if they are sub­

I

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Introduction

introduction

the impact of the project can take place. It is not likely that most sex
worker projects will be able to utilize laboratory-based indicators and
simpler modes of monitoring STD levels must be developed.

condoms available to Sonagachi's women. A similar move to selling
condoms has occurred in the SHAKTI project and, in both cases, the
sale of condoms by sex workers serves well to confirm the rising levels
of condom use.

Self-reported condom use is always a difficult measure, though heav­
ily depended upon by most projects. It is well recognized that women
are under pressure by these projects to claim improved condom use
and are highly likely to exaggerate. The large differences between
mid-term survey results and simultaneous monitoring results for con­
dom use at the Tangail brothel illustrates well the intense pressure felt
by sex workers when asked about their condom use by their own ded­
icated peer educators (as opposed to peer'educators assigned to edu­
cate other cohorts of sex workers). SHAKTI attempted to address this
question by collecting used condom covers, but this method did not
appear to be adequate.
Transex tried to diminish overreporting by means of improved inter­
view techniques, but had no other modes of verification. Condom use
is not a monitoring indicator and data on this aspect of outcome are
only available through repeated surveys. Fortunately, the protracted
period of initial baseline data collection allowed a trend analysis, and
the police component did have a follow-up survey. Its full evaluation
was designed from the beginning of the project to diminish bias by
moving outreach workers from one city to the other to serve as inter­
viewers in the follow-up survey.

I

I

Monitoring is an on-going process. The majority of monitoring indica­
tors for all projects focus on process or progress, not outcome. These
are of value if project personnel are able to critically review their
meaning and adjust activities accordingly. In all the projects c scussed,
time pressure and overworked personnel have been factors working
against the optimal use of monitoring indicators.

I

Monitoring growing levels of self-esteem or empowerment has been a
weakness in all these projects, particularly in a measurab’e form.
Qualitative documentation does exist, e.g. anecdotes and newspaper
articles. Only at Sonagachi has a quantifiable measure been devel­
oped, i.e. the number of sex worker meetings attended. This is possi­
ble only because of the advanced nature of the intervention's
approach to sex worker rights and self-directed activities, such as train­
ing other sex workers elsewhere.

Strategies for Strength and Replication

While Sonagachi also simply asked women about their condom use in
its earlier repeated surveys, more recently it has moved to asking how
many condoms they are buying. This is a far better measure, assuming
poor women will not buy what they do not plan to use, and is only
possible when free condoms are not being distributed. The very strong
social marketing component of Sonagachi has enabled this to come
about. Such a measure, however, does not accommodate the number
of condoms supplied by clients or boyfriends, but, in the absence of
targeted interventions for these groups, may well act as a proxy for all

II these projects have aimed at replication in other areas of
/vtheir respective countries or regions. The West Bengal Sexual
Health Project incorporates the Sonagachi experience directly and the
Sonagachi sex workers' organization, the Durbar Mahila Samanwaya
Committee, has trained hundreds of sex workers elsewhere in West
Bengal. Without the development of strong sex workers' organizations,
each project has had to rely upon the interest of other NGOs. This has
not been successful as yet in Papua New Guinea and is only partially suc­
cessful in Bangladesh. However, in Bangladesh the strong alliance of
SHAKTI with government during its early phases was very effective in
demonstrating the possibility of targeted interventions for prostitutes
in a highly conservative setting. Its strength grew as it linked with other

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introduction

Introduction

legal and human rights agencies. In Sonagachi as in Papua New Guinea,
the implementing agency was a government affiliate. Nonetheless,
other government sectors had to be convinced of the value of the proj­
ect. Partnerships with NGOs were well developed in Sonagachi and
have only recently developed in Papua New Guinea. In all cases, it is
clear that replicating the project must be done in a way that will allow
local groups to adapt the overall strategies to their own situations and
access the experience of the older project in the process. Planning for
expansion or replication at the early stages of such a project is impor­
tant for it allows the time for development of understanding and coop­
erative relationships with government agencies and NGOs.

with stigmatized people. Leadership in sex worker projects requires
honest commitment. It is not a job that suits everyone. The individuals
who led the projects discussed were deeply committed and personally
involved. Their families became involved and their personal time was
sacrificed. While this may lead to burnout, it may be necessary, at least
at the beginning of such projects. Others in such projects who are
deeply committed also experience burnout and the project must build
in methods to diminish feelings of ineffectiveness, monotony, and
grief. Persons living with HIV, whenever possible, should be incorpo­
rated into project activities. This can help them and help everyone else
remember why they are working so hard.

Efficiency and Management

Specific Points

\A
levels of efficiency in such projects will never approxiV V mate to those in successful profit-making businesses, they
can be tightened and improved. As a rule, it is more efficient to
address the top of a hierarchy that is in control of activities and behav­
iours of those lower down, as the Transex project did with the police,
than to spend a great deal of time and money directly reaching the
masses at the bottom. Sonagachi also conducted repeated formal and
informal advocacy meetings with senior government officials to win
their cooperation. To a large extent, this has paid off and allowed
major international meetings of sex workers to take place in Calcutta.

[Jeer education is one of a number of ways to convey informaI tion and persuade people to change their behaviour. Its great
advantage is that peers can utilize their normal venues and modes of
communication. If peer educators are separated from their colleagues
with special privileges, the value of the approach may be lost.

Large budgets are not always helpful. They can mislead inexperienced
project managers into thinking there is ample room for mistakes to be
made. Good budgetary control is required and needs direct coordina­
tion with project strategies and specific activities. Even small budgets
can thereby be well utilized.
AIDS prevention projects may attract NGOs and individuals who simply
understand that there is funding available for this kind of work. When
they realize the intensity of the problem, they may or may not be will­
ing to commit themselves and a large part of their lives to working

•

Addressing clients with specific programmes tailored to their needs
strengthens sex workers' abilities to negotiate condom use.

•

Boyfriends, husbands and other non-commercial sexual partners
frequently place sex workers at more risk than do their clients, par­
ticularly after they have learned to persuade clients to use con­
doms. This aspect of the lives of sex workers needs specialized
attention.

•

Personnel well trained in current STD diagnostics and treatment
must oversee the establishment and management of clinics for sex
worker projects. Sex workers are people with other health prob­
lems as well and these also need attention.

•

STD and other studies undertaken with sex workers must be carried
out with their full understanding and assure their right to refuse.

Transex, Papua New Guinea

itroduction

The Transex Project: Sex
Well-designed studies conducted
are of
sex work­
and Transport Workers,
ers too;
studies waste
time and are seen as abusive.
Results
to be fed back to the sex worker community
Police and Security Men in
fashion
their understanding, and timely
treatment must be given.
less is unethical and will
Papua New Guinea
their confidence
the project and its messages.
poor
need
appropriate
destroy

•

•

*

properly
their

value to

in an

to ensure
Anything
in

Project staff and sometimes sex workers too need training in
human sexuality in order to be able to speak about sex with ease
and convey explicit messages.
Lubrication, female condoms and encouraging non-penetrative sex
should be made part of the package of safer sex options.

Documentation is more than periodic surveys and counting moni*
toring indicators. Writing and/or using tapes and film to document
the history of a project is a worthwhile endeavour of its own and
has potential value to many others.

Conclusions
"The importance of designing and implementing successful tarI geted interventions for sex workers as part of HIV prevention

and control cannot be over-emphasized. In almost every country, sex
workers comprise a focal point of the epidemic, because, as women
who provide sex for many men, infections can easily accumulate
among them. They are the victims of discrimination, often violently
intense, trafficking, legal persecution and societal ambivalence — as
well as one of the first occupational groups to become heavily
infected. From them, the infection passes back to their clients and into
the general population of women, men and children. One of the clear­
est public health lessons emerging from the HIV pandemic is that pro­
tecting the human rights of sex workers is one of the best ways to prorect the rest of society from HIV.

Introduction
HF he Transex project, for transport
I and sex workers, began in 1996.
It was built on a foundation of extensive
research conducted by the Papua New
Guinea Institute of Medical Research
(PNGIMR), exploring both behavioural
risk factors and STD epidemiology. With
funding from the regional AIDSCAP (FHI)
project, in 1994 the PNGIMR conducted
an ethnographic situational assessment
of men in the transport industry (truck­
ers, sailors, dock workers) and the
women who sell them sex. In 1995 partic­
ipatory project design workshops held
with sex workers, hotel managers, and
maritime union, trucking, and shipping
company representatives, led to the
development of a proposal and an appli­
cation for funding. The Transex project
was then included within a larger threeyear HIV and Sexual Health Project
funded by AusAID in cooperation with
the Department of Health (DoH). Specific
activities were additionally funded by
USAID, WHO, UNFPA, and UNAIDS. The

19

18
W’

jfes---

Transex, Papua New Guinea

implementing agency has been
the PNGIMR, a statutory body of
the government.
The project operated, from its
beginning, in the shadow of a
dramatically increasing HIV epi­
demic, a free-fall economy and a
roller-coaster political scene. The
urban areas, where the project
was
based,
experienced
markedly increasing levels of
crime in the wake of a structural
adjustment programme that
devalued the currency and led to
rapid inflation. General compla­
cency about AIDS and lack of
understanding of behaviour
change programmes made for
slow progress. Despite these
obstacles and the short life of
this project, the project provided
the first successful example of a
targeted intervention for HIV in
Papua New Guinea (PNG). Sex
workers developed their own
organization, police and trans­
port workers were trained as
peer educators, condom use
increased in high-risk groups,
HIV testing increased, and the
project provided the first real
home-grown expertise in peer
education and numerous other
HIV issues to the national pro­

Transex ’'apua New Guinea

gramme, NGOs, and community
groups. The Transex project was
originally conceived to be a project implemented by an NGO, but
as no NGO emerged ready to
handle its objectives, it has been
brought forward for the next
phase of funding as Transex Plus,
The new project will include
youth and other groups and be
implemented by the National
AIDS Council, where its lessons
will be spread more widely.

Situational
Background
Qapua New Guinea is a
I country of about 4.3 million people spread out over a
land mass approximately the size
of Thailand. Except for a few
areas, population density is quite
low and people are scattered
over the landscape. About 85%
of the people live in rural areas
and speak over 860 different lan­
guages or dialects. About onethird are literate in English or
Melanesian Pidgin, the lingua
franca. Most have little access to
functioning health or other services. Traditional lifestyles are
under pressure as consumer
demand and a cash economy

expand without real growth in
income-earning opportunities.
The country is rich in natural
resources, with numerous gold
mines, oil fields and logging
camps, but, due to years of poor
management, it has become a
rich nation of poor people.

in late 1995. The Transex project
was designed to be executed
through an urban community­
based NGO, with PNGIMR acting
as major adviser. However, when
funds arrived, no NGO was will­
ing to implement it because of
the stigma of working with sex
workers. In mid-1997, a further
fruitless attempt was made to
find an NGO to help in imple­
menting the project. Poor coor­
dination between national and
provincial health departments as
well as mutual distrust between
government and NGOs has ham­
pered a solid national response
to the epidemic. In 1.997 legisla­
tion to establish a National AIDS
Council was passed and renewed
efforts to coordinate the public
and private sectors began.

Risk factors for HIV infection are
high in Papua New Guinea, with
high levels of STDs in many areas
around the country and wide­
spread risky sexual practices
(Jenkins and Passey, 1998). The
epidemiological patterns of HIV
infection are influenced by sev­
eral
factors,
including the
absence of injecting drug use,
high levels of infertility and STDs,
a diffuse urban and rural sex
trade, as well as clear patterns of
spread along transport routes
(Malau et al., 1994). Over the
past decade, most political lead­
ers chose not to recognize HIV as
a serious threat to the nation,
despite numerous studies by UN
agencies as well as local researchers
that sent clear warnings (Jenkins,
1993a; Mugriditcnian and Jenkins,
1993). Through AusAID, Australia,
the main foreign donor, funded
the initiation of the first major
programme for HIV prevention

In a national study conducted in
1992 in rural and periurban
areas, about half of all women
investigated revealed that they
exchanged sex for money or
gifts
(National
Sex
and
Reproduction Research Team
and Jenkins, 1994). While that
study was not carried out on a
representative sample, subse­
quent studies corroborated the
high frequency of commercial

21

Transex, Papua New Guinea

sex. Research conducted in three
urban areas (Goroka,
Port
Moresby and Lae, with total
populations of about 315 000)
estimated that approximately
15 000 women were working
more or less independently, at
least part-time, as sex workers
on the streets, along the
Highlands Highway, in small
guest houses and at hotels
(Jenkins, 1994a, 1994b). Their
main clients were reported to be
government workers, truckers,
sailors, dock workers, security
men and police. The project,
therefore, aimed at including as
many client groups as possible in
addition to the sex workers in
the two main port cities of the
country, Lae and Port Moresby.
Lae is the largest port and the
origin of the Highlands Highway,
the nation's main road artery
through the most populated sec­
tion of the country.

During the formative research,
sex workers indicated that their
most serious problem was being
picked up on the streets and
taken by police for group rape
sessions, known as line-ups, at
the police barracks or other
locales. They also indicated that

22

Transex, Papua New Guinea

they were frequently made to do
the same to obtain protection at
night
from
security
men.
Therefore, a targeted one-year
intervention
was
designed
specifically to diminish these
practices.

uncontrollable sexual desires
that must be satisfied, and
accept that rape is the natural
outcome of this. Sex workers,
therefore, represent the classic
"necessary evil" and are gener­
ally tolerated.

Prostitution is illegal in PNG,
though few women are impris­
oned for this reason. Sex work in
PNG is not brothel-based and is
seen as an unfortunate but rea­
sonable way for women to gain
an income for their families and
themselves. In the urban settle­
ments or slums, theft, perpe­
trated by "raskol" gangs, and sex
work carried out by women are
important income producers
(Jenkins, 1996). Sharing the fruits
of these activities with families
ensures protection and minimal
stigmatization. Outside of these
areas, sex workers are stigma­
tized and families often hide the
fact from outsiders that their
women are sex workers. Most
people consider these women as
carriers of infection, while, in
keeping with a strong sexual
double standard, their male
clients are seen as blameless vic­
tims. Most women themselves
accept the notion that men have

While most women work alone,
some also utilize boskrus, men or
women who find them clients.
Those working at hotels may
rent their own rooms and have a
regular clientele or may go to
the rooms of clients contacted
through hotel workers. Guest
houses serve as both contact and
action venues. A great deal of
sex takes place outdoors, with
street-based women working
during the daytime in busy areas,
and sometimes at night as well.
As this can be quite dangerous,
these women often have a wasman, a man who guards the area
she is working in, keeps out
intruders and helps her collect
her money if someone tries to
cheat her. The men or women on
the periphery of the., trade are
paid by the sex worker, either in
money or in kind, but do not
exert violent power over the
woman as is found in sex work
cultures elsewhere. The police,

however, harass them and obtain
sex on demand without paying.
The greatest abuse of sex work­
ers in PNG comes from the police.

Relevance
The HIV epidemic in PNG has
hardly
been
documented.
Although blood for transfusion
has been screened since the late
1980s, donors have increasingly
been drawn from young school
students; hence, few positive
cases are found through blood
screening. Sentinel surveillance at
antenatal and STD clinics took
place sporadically for several
years but was abandoned in
1993, due to the lack of confiden­
tiality and other problems. More
recently, it has been reinstated.
Passive detection at hospital clin­
ics has been almost the only
source of information on HIV
infection, and even these cases
are not always reported. Figure 1
shows the latest available figures
on HIV infection in PNG.
Therefore, the Transex project, as
the only behavioural change pro­
gramme working with highly vul­
nerable groups in the country, has
been extremely relevant. When

23

Transex, Papua New Guinea

Transex, Papua New Guinea

Figure 1. Reported new cases of HIV infection in PNG by year
700t1

600z
500'

400'
300
200'

100

I

0-^

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
the project began to train sex worker peer
educators in August 1996, the women
were already aware of probable deaths
from AIDS in their communities.

Formative Stages
preparatory qualitative research
I had taken place several years
before the project began. This included
observations conducted by researchers
working on trucks and on ships, and pri­
vate interviews with 85 sex workers, 116
clients and 36 key informants, i.e. men
and women on the periphery of the sex
trade. The Sex Workers Outreach Project
in Sydney provided a visiting consultant,
who pointed out that one of the most
difficult aspects of the sex worker scene
in PNG would be bringing independent,
often competing, street-level women
workers together, both for purposes of
training and for empowerment. Her
report also remarked that moralistic atti­
tudes on the part of some staff members
and others would be a deterrent to the
project.

I
5
1

The PNGIMR had conducted community­
based intervention research in the health
field for many years in rural communi­
ties. It has a well-developed infrastruc­
ture with branches in several parts of the
country and a staff including an STD epi­
demiologist, STD laboratory technicians
and an experienced social science unit.
This was the Institute's first major urban
programme and first HIV intervention.

24

The formative research found that the
situation for sex workers and dock work­
ers differed considerably between the
two cities. Sailors, on the other hand,
moved so readily around the coast that
their lives were little affected by loca­
tion. Sex workers in Port Moresby were
more often living with their families and
had larger incomes, whereas those in Lae
were poorer and often homeless, sleep­
ing on the streets or in parks. Dock work­
ers in Lae were recruited as village

25

I

I

..... w --

Transex, r'->pua New Guinea

Transex, Papua New Guinea

groups and came to the city
accompanied by relatives from
their home communities. This
placed a certain degree of con­
trol on their sexual behaviour,
whereas in Port Moresby dock
workers were recruited from the
urban settlements where many
sex workers lived as well. Many
acted as pimps for sex workers,
bringing them to sailor clients.
In mid-1995, a trial quantitative
baseline was begun with sex
workers (n=79), boskru or wasman (n=20), and a mixed group
of clients (n=68). Subsequently,
more complete quantitative
baseline surveys were completed
with sailors (n=251), truckers
(n=405), dock workers (n=202),
and sex workers in both Lae
(n=181) and
Port Moresby
(n=297). In Port Moresby, police­
men
(n=130),
policewomen
(n=53), and security men (n=154)
were also surveyed. Focus group
discussions were held with
policemen's wives. Results of
baseline surveys among dock
workers on rates of self-reported
STD symptoms as well as rates of
accessing commercial sex con­
firmed the differences by city
found in the earlier study.

Rapport building with sex work­
ers proved to be a long and deli­
cate process, as police continued
to harass them, even arresting
them for prostitution. The sex
workers thought the project was
contributing to their problems.
After one such arrest of 19 sex
workers in November 1996,
many of whom had become
involved with the project, they
scattered, some leaving the city.
As no agency other than the
Transex project had ever reached
out to these women, fear of
exposure was great. It took sev­
eral months, during which the
project's
outreach
workers
became quite discouraged, to
find them again and make con­
tact. The project tried to protect
sex workers and demonstrate its
sincerity. No publicity in the
media for the sex worker aspect
of the project was allowed. Staff
training was intensified to try to
- overcome all expression of the
moralistic stance and poor gen­
der-related attitudes sometimes
exhibited by the male staff. Role
plays, single sex and mixed sex
group sessions with monthly pri­
vate feedback to individuals
about their behaviour seemed to
help. Police were addressed on

.ZB

numerous occasions, not only
about their own sexual practices,
but also in an effort to help them
understand the damage done to
HIV prevention when they raided
sex workers' venues.
As there was no one in the coun­
try with experience in training
peer educators when the project
began,
the
South
Pacific
Commission was requested to
send their AIDS educator, who
had been training youth peer
educators elsewhere in the
Pacific, to PNG to help the proj­
ect get started. After preliminary
training for all new staff, they
and a police counsellor selected
by the Police Commissioner
attended a workshop on peer
educator training techniques.

Security issues loomed large, and
about 10% of the project's funds
had to be designated for guards
and a radio security system. Even
with this degree of protection,
the Port Moresby office was
attacked by armed thieves
(locally called raskols) during the
first year of the project, who
stole and destroyed the only
project vehicle in Port Moresby.
As public transport is not well

organized in Port Moresby and
does not run at all after 18:00, a
project vehicle was essential.
Personal attacks on project per­
sonnel in Port Moresby, when
they carried out work in settle­
ments where many sex workers
lived, continued to occur and the
project vehicle was frequently
out of order due to these attacks.

For various reasons, trucking
firms in Lae (where the trucker
intervention was based) were
less cooperative than other pri­
vate sector groups. Conditions
on the Highlands Highway were
very poor in recent years, with
inadequate road maintenance
and theft from highway gangs
acting as a major constraint on
the industry. Profits were threat­
ened and AIDS prevention was
not a high priority for trucking
firm managers under those cir­
cumstances. Eventually, after a
long period of consultation, they
decided that truckers could be
reached and educated while they
were working. In an attempt to
try this approach, outreach
workers rode for short distances
with truckers and met them a
the few places they stoppe.
along the Highway. This arranc

Transex, Papua New Guinea

ment was not very satisfactory.
Instead, other approaches evolved.
Dispatchers were trained and
given condoms to distribute, and
individual truckers came for­
ward, independent of their com­
panies, to become peer educa­
tors. Eventually, the trucking
firms joined the project's efforts.
Two of the larger companies
allowed workplace training ses­
sions and offered to build rest
stops along the road for their
drivers. These would allow out­
reach workers and peer educa­
tors to access the drivers more
easily.
From the beginning sailors and
dock workers were more accessi­
ble to the project. Shipping com­
panies, unions and workers' asso­
ciations were very cooperative,
allowing outreach workers to
enter the wharf, board ships, and
interview men whenever they had
a break in their work schedules.

Transex, Papua New Guinea

tion of change towards safer
sex, and the maintenance of
these new practices, aided by a
wider normative acceptance of
condom use in the society. This
latter was to be effected, in
part, by a social marketing proj­
ect that was never imple­
mented. The project's overall
aim emphasized facilitating a
shift towards safer sex practices
through peer education, but­
tressed by several enabling
strategies. One such strategy
was to increase the variety of
options, by making both male
and female condoms easily
•accessible and introducing lubri­
cation. While most client groups
of adult men managed to
obtain STD treatment, sex work­
ers typically did not, as the staff
at government STD clinics often
treated them harshly. The proj­
ect sought to find ways to
improve access to good-quality
STD treatment for sex workers.

Implementation
Working strategies
The project was designed as a
behavioural change programme
to move people through early
levels of awareness, considera-

28

In order to create an enabling
environment for improved con­
dom use, major client groups
were targeted and the per­
ceived needs of sex workers
addressed. These needs included
reducing the frequency of rape

and harassment by police and,
for many street-based sex work­
ers, provision of a place to
bathe. A strategy was devel­
oped to work on the very sensi­
tive topic of line-ups with the
police and the Police Commissioner
was confronted privately but
directly with this issue.
Project personnel repeatedly
reassured concerned groups that
they were not going to moralize
about prostitution or rehabili­
tate sex workers, but that they
would work with other NGOs to
provide skills training for sex
workers who wished to give up
the trade or simply supplement
their income. Such non-moralistic attitudes are not widespread
in PNG, but the project's success
has demonstrated their value. As
the project has grown, its per­
sonnel have been called upon
extensively by other agencies,
within and outside of govern­
ment, to help develop different
aspects of AIDS prevention.
Although this reduced the
amount of project work staff
members were able to accom­
plish, it was a necessary and
valuable act of bridge-building
in the wider society.

29

Outreach and peer education
While conducting the baseline
surveys, initial outreach began.
After
each
interview,
the
informant was given a short talk
on STD/HIV prevention with the
aid of a flip chart developed
previously by the PNGIMR in
cooperation with other agen­
cies, given condoms and taught
how to use them. Nearly two
thousand persons were reached
in this way over the early
months of the project. During
this time, criteria for selection of
peer educators were developed
and potential peer educators
were identified. Workplace pol­
icy workshops were held with
shipping firms, police, security
firms employing a total of about
3900 men, and eventually truck­
ing firms. Trucking firms and a
few large security firms were
resistant at first. Security men at
one of the cooperative compa­
nies suggested that their work­
shop be televised in order to
encourage cooperation from
the resistant ones. This was
done and was covered by the
newspapers as well. Eventually
all registered security firms, as
well as trucking companies,
became cooperative.

Transex, Papua New Guinea

Transex, Papua New Guinea

I
Peer educator training methods
and materials were developed
and adopted for each different
target group. Comic books were
designed and tested, with the
help of a well-known cartoon
artist, Biliso Osake. An excellent
flip chart by this artist developed
earlier and printed in a large for­
mat was reprinted in a smaller,
hand-held format for use in the
project as well as by others. A flip
chart specifically for teaching the
use of the female condom was
also developed. Modules cover­
ing a series of topics were
designed for each peer educator
training scheme. For sex workers,
special emphasis was placed on
the use of condoms with
boyfriends and husbands, and,
for condom-resistant clients, on
how to learn to ignore the con­
dom and concentrate instead on
the woman's pleasure. Sex-posi­
tive attitudes were always main­
tained in these messages.

By mid-1998 in Port Moresby, 403
volunteer peer educators had
completed training. A total of
357 sex workers had attended
130 training sessions, with 75
completing all learning modules.
In addition, 36 policemen (from

ject's focus on targeting specific
groups, took a great deal of time
and caused problems for project
personnel. For example, the
Correctional Institutional Services
in Lae became involved and put
four men through the peer educa­
tion training and two through HIV
counsellor training. This led to the
provision of condoms for the
prison, an unexpected and very
worthwhile action. Organizations,
such as UNFPA, the Salvation Army,
ADRA (Adventist Development
and Relief Agency) and others
came regularly to project person­
nel for help, resources and training
and to offer various kinds of sup-.
port in return. The Salvation Army,
for example, developed a pro­
gramme of counselling and care to
which the project could refer HIVpositive sex workers. The larger
AusAID HIV project repeatedly
called upon project personnel to
speak at meetings and to train oth­
ers. There was a great need to
Project personnel were frequently spread expertise in PNG during this
called upon to include others period, and the project has played
within their training sessions, a major role in this regard.
While this was positive in the sense
of overall AIDS prevention and Condoms
acceptance
of the
project's Condoms were given free and
approaches by a wider portion of obtained from the DoH's supthe community, it diluted the pro- Ply. During the first year, the

project had to distribute poor­
quality condoms as these were
the only ones available. A bet­
ter-quality condom was pur­
chased with the help of
AusAID,
but the project's
demands could not be met. The
project provided a regular sup­
ply to all police stations in the
project area (including those
along the Highlands Highway)
and the demand from sex and
transport workers continued to
grow. Supplying many groups
and individuals beyond those in
the designated target groups
caused more shortages. Others,
such as students and youth
groups and even various health
service facilities, turned to the
project for condoms. Their only
other access to free condoms
was family planning and STD
clinics, where staff expressed
negative attitudes about con­
doms or refused to give any at
all on grounds of morality, even
to STD patients. While project
personnel felt they should pro­
tect the supply for their target
groups, they also felt they could
not refuse to give condoms to all
those who requested them. It
was obvious that this situation
could not continue and could

14 police stations), 16 police­
women (from 10 stations), 14
wives of policemen, 20 security
men, 163 sailors (on at least 24
different ships), 65 dock workers,
and 14 hotel workers were
trained as peer educators. In Lae,
by March 1997, a total of 125
peer educators had completed
the full course (13 dock workers,
12 sailors, 21 truckers, 63 sex
workers and 16 from other
groups, e.g. prisoners, artists,
musicians, and slum dwellers).
Outreach workers were assigned
a cohort of trained peer educa­
tors to follow up. Given the num­
ber of peer educators, it was not
likely that the existing number of
outreach staff could monitor the
frequency and quality of peer
education interactions taking
place. In 1997 outreach workers
recorded discussions with and
distributed materials to about
14,000 persons.

30

31

Transex, Papua New Guinea

Transex, Papua New Guinea

Health care
The AusAID HIV and Sexual
Health project employed a spe­
cific officer whose task was to
improve the government STD
clinics. Although new clinics
were constructed and training
sessions held, most STD clinic
staff did not rapidly alter their
attitudes and sex workers contin­
ued to complain about the way
they were treated. The training
of peer educators emphasized
rapid recognition of symptoms
and treatment for STDs. Project
outreach workers met with STD
clinic staff and arranged specific
times when they could accom­
pany sex workers to the clinic.
Although
this
approach
appeared to secure more friendly
treatment, sex workers were still
stigmatized by having to come at
a special time. Gradually, they
were designated as 'project
clients' by clinic staff and even
further stigmatized, especially by
doctors, who tried to pressure
them to undergo HIV testing.
Private clinics were too costly for
most (but not all) sex workers
reached by the project. After
considerable negotiation with
both AusAID and the DoH, a
clinic was established at the proj-

only be corrected by ensuring
an adequate condom supply,
either free or through social
marketing.
During the project's first year,
USAID donated 2,000 female con­
doms and during the second year,
UNFPA supplied 15,000 female
condoms. These were a major
boon to the project. The latter
supply arrived after months dur­
ing which no free male condoms
had been available. Previous stud­
ies had shown the acceptability of
female condoms to sex workers
and to urban women in general
(Jenkins, 1995). The use of female
condoms added a major innova­
tive aspect to the project and
filled a gap when male condoms
were not available.

In general, sex workers were
enthusiastic female condom
users, as were many men who
came to the project office to
gain access to female condoms.
Female condoms were not avail­
able in shops in PNG, but
recently have been made avail­
able at government family plan­
ning clinics.

32

ect site in Port Moresby, provi­
sionally for the execution of an
STD study. Two female project
outreach workers, with previous
training as nurses, received HIV
counsellor training and special­
ized STD training as well.
Periodic visits by physicians, labo­
ratory back-up through the
health services, and the process­
ing of samples at the PNGIMR
headquarters in Goroka were
begun. Sex workers rapidly
began using the clinic and partic­
ipated in the study. The DoH sup­
plied all medicine and basic con­
sumables free of charge. In Lae,
sex workers could access HIV test­
ing and professional counselling
at the project site, but still had to
be referred to the local hospital's
STD clinic for treatment. These
efforts encouraged sex workers
to be tested for HIV, an impor­
tant step in prevention.

Empowerment
When the project began, 5-8
sites where sex workers could be
found in each city were desig­
nated as target sites, but later
expanded by another 6-8 in each
city. In particular, sex workers
requested that the project work
in the settlements in which they

lived. A theatre group in Lae
called SEEDS and a troupe of
musicians became associated
with the project, and helped
with the dissemination of AIDS
prevention messages in the set­
tlements and with World AIDS
Day activities. In Port Moresby,
outreach workers and peer edu­
cators themselves staged cam­
paign days in the settlements.
By October 1997, two sex work­
ers had joined the staff as parttime outreach workers, in an
effort to bring about greater
involvement in decision-making
by sex workers in the project's
management. One sex worker
was invited to speak at the
Fourth International Conference
on AIDS in Asia and the Pacific,
and to attend the satellite work­
shop on networking among sex
workers. Her appearance in
Manila was the first time a PNG
' sex worker ever publicly admit­
ted her trade. Both Papua New
Guineans and others in the audi­
ence were touched by her hon­
esty. Following that, several
other sex workers addressed
groups of church-related NGOs
in Port Moresby, and the
response was very positive, lead-

33
— .

..

■‘rafiS'

Transex, Papua New Guinea

Transex, Papua New Guinea

ing to improved attitudes of
acceptance and willingness to
promote condom use, even in
church youth groups.

It was recognized that having a
few sex workers on the staff
would not improve conditions
for the women as a whole, and
efforts continued to develop
associations run by sex workers.
It became increasingly clear, from
the rising numbers of women
who dropped in to the project
houses to request information
and supplies, that they were talk­
ing to each other. In Port
Moresby, a small group of
women established a group
called the Henao Sisters (the
project house is on Henao Drive).
This sex worker-run group
received funding in its own bank
account from an anonymous for­
eign client, a good example of
the power of enlightenment in
the sex industry.
Developing the means to meet
the other needs of sex workers
was slow. Building a shower for
them to use at the Lae house, for
example, was not possible as the
house was rented. Instead, they
used the shower in the room of

one of the" outreach workers. Numerous sex workers associated
Discussions with the city authori­ with the project took on the edu­
ties to build public showers and cation of women and men in
toilets did take place, but noth­ their own communities. They
ing happened. In Port Moresby, borrowed videos and other
an open-sided house where sex materials on a regular basis from
workers could gather and sleep the project offices to address
was built on the property owned church groups, youth groups and
by the project. On many nights, other gatherings. Some of these
sex workers slept at the Port women clearly showed evidence
improved
self-esteem.
Moresby house and used the of
However,
for
the
majority,
heavy
shower facilities. A more suit­
able drop-in centre with tempo­ alcohol consumption, violent
and
rary
sleeping
shower personal relationships as well as
arrangements would be an ambient violence in their com­
munities, continued to counter
improvement.
efforts at personal development.

During the formative research,
sex workers expressed their
interest in learning about make­
up and other ways to improve
their appearance, as well as
acquiring cooking and banking
skills. In Port Moresby, a profes­
sional hairdresser held sessions
at which personal hygiene, hair­
dressing and the use of make-up
were demonstrated. By early
1998, the YWCA joined as a
partner to provide literacy train­
ing for 53 women twice a week
and vocational training for
another 50. Women who were
already literate received com­
puter training.

V

Monitoring and
Evaluation
On-going monitoring of process
indicators was accomplished
through weekly submission of
forms from outreach workers,
showing how many peer educa­
tors visited for follow-up, how
many condoms and educational
materials were distributed, and
comments on difficulties and
signs of success. These were to
be summarized monthly by the
two project managers who
were also responsible for con­
ducting and monitoring, staff
and peer educator training.
Weekly meetings were to be
held by managers with all staff

V

T

1 M

■S

1

5
Henao Sisters during
a vocational traimna j
meeting at the project
house, where HVC.A
workers provided !
sewing lessons, j

...... .........

■ft:

*

Transex, Papua New Guinea

at which progress and problems
were discussed.
Impact on behaviour was meas­
ured by baseline and follow-up
surveys. A follow-up survey was
completed with police in Port
Moresby after only 9 months of
intervention, as the police com­
ponent was funded only for one
year. Among sex workers, quan­
titative evidence for progres­
sively increasing condom use
was provided by the data
obtained from these surveys,
which were completed over a
long period of time, during
which the peer educator train­
ing had begun. Shortage of staff
made separate research compo­
nents difficult to execute.
Baseline surveys included infor­
mation on sex acts with non­
commercial and commercial
partners, risk perceptions and
behaviours. In order tominimize
bias, the project design called
for the outreach team from one
city to move to the other in
order to conduct the final endof-project survey. A mid-term
evaluation was conducted in
1997 and an external evaluation
was
conducted
in
1998.
Evaluators examined project

36

Transex, Papua New Guinea

documents and interviewed all
levels of stakeholders and staff.
They produced a formal evalua­
tion in preparation for the
extension of the project into its
second three-year funding cycle
(Lepani and Stephens, 1998).
Although the survey data were
not ready when they conducted
their work, all of these sources
of information are reviewed
here.

The project design had also
called for a baseline STD survey
among sex workers, but for vari­
ous reasons this study did not
take place until the second half
of 1998. At that time, the preva­
lence of HIV in Port Moresby sex
workers was already 16.8% and
in Lae 3%. Levels of syphilis,
chlamydia, gonorrhoea and trichomaniasis
were
reported
respectively, as 31.3%, 32.8%,
39.4% and 21.2% in Port
Moresby, and 33.7%, 30.2%,33%
and 44.1% in Lae (Mgone,
Passey and Russell, 1999).

Increasing condom use
While it is commonly recognized
that altering condom use habits
is generally not easy or rapid,
the earliest phases of interac-

tion with sex workers saw a
rapid rise in condom use. The
women were able, with free
condoms, to increase the pro­
portion of acts covered, both
with clients and regular part­
ners. Full or consistent use has
been more difficult to increase.
The earliest baseline survey
among sex workers was carried
out
between
August
and
October 1995 in Port Moresby.
As the project had no presence
among sex workers at the time,
it was very difficult to find
women who would admit to
being
sex
workers
when
approached on the streets. Only
one interviewer tested a short
survey instrument, mainly by
going to the settlement where
sex workers lived and using,
essentially, a snowball sampling
technique. When project funds
arrived and outreach workers
had been trained, the baseline
survey
instrument
was
expanded to include informa­
tion on knowledge, .risk percep­
tion and STDs, as well as con­
dom use. The main areas where
the women find their clients
were mapped and six selected
where the work could begin.
Interviewers
in pairs to
-------- went
------- ..i

these sites on many days, talking
to women and handing out con­
doms, before interviews were
possible.

Analysis of the trends in condom
use among sex workers is shown
in Figure 2. Work began in Port
Moresby before it did in Lae. The
surveys were always conducted
ahead of the identification and
selection of women for peer
educator training, but it seems
clear that the large amount of
condoms and considerable infor­
mation disseminated through­
out the baseline survey period
was making an impact, even as
the data were being collected. A
review of the figures suggests
that condom use rose very
quickly in both cities in the ear­
lier phase of the project.
Although sample sizes of sex
workers varied between 74 for
the earliest survey in Port
Moresby and 442 in Lae in 1997,
an upward trend is clear, espe­
cially
in
Port
Moresby.
Proportions of acts of inter­
course covered by condoms,
with their upper and lower 95%
confidence intervals, are shown
in Figure 2.

i7.

...

■

Transex, Pamia New Guinea

Transex, Papua New Guinea

I

|

Figure 3. Numbers of clients and income per client reported
for the previous week between 1996 and 1998
among Port Moresby and Lae sex workers

Figure 2. Trends in condom use among sex workers in

100

45 -T

90 --

.a POM
• Lae

80 -

40
35

70 --

30

50 --

25

60

40

■?

1
i

□ Mean number
of clients
■ Kina per client
(1 Kina = USS 1.05)

20
*

30
15

20 10-

10 -

0

0 --- ---- 1---------------- --------Sep-95

Mar-96

Jun-96

Oct-96

Feb-97

Oct-98

In Port Moresby the trend is statistically
significant, but in Lae an early upward
trend slowed down. Survey results show
that economic factors may explain some
of the differences seen. Figure 3 shows
the mean number of clients reported for
the previous week by sex workers in both
cities compared to the average income
per client. When the project began, Lae
sex workers took more clients but made
less money per client than did workers in
Port Moresby. Consistent condom use the
previous week, i.e. 100%, did not change

in either city.

POM
1996

POM.

1998

Lea
1998

Lea
1996

As time passed, and economic conditions
worsened, sex workers in both cities
earned significantly less money per
client. However, in Port Moresby the
women were able to compensate by tak­
ing more clients (mean of 2.9 in 1996
and 4.9 in 1998), but this did not occur in
Lae (mean of 3.2 in 1996 and 2.6 in
1998). It may be that the competition for
clients in Lae became more intense,
incomes declined and so did insistence
on condom use. Were the project's activ­
ities in Lae working to diminish the num­
ber of men who went to sex workers?

39

Transex, Papua New Guinea

Transex, Papua New Guinea

Changes in the number of commercial
and casual partners reported by the pro­
ject's male client groups over the previ­
ous week, indicate that this may be the
case. Figure 4 shows a significant decline
in commercial or casual sex among dock
workers, most of whom were in Lae, and
among truckers, all of whom were in Lae.
Sailors were not separated by city as they
travelled readily from port to port. The
project only worked among police and
security men in Port Moresby. Neither
sailors nor police significantly reduced
their commercial sexual activities, and

Figure 4. Changes in levels of commercial or casual sex
among male client groups, 1996 to 1998
60

50

F

I
■

;

40

%

security men significantly increased their
commercial sex partners.
These groups of men seem to have
adopted different strategies after expo­
sure to HIV prevention education. Some
had less commercial sex as well as
increasing their condom use, while oth­
ers increased condom use but did not
decrease their purchases of sex. Figure 5
shows the changes in condom use with
commercial or casual partners among
these men. In all cases, condom use rose,
whether the men decreased, increased or

Figure 5. Changes in condom use with commercial or casual
partners between 1996 and 1998 among male
client groups

□ 1996
■ 1998

70
4 71

60

30

40

■

■

Q

ss
□

o
o_

£

o
o
Q

w

c,
cn

30

I

1

&
Q

w

□ 1998

%

,r

10
w

7

□ 1996

20

0

Z

50

I

ih
>
3
O
0)

20-

(s)= p< 0.05
(ns)= p> 0.05

w

40

10
OJ-S—J—
Truckers
(s)

J I U IIJJ
Dock workers Sailors
(s)
(s)

41
'-"T' SSBP^S

1
Police
(s)

l>

Security
(s)

|(s)= p< 0.05 |

^saB.

Transex, Papua New Guinea

made no change in the level of commer­
cial or casual sex. These changes were
least significant among truckers and
dock workers, the groups that decrease
their commercial sexual activity most sig- s
nificantly. Consistent condom use did not
orYmpn any
Anv of the men.
change among

Among police in Port Moresby, a survey
was carried out after 9 months of active
intervention, because? funding for this
only one year,
component lasted
I
had risen more steeply than i
Condom use 1.^------,
it did in later stages of the project, an
the proportion of men seeking sex with
"rot men" (women of the streets) had
already decreased from 25% to 18 A.
One of the issues that arose in discussions
with policemen's wives was that they
would be insulted and angry if they saw
condoms carried home by their hus­
bands, which may have discouraged

greater condom use among these men.
Reducing line-ups
The strategy for reducing line-ups ca
for pressure from the top through the
hierarchy of police, i.e. from the Police
Commissioner downwards; and pressure
from the side, i.e. from the poHcemen s
wives, who were informed about the
practice and the risk that it involved for
them. It appears that the efforts to tar­
get line-ups began to be effective. At
baseline, 10% of the men stated they

Transex, Pa^ua New Guinea

had been in a line-up during the previous
week, which reduced to 4.2% in the fol­
lowing 9 months (p=.O1). The average
number of men involved in each act did
not greatly change, 4.22 vs. 3.58 at that
time. In 1998, unfortunately, the ques­
tion was changed on the survey instru­
ment to number of line-ups in the past
month and results could not be directly
compared. In 1998, 8% of men reported
involvement in a line-up during the pre­
vious month. As a month, the period
queried, was 4 times as long as a week, it
is likely that the proportion of men
engaging in line-ups continued to
decrease, but results are inconclusive.
Anecdotally, as of mid-1998, sex workers
reported that sexual harassment contin­
ues to be diminished but, without moni­
toring indicators, this can only be con­
firmed by repeated surveys.
While it has always been difficult for a
sex worker to gain redress for rape or
theft, it has been nearly impossible for
her to prosecute a policeman. In the
course of the project, there were some
indications of change in this regard. In
August 1997, six policemen, who took
advantage of the situation to rape two
sex workers, raided one of the guest
houses included in the project's outreach.
The sex workers were arrested, but they
managed to lay complaints against the
police officers. All six policemen were

45

Transex, Papua New Guinea

jailed, pending trial, and the sex workers
were set free. The newspapers covered
this event. A few months before,
another woman had made a complaint
of rape against the police. When women
are willing to stand up for their right not
to be sexually harassed by police, both
human rights and HIV prevention are
well served. Police peer educators were
an important link into the police sub-cul­
ture, a valuable lesson in this project.

Transex, Papua New Guinea

I to 68% - Lae) and levels of condom use
(proportion of last week's acts covered)
with them (36% to 48% - Port Moresby
and 34% to 67% - Lae). Even consistent
condom use increased significantly, as
shown in Figure 6.

Figure 6. Consistent (100%) condom use reported for the
previous week among sex workers with regular
partners
60 <

Condom use and regular partners
During peer educator training, strong
emphasis was placed on using condoms
with regular, non-commercial partners.
Between 1996 and 1998, sex workers
reported an increase in regular partners
(64% up to 80% - Port Moresby and 57%

5040-

01996
□ 1998

% 3020-

10-

0
Port Moresby (s)

Police peer
educators
contributed
significantly to
discussions on
reducing
harassment of
sex workers
and reducing
risky sex
among police.

Lae (s)

(s)= p< 0.05

Among the men, truckers, dock workers
and security men reported significant
increases in use with regular partners, as
shown in Figure 7.
The consistency of use did not improve,
however. This pattern
is typical.
Although many people can learn to

44

Transex, Papua New Guinea

Transex, Papua New Guinea

Figure 7. Condom use with regular partners reported for the
previous week among male target groups
70-4

4

60

50

□ 1996

40

□ 1998

%
30
20

10

o

(s)= p-_ 0.05
(ns)= p> 0.05

—
Truckers
(s)

Dock workers Sailors
(s)
(ns)

Police
(ns)

Security
(s)

increase their use of condoms, it requires
very strong commitment to personal .
safety to use condoms every time.
Increasing knowledge
In all groups, levels of knowledge signifi- |
cantly increased over the course of the ‘
project, regarding both modes of trans­
mission and prevention. Sources of information also shifted, with the majority in ?
every group mentioning the project's I

outreach workers or peer educators. ’
Workmates were a significant source of ;
information, indicating that the diffu­
sion model of peer education was effec­
tive. Most other sources of information,

e.g. television, radio, health workers,
actually decreased between 1996 and
1998.
Condom and lubrication distribution
The project tried to maintain data on
condom distribution, showing the num­
bers distributed to each target group by
month. This did not work well as an indi­
cator because condoms were given with­
out payment, were often given to
encourage use (as opposed to ondemand), and were given in Ilarge
amounts to non-target groups as well.
Evidence of a major increase in demand
does exist, however. For example, the
police called for increasing numbers of
deliveries of condoms at the police sta­
tions in Port Moresby on repeated occa­
sions. Industry management was very
supportive of condom distribution and
some companies began putting condoms
I in pay packets. Five condom depots were
I set up at the wharves where sailor and
l dock worker peer educators could col­
lect and sign for their supplies. Others,
for example, fire fighters, also made reg­
ular use of the depots. In total, between
1996 and 1998, it is believed the project
distributed between 1.5 and 2 million
male condoms and about 8,000 female
condoms. Even without good data on
condom use, there is little doubt that
demand increased enormously, causing
numerous stock-outs.

4T

Transex, Papua New Guinea

During periods of condom short­
Female condoms were well
age, the sex workers were encour­
received by the sex workers and
aged to buy condoms at shops, and
reportedly used with considerable •
prices in the city were monitored
success. Many told their friends
so that suitable advice could be
about them and many new
given. In focus group discussions
women became associated with
during the final evaluation some
the project through a desire for the
people expressed concern about | female condom. The__________
statement in
i
the quality of condoms available
the box below from a sailor whose
from the government, reporting_ I’ ship was berthed in Lae illustrates j
breakage and the need to doublethe impact of female condoms on
. .
| ­sexual risk-taking.
up. cSome men wanted
more . vari
ety to choose from. Overall, supply
problems had not been solved. The
Earlier research on the female •
planned social marketing compo­
condom demonstrated that many i
nent, if implemented, could help
Papua New Guineans apprecisolve these problems as could more
ated well-lubricated sex. With
sensitization and training of DoH I encouragement from profespersonnel.
. sional sex worker organizations

U hen ire ^ot on shore the first thin^ that came into my mind teas to
find a u nman. J went to Club 96 where there was a dance going on.
While there I managed to get a girl out. around in the bush she started
negotiating about the male and the female condom.uWhich condom do
you prefer, the male or the female condom?” I paused for a while and
thought, if I refuse, then no sexfor me. Maybe I should accept the female
one. I knew this must be one of the trained sex workers, so I pretended
and insisted on having sex without a condom. The lady refused and
replied. ‘7 was taught about AIDS and STD. WJjo would know if either of
us has a disease? It’s safe with condoms, so which one do you prefer?”!
had no choice and accepted the female condom. After sex I had all my
sense back and thanked the woman for what she had done and paid
her extra. Otherwise, I would have had many sleepless nights. She was
so polite. I learnt something from her.

48

Transex, Papua New Guinea

elsewhere, extra lubrication was
introduced to PNG sex workers
for protection from abrasion. A
sachet with the Pidgin label Swit
Gris
(Sweet
Grease)
was
designed for a water-based
lubricant and 50,000 were pur­
chased. The peer educators dis­
tributed these to sex workers,
and transport workers also
began requesting lubricant.

to avoid placing blame on sex
workers and to illustrate the pos­
sibility of acquiring HIV from the
semen of previous men in the
line-up. The flip chart given to
each peer educator also had a
specific drawing illustrating this
sexual practice as did the comic
books for sailors and for youth,
in order to bring group sex to
immediate attention when dis­
cussing risk behaviours in the
PNG context.

The project developed five tar­
geted comic books in Melanesian
Demand for the comic books has
Pidgin, an STD picture album,
, a
been very high and over 30,000
poster and several flip charts
have been distributed. The proj­
used by the peer educators. One
ect
repeatedly
experienced
comic book was created about a
shortage of funds for reprinting
young sex worker and a trucker
these very popular materials. The
on the Highlands Highway;
one designed for sailors was
another about a party held with
adopted by the South Pacific
sex workers on a ship; another
Commission for use in other
one about STD treatment for sex
areas of the Pacific. Other comic
workers; and one specifically for
books for youth, not directly
police. The police comic book
related to the project's target
targeted line-ups and is called
groups,
were also developed,
Hit 'n Run', a term used by the
and over 20,000 of these have
police themselves. In the story, a
also been distributed through
sex worker who states she is HIV­
the project offices. A poster
negative because she just had an
specifically for women and suit­
HIV test, is forced into sex with
able for family planning clinics
numerous police, several of
and other women-oriented serv­
whom are later shown to be HIVices, was also designed, printed,
Positive. The story was designed
and 5,000 have been distributed.

49

Transex, Papua New Guinea

Transex, Papua New Guinea

An AIDS educational video film
distributed by the British Red
Cross, using electronic anima­
tion, was professionally dubbed
into Pidgin and several hundred
of these videos were distributed
to sailor peer educators for use
on their ships. Other language
versions, in Tagalog, for example,
were made available for use with
foreign sailors at PNG ports.

agencies. A few papers pre­
sented at meetings were pro­
duced from the formative
research (Jenkins, 1992, 1993b,
1994c, 1994d) and from the ini­
tial findings on the police com­
ponent (Anang and Jenkins,
1997).

Efficiency
The project was funded for the
first year by both AusAID and
UNAIDS, with the entire fund­
In addition, project personnel
ing for the second and third
worked with staff at the local
years from AusAID. The total
Maritime College to develop
annual
budget
of
about
training modules on STD/AIDS to
US$
215
000
supported
salaries
be used within the first aid
for two managers, 14 outreach
course. The local police training
workers, a hotline, rental of
college also instituted a unit for
one and purchase of another
their training programme with
house, maintenance of these
help from the project.
houses, office equipment (fax,
phone, computer, VCR, over- _
In March 1997 a hotline was
head projector), the purchase
installed in the Port Moresby
and maintenance of two cars,
office and three outreach work­
the development and printing
ers from Port Moresby and two
of educational materials, the j
from Lae were sent to an HIV
purchase and packaging of [
counsellor training course. Two
water-based lubricant, security ■
sex workers were trained as
systems, and training costs.
counsellors as well and helped to
Networking with other HIV pre­
manage the hotline.
vention projects has helped
meet the needs of target
To date, no documents have
groups that the Transex project
been written on the project,
could not provide.
other than reports to funding
ill!

Optimal efficiency was compro­
mised by several factors. The sen­
ior adviser left the project in mid1997 and skills were Post in behav­
ioural data collection, analysis
and documentation. The man­
agement structure changed sev­
eral times. Due to the general
complacency about AIDS, recruit­
ment of outreach workers was
very slow and, when found, they
needed a great deal of training.
Eventually several outreach work­
ers also left the project, which
required the training of new per­
sons. Budgetary issues delayed
the project's start-up dates, espe­
cially in Lae. Most of the forma­
tive research was conducted prior
to the arrival of project funding.
The set-up phase required 6
months, although baseline sur­
veys continued for longer due to
staffing limitations. In addition,
the project experienced problems
with staff members, their spouses,
lack of condoms, political unrest
on the streets, temporary lack of
transportation, and the intensive
use of project personnel by other
agencies.

mation were attached to survey
data. The project was approved
by PNG's national medical ethi­
cal review board. Problems
arose, however, with govern­
ment personnel to whom sex
workers were referred for HIV
testing.
Confidentiality was
breached and project personnel
were told the names of HIV-pos­
itive sex workers because health
officials wanted to find them
again, in a mistaken notion that
they could follow up on their
partners or even stop them from
selling sex. Project personnel
were placed in a very awkward
position and tried to make
health workers attend to issues
of confidentiality. The develop­
ment of experience with HIV­
positive sex workers began
largely through the Henao
Sisters, the organization run by
sex workers. The Salvation Army
has also begun to provide some
care for people living with HIV
and AIDS.
Replicability
As a pilot project based at a
research institution, it is not
likely that future projects, mod­
elled on this one and imple­
mented by other types of agen-

Ethical soundness
During all formative research, no
names or other identifying infor-

51

i afjua IMCVV UUlllEd

Transex, Papua New Guinea

cies, could maintain the same
Council, through which future
level of data collection and
funding will be channelled, will
analysis without special invest­
be responsible for developing
ment. Replicability of key com­
greater sustainability in the com­
ponents, such as the peer educa­
ing years.
tor approach, is certainly likely to
be successful. Important issues
Lessons
revolve around payment of peer
educators, their training and j The success of the Transex projsupervision. During the final
ect, in spite of numerous obsta­
evaluation, stigma, shame and
cles, is due to several factors. It
negative attitudes from health
was based on extensive sound
workers continued to be identi­
qualitative research on the
fied by sex workers as barriers to
real contexts of risk-taking in vul­
improved use of STD services. Sex
nerable groups. Hence, it has
workers prefer to go to the pro­
been able to develop materials
ject's own clinics. Without
and peer education modules tai­
improvement of the attitudes of
lored to the specific life situa­
service providers, and a reduc­
tions of those participating.
tion in moralistic attitudes over­
These materials and modules
all, future HIV prevention proj­
have been successful. Providing
ects in PNG cannot expect the I options, i.e. female as well as
same level of success.
I male condoms, and introducing

Learnt

Sustainability
The project is not at present sus­
tainable without donor funding.
Although project personnel have
tried to facilitate the develop­
ment of an AIDS-dedicated NGO
and a sex worker self-help organ­
ization, neither of these organi­
zations could function without
considerable investment from
donors. The new National AIDS

52

lubricant to sex workers, has
been innovative and highly use­
ful. Training to diminish
moralistic and judgmental
attitudes among staff proved
to be successful and a valuable
lesson to all observers. The proj­
ect showed that the develop­
ment of meaningful relation­
ships with target groups is a
key issue, requiring time and
empathy.

The project has targeted several
tized or marginalized groups, is
important groups of clients of
a major challenge everywhere.
sex workers at the same time
Communication, job role defini­
as the sex workers, who were
tions and other issues were
not relegated to a later stage or
problems throughout the life of
lesser position of importance.
the project. Numerous recom­
This has certainly enabled sex
mendations made by the mid­
workers to negotiate condom
term evaluation were not acted
use more easily. Addressing
upon. Continued training of
harassment of sex workers by
staff was not well implemented.
police has not only benefited
It is clear that some components,
the police and their families, but
e.g.
the hotline, were not very
has demonstrated that non-judguseful and could have been
mental approaches even to
dropped. Workplace policy
highly sensitive sexual practices
workshops were highly use­
such as group rape, can be effec­
ful, but could have been more
tive. Evaluation of such changes
productive if staff with appropri­
would be better served by hav­
ate skills were available. Some
ing sex workers themselves monissues were known but not
itor events.
planned for, such as care and
counselling for HIV-positive sex
The project has demonstrated
workers,
and these emerged
that, in Papua New Guinea, sex
during the course of the project.
workers can become a major
Issues dependent on govern­
part of the solution, despite
ment, such as condom supply
their illegal status. Their self-run
and the improvement of STD
organization has the potential to
services, remained unsatisfactory
carry out important work in both
at the project's end. As the first
prevention and care and it seems
targeted intervention using peer
that government and donors
education as a r
strategy, the projhave come to recognize this.
ect has attracted
-J a great deal of
attention, and many extra
Management of large commu­
demands were made of
project
nity-based HIV prevention proj­
personnel. Skills in manage­
ects, particularly with stigmament, advocacy, data analysis,

Transex, Pap"i New Guinea

iransex, Papua New Guinea

and documentation were not
well developed among project
personnel and would have been
valuable. However, as in many
developing nations, the pool of
people available with such skills
is small. Continued learning
and capacity-building must be
taken seriously by donors and
country-based planners alike for
the better implementation of
targeted HIV preventions.

Acknowledgements

References

Many thanks to the staff of the
PNGIMR, the DoH and the
AusAID Sexual Health Project for
access to documents and data
with which to construct this
review.

1997 Anang, J. and Jenkins, C.
Encouraging safer sex among
police, security men and sex
workers in Port Moresby, Papua
New Guinea. Paper presented at
the 4th International Congress
on AIDS in Asia and the Pacific,
Manila, Oct 1997 (Abst A (O)
045, p. 45).

Guinea, Prevention Research
Unit/GPA, WHO, Sept, 23 pp.

1994b Jenkins, C. Behavioural
Risk Assessment for HIV/AIDS
among Workers in the Transport
Industry, Papua New Guinea,
AIDSCAP (FHI), Bangkok, Sept,
19 pp.
1994c Jenkins, C. Knowledge vs.
Behaviour Change: Preventing
AIDS Transmission in PNG. 30th
Annual Symposium of the
Medical Society of Papua New
Guinea, Sept 7-10, Mt. Hagen
(Abstr).

1992 Jenkins, C. The Risk of AIDS
in Papua New Guinea. Paper
presented at Second Conference
on AIDS in Asia and the Pacific,
New Delhi, Nov 8-12 (Abstr).

i

1993a Jenkins, C. Fear of AIDS the second outbreak in Papua
New Guinea (June 2); AIDS and
the economy of Papua New
Guinea (June 9); A national AIDS
prevention programme for
Papua New Guinea (June 6/
The Post Courier: 11.

1993b Jenkins, C. Sex and
Society in Papua New Guinea,
paper presented at IXth
International Conference on
AIDS, Berlin, June 7-11 (Abstr).

1994d Jenkins, C. Sex as Work in
Papua New Guinea (Poster), Xth
International Conference on
AIDS, Yokohama, Aug 6-12
(Abstract Book 2, p. 325).

• 1995 Jenkins, C. A Study of the
Acceptability of the Female
Condom in Urban Papua New
Guinea, UNFPA, Port Moresby,
May, 22 pp.

1996 Jenkins, C. Final Report:
Poverty, Nutrition and Health
Care: A Case Study in Four
Communities in Papua New
Guinea, 53 pp., report submitted
to The World Bank, June.

1994a Jenkins, C. Situational
Assessment of Commercial Sex
Workers in Urban Papua New

S5

Transex, Papua New Guinea

1998 Jenkins, C. and Passey, M.
Papua New Guinea. In: Sexually
Transmitted Diseases in Asia and
the Pacific, eds. Brown, T, Chan,
R., Mugrditchian, D., Mulhall, B.,
Plummer, D., Sarda, R. and
Sittitrai, W. East-West
Center/Thai Red Cross
Society/Venereology. Armidale:
Venereology PubL Co,
pp. 230-255.
1998 Lepani, K. and Stephens, D.
Evaluation of the IMP Transex
Project: Port Moresby and Lae.
Unpublished report for AusAID,
28 pp.
1994 Malau, C., O'Leary, M.,
Jenkins, C. and Faraclas, N.
HIV/AIDS prevention and control
in Papua New Guinea. In:
Current Opinion in Infectious
Diseases. AIDS in Asia and the
Pacific, ed. Kaldor, JM. 7: S117S124.

1999 Mgone, C., Passey, M. and
Russell, D. Prevalence of HIV and
STDs among commercial sex
workers in Port Moresby and
Lae. Unpublished PNGIMR
Report.

1993 Mugriditchian, D. and
Jenkins, C. Assessment of the

Sonagachi, India

I STD/AIDS Situation in Papua New
Guinea and Proposed AIDSCAP
Activities. Nov 14-Dec 4. AIDSCAP
Report.
1994 The National Sex and
Reproduction Research Team
and C. Jenkins. Sexual and
Reproductive Knowledge and
Behaviour in Papua New
Guinea. Papua New Guinea
Institute of Medical Research
Monograph No. 10. Goroka:
PNG Institute of Medical
Research.

Sonagachi: A Sex Worker
Project in a Red Light
District of Calcutta, India
Introduction
T"he Sonagachi project is a wellI known project, having had wide
media coverage in recognition of its
impact on the lives of sex workers and
the social change approach it has added
to standard public health strategies As
an HIV intervention it has had several
evaluations, both external and internal
It was initiated by the All India Institute
of Hygiene and Public Health (AIIH&PH)
m 1992 as the STD/HIV Intervention
Programme (SHIP), in consultation with
the National AIDS Control Organization
(NACO) of India, the Ministry of Health
and Family Welfare of West Bengal, and
WHO. Later donors included NORAD
DfID, and HORIZONS/USAID. It also
includes two NGO partners, the Health
and Eco-Defence Society and the Human
Development and Research Institute. As
a relatively mature project, it has broad­
ened its support base in the area since
1994 by enlisting a women's organiza­
tion (Sramajibi Mahila Sangha) and a
legal aid agency (Socio-legal Aid
Research and Training Centre). Most

56

57

i*-

u..:. ._s..

. ^^^Kwaww^g

Sonagachi, 'ndia

Sonagachi, India

importantly, the Sonagachi sex
workers formed their own
organization in 1995, the Durbar
Mahila Samanwaya Committee
(DMSC), which has become the
major mover of the programme.

Gradually, what started as a nar­
rowly conceived HIV prevention
project, has become a social
movement in West Bengal of no
mean importance, and is draw­
ing in sex workers and women's
rights organizations from all
over India and beyond. As about
one-quarter of the sex workers
in the Sonagachi area are from
Nepal and Bangladesh, linkages
to sex worker projects in those
countries have also been devel­
oped. The potential to move sex
work out of its feudal social and
economic bases to emerging
alternative forms of service pro­
vision underlies the project's
growing vision, articulated by
the sex workers themselves. In
so doing, sex work could
become an industry-regulated
business with mechanisms to
sustain safer sex practices. Such
a vision is far beyond what most
HIV prevention projects with sex
workers, particularly in develop­
ing counties, are ready to con-

ceive. There are'examples, how­
ever, of government policies in
Thailand and Senegal that incor­
porate some of the same aims
and mechanisms. The essential
difference between the process
that
has taken
place
in
Sonagachi and elsewhere in the
developing world is that the sex
workers themselves, including
their families and friends, have
taken the lead and carry out the
work of the intervention. This
includes support of the behav­
ioural, clinical, financial, politi­
cal and legal aspects of the proj­
ect. As such it provides a
remarkable example of power­
less women moving into the 21st
century with an altered image
of what they can accomplish for
themselves, and a lesson for
those involved in the women's
movement, poverty reduction,
and public health in general. It
requires that thorough consid­
eration is given to society's
stance on prostitution and that
sex workers can have a voice in
the ensuing debate.

The project is complex with
numerous components and is
well documented in both English
and Bengali. Its original specific

n

aims were simple: to reduce lev­
els of STDs, increase condom use,
and to develop an effective strat­
egy that could be replicated else­
where. In this the Sonagachi
project has been successful. In
terms of HIV and sexual health,
current syphilis infections and
clinically detected genital ulcers
have diminished. HIV positivity
rates in eastern India are gener­
ally lower than elsewhere in
India. Among the sex workers at
Sonagachi, they also remain rela­
tively low, at approximately 6%
(as of 1998). The project is now
expanded to many other areas in
Calcutta and West Bengal. Of
greatest significance is the
emphasis on meeting the felt
needs of sex workers and
enabling them to take charge of
solving their own problems.
Ultimately, this is the final goal,
one appreciated by sex workers
themselves from around the
world.

The project has had contentious
moments dealing with a large
array of actors, sensitivities, and
conflicting interests. It has also
had some difficulties in tech­
niques and modes of monitoring
and evaluation. It has not been

able, to date, to deal with all the
factors that place the Sonagachi
sex workers at risk. These imper­
fections, however, have noc
destroyed its obvious effective­
ness or credibility. There is little
doubt that the Sonagachi project
is one of the best examples of an
HIV prevention project that
addresses the short-term needs
to control the epidemic as well as
the longer-term requirements to
reduce vulnerability of women in
the sex industry.

Situational
Background
Calcutta, sometimes called 'the
city of joy' is also a city of
extreme poverty, of Mother
Theresa's domain, and the histor­
ical seat of the British Raj. It is a
crowded and underserved city,
struggling to clean itself up and
modernize. It is also the tradi­
tional centre of Bengali culture
and society, a culture that takes
great pride in its poetry, arts,
music and political thought and
action. The relentless oppression
of women in India is powerful
precisely because it is deeply
integrated into class, caste, and
ethnic hierarchies. Resistance to

'tfSFT-

Sonagachi, India

Sonagachi, India

class exploitation and social den- I donment, running away from
igration has fuelled numerous
the cruelty of husbands and in­
movements in modern Bengali
laws, and becoming a family out­
history. It is within this cultural
cast due to personal attempts to
and historical context that the
break through the intense
Sonagachi project has grown.
restrictions on the lives of young
Surrounding West Bengal are the
women. To this list today we
states of Bihar and Uttar Pradesh
must add poverty from birth,
in India and the nearby countries
fake marriages and sale, situa­
of Nepal and Bangladesh, all of
tional poverty due to family
which are substantially poor and
losses, trickery and trafficking,
disadvantaged, both ecologically
abduction and sale. In addition,
and socially. From these areas
some family traditions of dancers
hail a significant minority of
and entertainers, e.g. Agrawalis,
Sonagachi's resident sex workers.
have gradually become family
lines of sex workers.
Sonagachi is the derived pronun­
ciation of a lane called Sanah
The pattern of recruitment into
Ghazi, named after a dacoit or
the sex trade includes cross-bor­
hoodlum, recast as a religious
der movements and a significant
teacher. The Sonagachi area was
number of young girls, approxi­
first identified as a significant
mately 15% under the age of 15
red light district of Calcutta
at the time the project began,
when the British enacted the
entered in that way. The sex
Indian Contagious Diseases Act
industry is controlled by police,
in 1868. This was done in an
politicians, local hoodlum gangs,
effort to control STDs reaching
brothel owners, madams and
England via British soldiers serv­
pimps. While some sex workers
ing in India. At that time, about
are independent, others, particu­
30,000 sex workers were esti­
larly those newer to the trade,
mated to work in the area. A sur­
have madams and/or pimps.
vey conducted in the late 1800s
Some madam-controlled sex
noted three major reasons why
workers known as chhukris are
women entered prostitution.
completely bonded and each one
These were seduction and abanis obliged to earn enough to pay

Q

off an advance given to her or,
clients and then form longermore often, to the persons who
term relationships. While some
'sold' her into the trade. Another
of these men actually care for
madam-controlled arrangement
their women lovers and con­
is called the adhia system, in
tribute to their expenses, many
which the sex worker turns over
are abusive and exploitative.
50% of her income to the
Nonetheless, many women need
madam. Pimps take 25% of the
these companions for emotional
sex worker's income and are
and practical reasons, and are
organized in a hierarchical and
tied to these relationships.
regulated system headed by
mukia, or political headmen.
The Sonagachi project area
Rooms are rented at high rates.
includes four main colonies of
The sale of sex is legal in India if
brothels, located relatively close
it takes place "within a room". In
to each other, known as
order to avoid arrest, freelance
Sonagachi,
Rambagan
and
or 'flying' sex workers must also
Sethbagan, Jorabagan, and
rent rooms at high hourly rates.
Rabindra Sarani. Collectively,
The Prevention of Immoral
this is the largest red light area
Traffic Act, aimed at regulating
in Calcutta, with about 370 sep­
the flow of new women into the
arate brothels housing about
trade, in fact simply makes it eas­
4000 sex workers. The total
ier for sex workers to be
number swells to about 5000 in
harassed,
extorted,
beaten,
September and October during
raped, and otherwise abused,
the Hindu Puja season, a time of
when the Act is used to raid
revelry and greater earnings for
brothels on the pretext of
sex workers. In addition, on the
removing younger women. The
crowded streets and tiny lanes
attitude of the surrounding soci­
below the multi-storey tene­
ety is generally to despise and
ment brothel buildings, about
stigmatize sex workers on moral
1500 flying sex workers operate.
and social grounds.
The whole neighbourhood is
served by innumerable small
In addition, many sex workers
shops, itinerant traders, veg­
have babus, men who begin as
etable hawkers, youth clubs,

61

Sonagachi, India

Sonagachi, India

wine shops, and medical clinics,
some run by quacks. Prices at
. these establishments are higher
than in other neighbourhoods
in Calcutta of similar class.
Hordes of people can be seen at
any time of day and night trav­
elling on bicycles, scooters, rick­
shaws and on foot. It is a
crowded, dirty, lively, and dan­
gerous area where daily about
20,000 men come to drink and
find sex. Not only the sex work­
ers, but their clients as well, are
preyed upon by hoodlums. As in
most such areas, the police
either ignore or are involved in
the ambient violence.

S')

K'
A'
I

tus

______
.At a street corner with Sonagachi pimps
learning about HIV/AIDS.

Each building has several broth­
els in it with 5 to 25 rooms. Sex
workers fall into different cate­
gories
according
to
their

income, which is largely based
on age and attractiveness.
Higher-income women have
pleasant rooms, sometimes with
air conditioning, while the
lower-income group may share
a single room among up to five
women, with beds separated by
curtains. Ages range from 13 to
45 with incomes from Rs. 10 to
2,000 per night (39 Rs.=1US$).
Despite crowded quarters, the
women live their lives in consid­
erable isolation from each other
and from the larger society.
Madams and pimps impose rules
that keep sex workers from visit­
ing each other. Older sex work­
ers,
unless
they
become
madams, are unable to secure
many clients and many work at
housekeeping chores or babysit­
ting to make a living. Eventually,
many become destitute.

terns dictating very low status
for women, Indian women are
rapidly becoming the bearers of
the HIV burden. Sex workers
represent those with the lowest
status and the highest risk,
among all women. The All India
Institute of Hygiene and Public
Health (AIIH&PH) has been
known for its various health
interventions and hence, has
been able to lead in the devel­
opment of a broad-based sup­
port system for the project. This
support mechanism is known as
the Conglomerate, and includes
NGOs, community-based organi­
zations (CBOs), and government
institutions. At the time the
project began, the prevalence of
HIV was very low in West
Bengal, providing an opportu­
nity for a creative and flexible
intervention.

Relevance
The AIDS epidemic in India is a
rapidly growing one. As one of
the world's most populated
countries, its absolute numbers
of HIV-infected and affected
people are likely to become
staggering in the next decade.
With high proportions of very
poor people and cultural pat­

Formative Stages

ogy, socio-demographics and
behaviour. Flying sex workers
were excluded. After an initial
count of 362 brothels housing
3,664 sex workers, the sampling
methods were designed. Sex
workers were grouped into
those with charges higher than
Rs. 100 per client (Category A),
those with charges between Rs.
50 and Rs. 100 (Category B) and
those with charges less than Rs.
50 (Category C). Sex workers
were sampled randomly in pro­
portion to the number in each
category. Sixty-five brothels
were randomly selected out of
the possible 362 and about 6-7
sex workers interviewed in each
(with non-responder replace­
ment), for a total sample size of
450 (12% of the possible total).
In addition, 360 women from
this sample were willing to
undergo an STD examination
conducted at a two-room clinic
set up in a volunteer local club
in the heart of the red light dis­
trict. STD specialists from the
Calcutta
Medical
College
attended the clinic, and labora­
tory work was carried out at
the Bacteriology Department of
the Calcutta School of Tropical
Medicine.

The initial baseline survey, con­
ducted by personnel from the
AIIH&PH with the aid of an NGO
that had been working in the
area, the Society for Community
Development, was carried out
from April to June 1992. The
survey covered STD epidemiol-

63

Sonagachi, India

Sonagachi, India

Briefly, the social survey found
that 85% of the sex workers
were between 15 and 29 years
old. Most stated they entered
the trade due to poverty
(49.1%), family disputes (21.6%)
or being misguided (15.6%).
Also, 85% were illiterate and
many were heavily dependent
on alcohol, and 9.3% were new­
comers, having been in the
trade for less than one year. In
this sample 43% of the women
visited and worked in other
areas of the city as well, staying
there for some weeks or months
before returning to Sonagachi.
The majority had 3 to 4 clients
per day for weekly incomes that
varied between less than Rs. 300
to over Rs. 5,000. Many women
(27%) reported that men hired
them in a group, a situation that
seriously
diminishes
the
woman's control. About 40% of
the women had children, but
the proportion with babus was
not determined; 45% of the
women used some form of con­
traception but only 27% did so
consistently. Condoms were
always used by only 1.1% and
often used by another 1.6% of
women. At that time in 1992,
90.6% of sex workers had never

64

used condoms and only 31%
had heard of AIDS. More, 69%,
knew something about other
STDs.
Endocervical smears detected
10.5% positive for gonorrhoea,
with 4.9% confirmed by culture,
although, for technical reasons,
it later appeared that the meth­
ods used were insensitive and
underestimated the true rate of
gonorrhea. Trichomonas vagi­
nalis infection was detected in
11.1%. Genital ulcers were seen
in 6.2 % of the women.
Serological testing for syphilis
found 25.4% positive by VDRL
(dilution=> 1:8). The HIV positiv­
ity rate was 1.1%.

Later in 1993 a client survey was
conducted by 193 sex workers,
as they had the easiest access to
these men. Sex workers from
each category of income were
selected to conduct a brief ques­
tionnaire-based interview with
one client each. As these women
were mostly illiterate, they had
to memorize the questions and
answers. Social workers visited
them in the mornings and filled
the form in with their help.
Literate clients filled in their

own questionnaires. The sample
was biased towards men they
knew, men who were spending
the night, and fixed clients and,
while useful, cannot be consid­
ered
representative of all
clients. Those clients who
entered and left the brothel
rather quickly were underrepre­
sented. Thirty-seven clients of
sex workers of category A, the
highest income group, were
interviewed, as were 75 and 81
of categories B and C, respec­
tively. Results revealed an age
range of 15 to over 40, with a
tendency of younger clients to
visit less expensive sex workers
and more educated clients to
visit
the
more
expensive
women. The mean ages of
clients by sex worker category
were: A-42, B-39, and C-34. Of
the clients, 87% were literate
and 44% were businessmen.
Others were wage-earners, pro­
fessionals, drivers, students and
police. The proportion of stu­
dents (8.8%) was as high as that
of drivers (8.3%). Slightly over
half (52.3%) visited the brothels
once or twice a weekend and
9.3% visited daily. Most were
alcohol drinkers and spent time
entertaining themselves in wine

bars. While vaginal intercourse
was most common, 47% also
enjoyed oral sex. Anal sex was
reported as rare, and 4% paid to
be masturbated.
Another survey of 200 babus was
conducted, showing that 26%
were illiterate, but 9% were grad­
uates of universities. Similarly,
46% had low incomes, less than
Rs. 1,000 per month, and 4% had
incomes over Rs. 2,500 per month.
Although half had heard of AIDS,
73% had never used condoms.
Only 4.5% reported using con­
doms regularly.

In addition, in 1993 the project
undertook another survey of sex
workers to learn about their sit­
uations and aspirations regard­
ing their children. Some 2,338
women were interviewed, 47%
of whom had children under 14
years old. Despite the consioerable felt need for children,
largely for emotional and social
reasons, pregnancy was a serious
risk for these women, with 14%
stating they had deliberately ter­
minated their pregnancies, many
more than once. A total of 768
abortions had been experienced
by 330 women, or an average of

Sonagachi,. Jia

Sonagachi, India

2.3 abortions per woman. One
woman had had 15 abortions
and one live birth. An even
greater problem is the future of
those born. About half were
brought up in the brothel with
little in the way of decent care.
Some sex workers paid older sex
workers to raise their children,
but the majority kept their chil­
dren with them, arranging
makeshift creches when work­
ing. The others were brought up
outside the brothel, either with
family members or in orphanage
homes, with 90% of the financ­
ing supplied by the mother. Less
than 5% were raised in govern­
ment or NGO-run homes. About
half of the children had received
some form of education, but
drop-out rates from primary to
secondary school were very high.
None managed to go beyond
secondary school. The mothers
stressed their need for hostel or
boarding facilities with proper
schooling and supportive envi­
ronments for their children.

Implementation
Working strategies
The project began with a philos­
ophy
based
on
Reliance,

Respect and Recognition, i.e.
giving due respect to the
women, relying on their knowl­
edge and recognizing their pro­
fession. The project team mem­
bers had to make it clear to all
that they would not disturb the
existing power structure or seek
to remove women from prosti­
tution. Throughout the pro­
ject's life, all those who influ­
ence the sex trade, even if in a
negative way, have been drawn
into its activities. At the same
time, abuse by thugs, power
brokers, unethical researchers,
and others has been resisted by
the sex workers and their sup­
porters. The project itself has
become a sentinel of resistance
through organization and affili­
ation, in order to create a plat­
form upon which sex workers
could personally and collec­
tively grow. Therefore, allies
among government agencies,
NGOs, CBOs, academic institu­
tions, and numerous other
organizations have been incor­
porated in one way or another.
Publicity in newspapers, dozens
of public appearances, confer­
ences, workshops, and visible
campaigning have been used to
draw attention to the issues

W!

requiring reform. These issues
are those most relevant to the
safety and well-being of sex
workers, as defined by them­
selves. They include their rights
as workers, the rights of their
children, the safety of their
neighbourhoods, their concern
over the trafficking of children
in the sex trade, and their legal
and constitutional rights.
For project staff, misgivings had
to be overcome. Some felt
endangered by being close to
sex workers, and feared catch­
ing diseases. Others felt embar­
rassed having to deal so directly
with sex. Hoodlums were a very
real threat. Gradually, they
overcame their fears and have
become true supporters of the
women.

Police raids have been a major
problem in this project, keep­
ing the sex workers insecure
and frightened. After every
raid, staff believed that con­
dom use declined and STDs rose
among
clinic
attendees.
Therefore, the AIIH&PH in
cooperation with the Calcutta
Police Department arranged a
training programme for police

personnel. By April 1996, 180
police officers had undergone
this training.

Health care
A clinic, called the Health
Service Centre, was established
in 1992 on the premises of a
local youth club, Palatak, in the
middle of the Sonagachi area.
The Health Service Centre is
staffed by one of two rotating
STD specialist doctors and is
open 6 days a week from 11:00
to 14:00 to sex workers and
members of their families.
Treatment is free and serum
samples are collected oppor­
tunistically for syphilis screen­
ing. Sex workers are encour­
aged by their peers to attend
the clinic for screening even
when asymptomatic. Follow-up
on treatment is carried out
through the work of peer edu­
cators. On average, in 1998, 730
women came to the morning
clinic per month. In 1993
another clinic was opened for
evening sessions 5 days a week
nearby in another club, specifi­
cally for clients. Demand has
grown greatly and the clinic is
now crowded; other clinic days
are needed.

Sonagachi, India

i

Sonagachi, India

I

I he morning clinic stall lined up for
photos with one of many guests who visit
regularly.

Gradually, throughout the life of
the project, due to the demand
of sex workers, additional clinics
of a similar kind have been
opened. In 1994, one opened in
Sethbagan and another outside
the project area in Bowbazar,
another red light district in
Calcutta. These are operated, on
behalf of the AIIH&PH, by the
project with an NGO conglomer­
ate. Between 1994 and 1998, 9
more clinics were opened in red
light districts in Calcutta specifi­
cally for sex workers and their
families. As the years have
passed, the women have seen
the value of good-quality health
services and have noted the
poorer quality and disrespectful
treatment in other facilities in
the city.

68

In 1995, the peer educators
undertook a rapid assessment of
the situation of sex workers in
the rest of West Bengal. They
found 254 red light districts and
spots throughout the state. After
prioritizing 30, they began
organizing and, as of late 1999,
14 new projects had started. New
clinics were erected, peer educa­
tion begun and condom sales
carried out. This effort is funded
by the project and managed by
the DMSC.

-

Newly constructed DMSC clinic at
Durgapur, West Bengal.

Technical aspects of STD care,
such as resistance to antibiotics’
and verification of cure, remain
to be handled. Aggressive
screening and more referral and
follow-up of babus and other
clients are required in the next
phase of growth.

Peer education
perform plays about STD/HIV
Peer educators were selected
prevention as well as the issues
and trained, starting with an ini­
surrounding prostitution. This
tial group of 12. By 1997 there
dance/theatre
troupe
has
were 65 trained peer educators
become an important medium
who were paid the equivalent of
by which the sex workers can
US$1 per day. These women
express themselves, forge a pub­
were given 6 weeks of training
lic identity and reach a large
and utilized specially designed
number of persons of all walks of
flip charts, requiring little liter­
life. It won first prize at a
acy, to explain the basics of sex­
National Cultural Competition
ual health and safer sex to their
for Sex Workers, held in Benares
peers. The Sonagachi area was
in mid-1997 and, in 1998, it per­
divided into 11 zones that were
formed at the Twelfth World
covered by the 65 peer educators
AIDS Conference in Geneva.
with 7 supervisors. From 10:00
until 13:00 every day, each group
contacts 40 to 50 sex workers and
10 to 15 madams. They encour­
age the women to go for regular
check-ups as well as seeking care
when they have symptoms.
Leaflets are given to those who
are literate. In addition video
■
-ilSrtilM J
'fc
’
shows, slide presentations, small
Komol Gandhar. performing in Geneva at
the World AIDS Conference 1998.
group meetings and ventrilo­
quist performances have been
used to reach larger groups of
After expanding to other broth­
sex workers and clients.
els in Calcutta, the number of
trained peer educators has
They have also developed a per­
reached 200 with a coverage of
forming group, Komol Gandhar,
about 20,000 sex workers and
that includes male and transgen­
babus. As the project has
der sex workers, and perform at
expanded, it has become difficult
different cultural events. They
to continue to pay all the peer

69

-HIIIIH 111

Sonagachi, India

- :-

Sonagachi India

educators needed in order to
maintain a ratio of one peer edu­
cator to 50 sex workers reached.
Now the ratio is 1:160. In order
to deal with this problem, the
project has developed an addi­
tional cadre of volunteers to help
the
peer
educators
reach
women. Monitoring the quality
of work of these volunteers rep­
resents a challenge in scaling-up,
typical of most trainer-of-trainerlike projects.

positive people. As the number
of HIV-positive people grows in
India, the aim is to develop a
model of community-based care
for West Bengal.
Condoms
In the beginning, the peer edu­
cators distributed free condoms
and enquired about the extent
of condom usage. Demand for
the high-quality, imported con­
doms distributed by the project
grew faster than the supply.
During the first month of the
project, 3592 condoms were dis­
tributed; by 1994, during the
month of December, 79 420 con­
doms were distributed. This rose
to 110 328 in December 1996.
Because of budgetary con­
straints, the project was unable
to meet demands.

In 1998 the Positive Hotline was
initiated and maintained by the
sex workers in response to hear­
ing about the sad situation of an
HIV-positive woman who was
not a sex worker. It has started
with a single phone at one of the
field offices and is staffed at
night by the children of sex
workers. This service to the
larger community emerged from
recognition of the need for
counselling and support for HIV­
positive people, whether sex
workers or not. A core team has
been formed of volunteers, a
doctor, a nurse and a counsellor.
In addition to medical care, .the
service offers psycho-social and
legal aid support and the team
can be sent to the homes of HIV-

In July 1995, the sex workers of
Sonagachi formed a registered
society
called
the
Usha
Multipurpose Cooperative Society
Ltd., a consumers' cooperative
which would help them save
money and avoid the exorbitant
interest charged on small loans
by money lenders in the area.
Registering as sex workers,
instead of 'housewives', required
' J

a long struggle with authorities,
chased a piece of land outside of
but with a growing capacity for
Calcutta at which they have been
advocacy and publicity, DMSC
able to construct a training cen­
was successful. Starting with only
tre where they conduct most of
13 members, it now has over
their training. The older sex
1000 and regularly gives loans at
workers produce handicrafts
low-interest rates to sex workers.
there when specific market
Small investment schemes utiliz­
opportunities emerge.
ing bank deposits have also been
developed. Its funds provide a
Empowerment
creche for sex workers' children
Organization has been the key
during working hours and it
to empowering the sex workers
gives employment to older, outof Sonagachi. Several influences
of-work sex workers. In April
converged to encourage the sex
1997, it developed its first forworkers of Sonagachi to organ­
profit business, the marketing of
ize themselves. First, a previous
condoms. Bought in bulk, the
organization of sex workers,
condoms were sold to any group
called Mahila Sangha, had
wishing to buy. Recorded sales
formed in the Sethbagan area in
increased from a total of 213 056
the 1970s, to fight against the
in 1997 to 443 805 in 1998 and
regular and violent extortion of
730 656 in 1999. The project still
money from sex workers by a
distributes free condoms as well
local mafia. After' gaining vicfor newcomers to the brothel, to
tory, they moved on to literacy
men who attend the STD clinics
and
health
programmes.
and to very poor sex workers. In
Eventually, one of the leaders
the meantime, condoms manu­
moved over to the Sonagachi
factured in India have improved
project and led the Sonagachi
and importing is no longer con­
sex workers in their first appear­
sidered necessary. An activistance at the Calcutta Book Fair in
cum-sales arm of the Usha
1992. Second, regular meetings
Cooperative, Besanti Sena, now
of the peer educators began to
markets condoms in 40 red light
knit them together and, to
districts of West Bengal. With the
resolve conflicts, they formed an
profits made, they have purAdvisory Board and a committee

7E

Sonagachi, India

Sonagachi, Ind'

to handle grievances. In 1993,
the peer educators and supervi­
sors held a candlelight proces­
sion against AIDS which made
the headlines. Step by step, new
elements were added. The peers
were given a green uniform
jacket with a printed red cross
on it and an identity card. With
this they could feel like real
health workers. Women began
to take their clients into the
clinic to have their STDs treated
and were sought after for advice
and information. It was found
that, in the beginning, women
with children were the most
enthusiastic about becoming
peer educators as it gave them a
more respectable status in the
eyes of their children.
Running their own project and
organizations
required that
some of the women, at least,
were
literate. The women
wanted a literacy project for
themselves. One of the supervi­
sors agreed to teach and they
began, but soon it became
apparent that adult learners
with special life experiences
could do better if the literacy les­
sons grew from their own dis­
courses. A new mode of learning

emerged which is participatory
and has its own primer. A small
newsletter with an attractive
glossy format, Namaskar, was
started, in which they can tell of
their experiences. These are sold
by the peer educators at fairs
and meetings, particularly the
annual prestigious Calcutta Book
Fair. Four editions have been pro­
duced so far. In addition, daugh­
ters of sex workers were
recruited to be teachers of liter­
acy and there are 14 such teach­
ers so far. This strategy has had
the advantage of giving pride to
the mothers and to the daugh­
ters, and helping them gain sta­
tus in society. Indirectly, their
new identities may make it easier
to negotiate better positions
with regard to dowry and mar­
riage at a later age.

DMSC began to develop cultural,
sports and artistic activities for
sex workers' children and, with
the help of the project, placed at
first 50, and now 100 children in
mainstream boarding schools
yearly. A creche now operates for
brothel children as well as sev­
eral other programmes spon­
sored by donors and operated by
collaborating NGOs/CBOs.

72
if

•n 1994, researchers, with the I of sex workers in other parts of
help of an NGO and police, col­
Calcutta
and
demonstrated
lected blood samples from 50
against the unethical and illegal
Sonagachi women without their
testing of an unqualified AIDS
consent. This created panic in the
vaccine. They collected money to
area and the Institute registered
give to the State for flood victims
its protest. Eventually, the situa­
and, by 1996, began touring
tion calmed down but left the
other parts of West Bengal to
women with determination to
examine the situation of sex
form an organization that could
workers, which, in many cases,
deal with local issues, such as
they found shocking. They visited
that one, which directly affected
sex
worker
projects
in
their lives.
Bangladesh and Nepal. Not long
afterwards, representatives of
In 1995, the DMSC Committee led
the Committee attended interna­
a group of 1,000 sex workers to
tional meetings of sex workers,
demonstrate against police raids
meetings on the trafficking of
in the Sonagachi area. They
children in the sex trade, and
joined rallies against the eviction
national and international con-

®

" HMBL

K 7'W
i

Sex workers’
children
dancing and
playing in front
of the main
clinic.

A
1 __

--.X

■iff’ail

aaixus

Sonagachi, >-1ia

Sonagachi, India

gresses on AIDS. In late 1997, the
Committee brought together sev­
eral thousand sex workers,
including males and transvestites,
for the First National Conference
of Sex Workers in Calcutta. They
have taken on the role of the
Secretariat for the Asia/Pacific Sex
Workers' Network. In March
1998, they held another confer­
ence, the Follow-up Phase of the
First National Conference of Sex
Workers. This conference was
attended by 2,000 sex workers
from 48 red light areas all over
India. At this conference they
were able to attain several of
their objectives,
particularly
those related to networking.
They now have a vision and a
platform of goals, aimed at inte­
grating
themselves
into
a
worker's world of rights and
responsibilities. The Committee
now has over 250 male and trans­
gender members.

Three hundred sex workers have
received legal training. As some
wanted more than the short
course originally given, another
60 had additional legal training.
One vexing issue has been the
presence of young sex workers in
1

the brothel. This Fs both against
the law, causing the police to
make repeated raids, and a prob­
lem to older sex workers. The
younger women have less capac­
ity to insist on safer sex, are bio­
logically more vulnerable to HIV
infection and draw clients away
from the older ones. The mem­
bers of DMSC have taken the
stand that they can better regu­
late the entry of young women
into the brothels themselves
than can the police or other
agencies. They set up a system
through which they could moni­
tor new arrivals and counsel
them before they actually enter
the brothel trade. At first they
were attempting to send them
back to their homes, but the
majority simply refused to go,
having run away from abusive or
difficult circumstances. With the
help of the Social Welfare
Department, they now have an
arrangement whereby most of
the girls are sent to boarding
schools sponsored by the Social
Welfare Department. Over the
years this process appears to
have reduced the proportion of
bonded sex workers, usually the
youngest, entering the brothel,
although indicators have not

been recorded for this. With the
aim of spreading this type of selfregulatory action, DMSC set up
in 1999 three more Self-regula­
tory
Boards at Sethbagan,
Tollygunge and Rambagan in
Calcutta. These boards are com­
prised of members from the state
government, women's' rights
groups, other local people and
sex workers. Members of DMSC
frequently take part in meetings
and debates on trafficking, an
issue of intense concern in the
South Asian region.

ber of pimps and madams
appears to be dropping. At
Sonagachi, as elsewhere, the
AIDS epidemic has led to the
realization by many sex workers
that they can avoid the repres­
sive and unsafe conditions in ille­
gal brothels by diversifying their
work modes. Many have moved
into residential or hotel-based
sex work, a situation having
implications for future HIV pre­
vention as well as the evolving
nature of the relations between
the state and the sex trade.

Helping sex workers leave the
sex trade has never been an aim
of the project but, inevitably,
growth in self-esteem and a
sense of control over one's own
life has led some women to
choose to leave the trade. About
one-third of the peer educators
who have been active for at least
several years have moved out of
the brothel. They return daily to
conduct their work; about 60
women have left sex work
entirely. The small salaries they
receive from the project must be
supplemented by other income
and many of these women now
sell saris and other small mer­
chandise. In addition, the num-

Clients and lovers
For clients, a clinic has been
established with free treatment,
free condoms and counselling,
but no clear mode of establish­
ing client-targeted programmes
has emerged. Police, youth
groups and the general public
have received several awareness
programmes. Some clients have
been reached at wine shops and
through forms of 'edutainment',
such as ventriloquist shows.
Babus, however, represent a spe­
cial problem and, as fixed clients,
have received special attention.
A meeting in the local Botanical
Gardens was held in June 1997,
attended by about 150 babus,

layaMil; II mid

Sonagachi, India

which discussed the problems of
the Sonagachi area and the role
of babus in the establishment of
safer sex norms. This was fol­
lowed by four more such meet­
ings. Subsequently, a babu com­
mittee and a collective, known as
Sathi Sangathan (Companion's
Collective), were formed. The
aim is to work with DMSC to
fight against all forms of harass­
ment and violence against sex
workers and their clients. One of
their services has been to escort
clients past the bands of gundas,
or hoodlums that operate on the
streets of Sonagachi.

Monitoring and
Evaluation
The project collects data on sev­
eral different monitoring indica­
tors both at the clinics and
through the peer educators. It
also relies on periodic cross-sec­
tional surveys for feedback on
effectiveness, with one com­
pleted at the end of 1993,
another in mid-year 1995 and
the latest in 1999. The first exter­
nal evaluation took place in 1996
and another in 1999. One impor­
tant recommendation made by
these teams was that the project

should develop different indica­
tors. Instead of focusing nar­
rowly on effectiveness in STD
control, it should find a way to
document the emerging strength
and self-esteem of sex workers.
By 1998 several new indicators
were added. The attendance of
clients at the project's clinics had
been difficult to monitor as men
sought treatment who may not
have been clients. A referral card
given by the sex worker to the
client (and later handed in at the
clinic) now makes it possible to
monitor how many clinic atten­
dees are clients referred by sex
workers. The duration of self-rec­
ognized symptoms when the sex
worker presents to the clinic is
now recorded. Instead of contin­
uing to ask how many sex acts
were covered by condoms, the
project now monitors how many
condoms were sold, on the
assumption that women will buy
what they will actually use.
Levels of empowerment and
engagement in the community
movement are now measured by
asking how many times the sex
worker manages to negotiate
with landlords, police and other
power brokers, as well as how
many sex worker organization

meetings or conferences she
attends. Changing the indicators
Tor monitoring the success of an
evolving intervention is essential,
out must be done with care so
that continuity with the past is
minimally affected.
Effectiveness
At the end of 1993, 14 months
after the intervention was imple­
mented, the first follow-up sur­
vey was conducted. Sampling
methods were essentially the
same as the baseline survey and
612 women were interviewed.
Age distribution was similar to
the first survey and the literacy
rate remained very low. The pro­
portion of new sex workers (in
tne trade less than one year) was
considerably higher (22.6%) than
a. baseline (9.3%). The median
number of clients the previous
day was 3. Group sex appeared
to increase from 27.3% at base­
line to 48.7%. The proportion of

women reporting
oral
sex
appeared to decrease from
74.4% to 38.1%. It is not unlikely
that the questions were asked in
different ways in each survey,
causing this puzzling result. The
proportion of women ireporting
some knowledge of AIDS
—> rose

76
4’

77

from 30.7% to 85.8%. The per­
centage of clients using condoms
always or often increased from
2.7% at baseline to 69%, a con­
siderable increase. By 1998, this
percentage rose to 90.3.

Although the methods used to
detect gonorrhoea were too
insensitive to detect all cases,
these same methods were used
for the baseline and first follow­
up surveys. This showed a
decrease in gonorrhoea from
13.2% to 3.9%. Neither HIV nor
recent
syphilis
infections
showed any significant change
in prevalence.
In an attempt to improve the sur­
vey methods, decisions were
made for the second follow-up
survey conducted in July-August
1995 to alter the sampling and
STD detection techniques. This
decision meant sacrificing some
of the past data in order to have
improved measurement capacity
in the future. However, the
hoped-for improved random
sampling methods did not work.
True randomization is very diffi­
cult without identifying the
women in some way, especially
because the sex workers were

Sonagachi, India

Sonagachi, India

interviewed at the brothels and had to
go voluntarily to the clinic for examina­
tion and testing. In fact, more went to
the clinic than were randomly selected
and it was hard to know who had really
been interviewed. In addition, although
the laboratory methods to detect gonor­
rhoea were improved, laboratory capac­
ity was not increased, and only 10 sam­
ples could be handled per day. In
November 1995, when an external team
of experts evaluated the project, it was
recommended that in the future the lab­
oratory work should be handled by a
commercial laboratory with greater
capacity and that a reference laboratory
be utilized for quality control.

Figure 1. Change in proportions of sex workers with genital
ulcers, recent syphilis and HIV over time

Nonetheless, clear evidence exists of a
reduction in levels of recent syphilis and
the presence of genital ulcers. Measures
of current syphilis are higher for those
who have more clients than others, are
illiterate and have not attended any
meetings organized by sex workers.

Although the rates of HIV among sex
workers in most parts of India had, by
then, shown dramatic increases, by 1998,
among 503 randomly sampled women at
Sonagachi, only 5.5% were found to be
HIV positive.

30 i

25

20 -O-VDRL=>1:8
-®- Genital ulcer
HIV+

10

©--

5

0
1992

1993

1995

1998

While condom use has increased greatly,
it has not reached total or near-total cov­
erage. Only about 50% of the sex work­
ers use condoms all the time with clients
and, as is typical in sex worker projects,
the greatest proportion of this level was
reached early in the project. The project
has not placed a great deal of emphasis
to date on specific negotiation skills or
materials. Options that would enhance
79

Sonagachi, India

Sonagachi, India

usage rates, such as female condoms and
lubrication, are not yet incorporated.
Measures of condom use with babus are
collected within cross-sectional babu sur­
veys and show a reported rise in use at
last sex from 4% to 30% between 1995
and 1999. Babus continue to exercise
considerable control over their relation­
ships with the women as well as denying
risk for-themselves and their own wives.
Despite enormous changes in levels of
self-esteem for many of the women at
Sonagachi, these effects have not
reached all. Passivity, fear, and desperate
need for money militate against the
assertiveness necessary to make demands
on a man who may be drunk and poten­
tially violent. One important way in
which babus can exert power is the giv­
ing of their name to sex workers' chil­
dren so the children can be enrolled in
school. As they can repudiate this assign­
ment at a later date with the school sys­
tem, this gives them continuing leverage
and power over the women. In addition,
madams and pimps can demand that
their workers take clients without con­
doms and many young women share sin­
gle rooms with other women, making
assertiveness embarrassing and difficult.
There are some victories as well. For
example, one of the most resistant
groups, the Nepalese women, has begun
to ask for condoms. Table 1 shows the

80

percentage of sex workers using con­
doms always or often with clients.

Table 1. Patterns of condom use with clients over time
Sex Workers' Condom
Use

1992

1993

1995

1998

%

°/o

%

%

Always uses condoms

1.1

47.2

50.1

50.4

Often uses condoms

1.6

22.1

31.6

40.1

Total

2.7

69.3

81.7

90.5

Table 2 (and Figure 2) show the proportion
and the respective confidence interval of
clients who used condoms in the previous
24 hours, a question asked in all surveys
after the baseline in 1992. Although the
change in proportions is not very large,
the trend is statistically significant.

Table 2. Proportion of yesterday's clients who used
condoms at all
Client's Condom Use

1993

1995

1998

No. of clients

2 139

1 362

1 174

No. using condoms

1 528

1 037

921

% using condoms

71.4

76.1

78.5

81

I

Sonagachi, India

Sonagachi, India

The project has relied so far on the abil­
ity of sex workers to convince each other
of the value of using condoms and
obtaining STD treatment. The main tool
of communication has been the original
flip chart developed early in the project.
Although some sex workers have learned
how to present a slide show on STDs, the
majority of peer educators have not been
equipped with materials that could
expand their messages and help them to
present them to others, including other
sex workers and clients. Investment in
materials for behaviour change commu­
nication has been quite scant compared
to many other projects.

Figure 2. Trend in condom use among clients
82

80
78
76
74
£ 72
70
68
66
64
62

1993

1995

1998

One important facet of this project has
been the way in which new entrants to
the sex trade are reached, with 48% of
sex acts covered by condoms on the pre­
vious day by women who entered the
brothel only 2 months ago or less: This
compares to 63% of acts covered by
those working for 6 months at the
brothel. This success is attributed to peer
pressure and improved self-control
among sex workers. In the 14 clinic catch­
ment areas now run by DMSC in West
Bengal, survey data between 1996 and
1998 show a rise in condom use from
28.8% to 52.2%.

82

Police violence, a major barrier to the sex
workers' ability to control their own
lives, has diminished somewhat, but few
objective indicators exist to measure this.
It is easier to demonstrate that sex work­
ers are more able to confront the police
than before the intervention.

Efficiency
Initially the project was funded by WHO,
followed by NORAD for two years. In
October, 1994, DfID began its financing.
The number of staff working for the
Sonagachi project is 49 full-time, 216
part-time and 25 volunteers. The project
currently costs about US$ 90 000 per year
to run. The salary of the project director
has, until recently, been paid by the

83

Sonagachi, India

Sonagachi, India

Government of India. There is a
central office and two field
offices in Rambagan and Chetla,
as well as 3 rented cars. Given
the high level of activity, every­
one seems overworked and
space is at a premium and often
shared by different project activ­
ities. A few university students
are conducting their own
research on the project, which
aids in documentation. Overall
direction and management is
conducted through a large
group of partners called the
Conglomerate. Although this
might add some burdens to deci­
sion-making, it ensures greater
spread of responsibility and
strategic thinking.

The World Bank reviewed the
cost of the project, though a fullscale economic study has not
taken place. A rough estimate,
expressing the reductions in STDs
as DALYs (disability adjusted life
years), showed the cost per DALY
saved to be within the range of
Rs. 30 to Rs. 50. An impact-ori­
ented cost-effectiveness study
would require knowing how
many
HIV infections were
averted in the intervention and
control groups, an expensive, I

84

prospective study of question­
able ethics. Instead a cost-effec­
tiveness evaluation was com­
pleted in 1999 that calculated
the cost per service. It found that
the cost per condom sold was Rs.
9.2 (US$ 0.22), per interpersonal
contact for behaviour change
communications was Rs. 35.3
(US$ 0.84) and per STD patient
treated was Rs. 560 (US$ 13.3).
The latter cost in the community­
based
STD
programme
in
Mwanza, United Republic of
Tanzania was USS 10.8. Overall,
the project invests 12% of its
expenditures in advocacy, a much
higher level than most HIV inter­
vention projects. Cost recovery
has not really begun, although a
fee for service has been insti­
tuted in the extension clinics out­
side of Sonagachi.

Ethical soundness
Ethical
concerns
permeate
throughout the project's activi­
ties. Standard procedures for
confidentiality and de-linking of
HIV specimens were used during
the survey work. While sex work­
ers are gradually gaining more
pride in themselves, the sur­
______
^...ycpuyanyrounding
society still greatly stigmatizes them and their children.

Many do not wish to have their
names attached to printed state­
ments or in any way admit to
their families that they are sex
workers.
This
concern
is
respected by the project. Special
attention is paid to protecting
the identity of STD- and HIVinfected women. In general, the
project takes a very strong stance
on ethics with regard to treat­
ment of sex workers.
Replicability and
sustainability
The project has already begun
replicating itself in various ways,
with
clinics,
outreach
pro­
grammes and peer education
training for other brothel areas
and flying and street-based sex
workers in and around Calcutta.
Fourteen clinics are now run by
the DMSC. As of July 1997, 34
peer educators were recruited
and trained from among approxi­
mately 1,500 flying sex workers in
the vicinity. The intervention has
reached out to cover about 8,000
of an estimatedl2,000 street­
based sex workers in Calcutta as
well. The Usha Multipurpose
Cooperative Society has initiated
the marketing of condoms and
has plans for developing a

85

department store. As most con­
sumer goods are overpriced in the
Sonagachi area, this would
enable the sex workers to make
basic commodities available to
themselves at a lower cost. A reg­
istered organization, the Society
for Human Development and
Social Action, has been formed,
composed of the project partners,
including NGOs and sex worker
organizations. The new project
director is the son of a sex worker
who has been active in the proj­
ect since its inception. Such an
organization has the potential to
provide the basis for the mainte­
nance and growth of future
efforts to provide sexual health
and many other basic services, as
well as a platform for advocacy
where the sex workers can play
the driving role. Skills, such as
basic accountancy and literacy,
are needed and gradually these
needs_ are being addressed.
English language skills are also
generally lacking, requiring the
use of interpreters when interact­
ing with most outsiders. The
capacity of Sonagachi's women
to provide the basis of a regional
network of sex workers has been
recognized and such a network
was launched in 1998. Six sex

-.■■JIJIIII—IUII

Sonagachi, India

workers are receiving computer
training which should help them
maintain networks via email,
though language barriers still
remain. The peer educators
themselves have trained 600
other sex workers, 200 each at 3
workshops for brothel-based sex
workers.

Lessons Learnt
The Sonagachi project has
demonstrated the great value of
gradually placing the control
of a community-based health
intervention into the hands
of the community. It has been
possible to meet the costs of
expansion, incorporating new
components, and staffing them
due to enthusiastic voluntarism
on the part of the sex workers.
Whether an HIV or malaria
intervention, this approach is
one of the most sustainable, if
not biomedically perfect, in the
reality of an imperfect world.
Impact and effectiveness in such
behavioural change interven­
tions are difficult to achieve and
to measure, but are far more
likely to be sustained, once
achieved, if the target group
itself takes over. This has been

■.■uv.,,. ■■

.

“ *T

accomplished to- a greater
degree in Sonagachi than else­
where in the Asia-Pacific region.
This project has had a remark­
able evolution, even if sex
workers are not yet ready to
staff and completely manage
their own clinics. A great deal
of investment has been made in
building capacity of staff
and sex workers. The project,
at times, has had detractors and
critics, but its basic soundness is
reflected, not merely in impact
indicators or the opinions of
experts, but in the commitment
and active involvement of sex
workers themselves. This could
only be accomplished by treat­
ing the sex worker as a
whole person, encouraging
her to recognize and express
her needs and treating her in a
fully ethical manner. Meeting
the felt needs of the sex
workers has encouraged them
to commit themselves to HIV
prevention.
It was unfortunate that the labora­
tory STD work and sampling has, at
times, been unreliable. Such proj­
ects have considerable scope to
recruit more expertise. A scien­
tific research and training centre

Sonagachi 'ndia

is envisaged for the future of
Sonagachi, which is one way of
assuring greater involvement of
scientists. Nonetheless, biomed­
ical and self-reported behav­
ioural data from repeated sur­
veys ensured adequate repli­
cation to demonstrate effec­
tiveness. In the future, monitor­
ing and evaluation in Sonagachi
should be able to correct past
mistakes
and
incorporate
measures and documentation
of personal growth and social
empowerment
among the
women.

The fuller involvement in HIV
prevention is needed of
important men and women
who strongly influence the
safety of the sex trade, e g.
police, madams, pimps, babus.
Repeatedly, this project has
spawned various organiza­
tions that provide a demo­
cratic basis for sharing deci­
sion-making power. Reforming
the sex trade without involving
police, madams, pimps and hood­
lums will be very difficult, and
they need to be included.
Recently, as the number of pimps
and madams declines, landlords

The process of struggle that we, the members of Durbar
Mahila Samanwaya Committee, are currently engaged in has
only just begun. We think our movement has two principal
aspects. The first one is to debate, define and re-define the
whole host of issues about gender, poverty, sexuality that
are being thrown up in the process of the struggle itself...
Secondly, the daily oppression that is practised on us with
the support of the dominant ideologies, has to be urgently
and consistently confronted and resisted. We have to strug­
gle to improve the conditions of our work and material qual­
ity of our lives and that can happen through our efforts
towards us, sex workers gaining control over the sex indus­
try itself.
(From the Sex Workers’ Manifesto, Theme Paper of the First National Conference of
Sex Workers, organized by Durbar Mahila Samanwaya Committee, Calcutta,
November, 1997)

Sonagachi, India

Sonagachi, India
. - ■'
- .
r

have begun to harass sex workers
more directly. The future direc­
tion and management of the
project through the HARD Trust
has the potential to include all
players and stakeholders.
India and the rest of the world
will have to reckon with the
awakened women of Sonagachi
as they move towards greater
outreach to other sex workers in
their region and around the
world. The main remaining
obstacle is the attitude of society
to sex work and sex workers.

Further Reading

Community Based Survey of
Sexually Transmitted Diseases,
HIV
Infection
and
Sexual
Behaviour among Sex Workers in
Calcutta, India (April-June, 1992).
Dept of Epidemiology, All India
Institute of Hygiene and Public
Health,1992.

Chakraborty, AK, and Jana, S.
Socio-behavioural aspects of
clients of commercial sex workers
of
Sonagachi,
Calcutta.
Sonagachi Research Series Report
No. 2. Dept, of Epidemiology, All
India Institute of Hygiene and
Public Health, Calcutta, 1992.

Durbar
Mahila
Samanwaya
Committee.
First
National
Conference of Sex Workers, Nov
14-16, 1997, Calcutta.

Chakraborty, AK, Jana, S, Das, A,
Khodakevich, L, Chakraborty, MS
and Pal, NK. Community based
survey of STD/HIV infection
among commercial sex workers
in Calcutta (India). Part I. Some
social features of commercial sex
workers.
J.
Communicable
Diseases 26 (3): 161-167, 1994.

HIV infection, while a serious and
sad disease problem for the
world, is also an opportunity to
set right many of the abuses of
the past. The Sonagachi project
has begun to wed prevention
and cure in the best traditions
of public health activism.

Fox, R. Red light on Calcutta:
health via schools in Andhra
Pradesh [Commentary]. Lancet
344:1038 (Oct 25), 1994.

Gonzalez, V., Grosskurth, H.,
Guiness, L, Pangare, V., and
Sethi, G. Evaluation of Four
Partner Projects of the West
Bengal Sexual Health Project.
Final
Report.
International
Family Health, September 1999.

Chakraborty, AK, Jana, S, Das, A,
Khodakevich, L, Chakraborty, MS
and Pal, NK. Community based
survey of STD/HIV infection
among commercial sex workers
in Calcutta (India). Part II. Sexual
behaviour, knowledge and atti­
tude
towards
STD.
J.
Communicable
Diseases
26
(3):168-171, 1994.

88
■

■

W";:-

Jana, S. Without shame or
stigma. Health Action 10:11
(Sept-Nov), 1994.

f

Jana,
S,
Chakraborty,
AK,
Chatterjee, BD, Chakraborty, MS,
van Dam, CJ, and Mehret, M.
Knowledge, attitude of CSWs
towards STD/HIV and prevalence
of
STD/HIV among
CSWs.
Presented
at
the
IXth
International Conference on
AIDS, Berlin, 1993.

Jana, S, Banerjee, B. (eds), A
Dream, A Pledge, A Fulfilment:
Five Years' Stint of STD/HIV
Intervention
Programme
at
Sonagachi. All India Institute of
Hygiene and Public Health,
Calcutta, 1997.
Jana, S, Choudhury, R, Bhaskar, B,
Mukherjee, M, and Basu, I.
Putting barricade against AIDS
through mobilisation of female
sex
workers
in
Calcutta.
Proceedings
of
the
4th
International Congress on AIDS in
Asia and the Pacific, Manila, Oct.,
1997. Abst # C(P) 118, p. 349.

Jana, S, Bailey M. All part of the
service. AIDS Action 26 (SeptNov), 1994.

Dept, of Epidemiology, All India
Institute of Hygiene and Public
Health.
Report
of
the

Jana, S., Bandyopadhyay, N.,
Mukherjee, S., Dutta, N., Basu, I.,
and Saha, A. STD/HIV interven­
tion with sex workers in West
Bengal, India. AIDS 12 suppl. B,
S101-S108, 1998.

89

SHAKTI, Bar 'adesh

Sonagachi, India

shakti: A Brothel and Street-

Based Sex Worker Project in
Bangladesh

Mukherjee, S, Jana, S, Mitra, M
and Choudhury, R. Situational
analysis of sex trade with the
help of FSWs (female sex work­
ers) and their networking.
Proceedings
of
the
4th
International Congress on AIDS
in Asia and the Pacific, Manila,
Oct., 1997. Abst # C(P) 117, p.
349.

Introduction
^HAKTI ("power'* in Bangla), or
^"Stopping HIV/AIDS through

Knowledge and Training Initiatives", is
the name of a project implemented by
CARE, Bangladesh, with several compo­
nents. The larger SHAKTI project has
been working with three groups:
brothel-based sex workers, street-based
sex workers and injecting drug users
(IDUs). The first component began in
mid-1995 in a brothel located in a town
named Tangail, a few hours drive away
from the capital city, Dhaka. The second
component started in 1996 among
street-based sex workers in Dhaka. The
project aims at improving condom use
and making treatment of sexually trans­
mitted diseases (STDs) available among
about 600 brothel-based, and about
3,000 to 5,000 street-based, female and
transgender (hijra) sex workers in a
highly conservative and repressive set­
ting. In addition to increased condom
use, measurement of changes in STD
prevalence was included as an indicator
and the project baselines were estab-

Nayanita, S, Singh, S, Moulik, R,
Brahma, S, Jana, S, and Basu, I.
Enabling female sex workers to
create a milieu of negotiation.
Proceedings
of
the
XI
International Conference on
AIDS, Vancouver, Pub C 1166, p.
464.

Singh, Sujata. Three Year Stint at
Sonagachi: An Exposition. The
STD/HIV Intervention Programme
at Sonagachi, 1992-1995. Aug
1995.
Jana, S. and Banerjee, B, eds.
Learning to Change. Seven Years'
Stint of STD/HIV Intervention
Programme
at
Sonagachi.
Calcutta: Society for Development
and Social Action. August, 1999.

yri

SHAKTI, Bangladesh

SHAKTI, Bangladesh

lished by clinical and laboratory
research. This project, inspired by
the
Sonagachi
Project
in
Calcutta, was conceived as one
that could be expanded to other
parts of the country through a
strategy of NGO and govern­
ment partnership. This remains
its aim.
Bangladesh has low HIV preva­
lence. In 1998 the first welldefined HIV sentinel surveillance
took place among high-risk
groups, revealing the highest
rate of 2.5% among injecting
drug users in Dhaka. A sample of
400 Dhaka street-based female
sex workers revealed no HIV,
while similar samples at two
brothels, Tangail and another,
showed none at Tangail and
1.5% at the other. Levels of
syphilis infection (TPHA and RPR
positivity) were high, with 57%
among the street women and
46% at Tangail (Azim et al.,
1999). Following the completion
of surveillance, the brothel at
Tan Bazar, the largest in the
country, experienced intense and
violent repression and was
closed. Gradually over the past
years, brothel sex work has been
diminishing. Tangail and 14

92

other brothels remain open, but
over the past several decades,
prostitution in Bangladesh has
been undergoing change as
more women work in hotels, res­
idences, other types of informal
brothels, through beauty par­
lours and other less obvious ven­
ues. Street-based sex work
remains the most visible, poorest
paid, with the lowest status and
has the roughest clientele.
Government authorities view
prostitution as a shameful blem­
ish on Bangladesh's social record
and seek to abolish it, primarily
by abolishing brothels and relo­
cating slum dwellers into rural
areas. It is within this context
that SHAKTI's success can best be
seen.

As it was the first major project
with sex workers in the nation,
CARE personnel had many les­
sons to learn. Objectives of the
project have shifted several
times, with numerous manage­
ment changes, additional fund­
ing being required, and different
partnering
strategies
being
developed in order to meet
changing perceptions of need on
the part of sex workers. The sex
workers
themselves
have

changed, not only in the sense of
group composition, but in terms
of their own understanding of
the issues surrounding HIV. While
the strictly health-related issues
have not been easy to solve, the
human rights issues have posed a
far more serious barrier to
improved sexual health and safer
sex practice. Against all odds, a
strong street-based self-run sex
worker
organization
has
emerged, made up of over 900
dues-paying women who are
determined to gain recognition
of their rights as citizens of
Bangladesh. Hijras have joined as
well, recognized by the women
as colleagues. A similar move­
ment has taken place, but more
haltingly, in the Tangail brothel.
Hence,
empowerment
has
evolved to hold a primary place
among the project's objectives.

Throughout its life, the project
has been funded by the United
Kingdom
Department
for
International
Development
(DfID, formerly ODA). SHAKTI
has undergone an external mid­
term review and an additional
near-final evaluation. Also, quar­
terly monitoring takes place
through surveys as well as on-

going monitoring by its peer
educators.

Situational
Background
Tangail brothel
Bangladesh has had brothels for
centuries that have gradually
become part of the local culture.
Some are residential, relatively
uncrowded, with small rooms
rented to individual women.
Others are crowded, with many
small rooms housing three or
more women together. Although
not technically legal, brothel
prostitution is regulated by the
local authorities in Bangladesh.
Sex work is considered a black­
listed trade, and sex workers are
highly denigrated by most mem­
bers of society. Police exercise a
degree of regulatory power, and
for a fee ranging from 5,000 to
15 000 taka (US$ 1=50 taka),
place an affidavit with the court
when a woman enters a brothel.
This enables her to avoid arrest
when working in the brothel.
This system is supposed to ensure
that only willing women who are
at least 18 years old enter the
brothels. The system is ambigu­
ous and recognizes prostitution.

93
•UW1 »»"

-•

.............. ^M^j***

JL . A

SHAKTI, Bangladesh

SHAKTI, Bangladesh
3-

but does not make it legal. At
Tangail, the police, landowners,
house owners and/or bariwalli
(residential landladies), madams,
sardanis (senior madams), and
mastans or hoodlums associated
with local political parties, really
run the establishment, which has
a regulating body called the
Shamaj. Although most women
are "independent" operators,
about 60% of their income goes
to the aforementioned authori­
ties. A minority of newcomers,
called chhukris (19%), were
totally under the control of sen­
ior sex workers or sardanis, and
made to work for at least 6
months to pay them off, i.e.
100% of their income was paid
to their controllers.
At the time of the baseline sur­
vey (Sarkar et al., 1997a), the
average age of the women was
24 and 86% were illiterate.
Almost all (97%) were Muslim
and had been working in the sex
trade for an average of 7 years.
Most (62%) had long-term
clients or lovers, whom they call
bhalobashai lokh (literally, good
home men), with whom they
formed a marriage-like relation­
ship. At the time the lokh are

present, their women do not
take clients. Some women have
permanent relationships and
give up taking clients altogether,
but continue to live at the
brothel. Some women are the
children of sex workers and were
raised in brothels, and in turn,
many raise their own children at
the brothel. Many send money to
their mothers and other rela­
tives. Tangail sex workers were
not allowed to leave the brothel
at will, and when out, could not
wear any shoes or slippers; if
they did, they would be fined by
the police. This imposition on
their rights was supposed to
ensure they would not sell sex
outside of the brothel. Their chil­
dren were unable to register for
school because they could not
name their fathers.

4’

r~i

Street sex work in Dhaka
Street sex workers are the most
visible of the various types of sex
workers. In Dhaka, they are ubiq­
uitous, found in most areas of
the city, parks, railway stations,
bus and truck stops, cinemas,
markets and shrines. Many other
sex workers operate in Dhaka as
well, mostly out of hotels and
residences that pose as normal
family homes. It is well known
that many university students,
married women from middle­
class families and others supple­
ment their incomes through the
sex trade. These women do not
stand in public places, however,
to acquire their clients, but
instead have agents to bring
clients to them or make appoint­
ments for them to go to specific
sites. Public soliciting to sell sex is
strictly against the law. Street­
based sex workers comprise the
lowest class of sex workers and,
as such, are far more subject to
violence perpetrated by clients,
mastans and police. The police
are generally paid off to allow
them their right to work, with
sex and/or money. Territoriality is
also evident, with some mastans
or pimps fighting for specific
spaces in which the women asso-

Although violence has not been a
major problem at Tangail, sex
workers are heavily stigmatized
by the surrounding community.
Police exercise a great deal of
control. Sex workers are made to
pay extra money to the police if
they take a client for the whole
night. Consequently, few women
have all-night clients. Most of the
time at the brothel there is a rea­
sonably peaceful and sociable
atmosphere, with open court­
yards where women, children,
lovers and friends gather. This
isolated and controlled environ­
ment has afforded certain advan­
tages for the SHAKTI project.
However, it is not typical of all
Bangladeshi brothels, is not sta­
ble, and it certainly is not an envi­
ronment in which sex workers
have adequate control of their
own lives and bodies. Pressure to
earn for themselves, their fami­
lies and their controllers, while
facing eviction and forced reha­
bilitation at any time, makes
safer sex a difficult goal to
achieve. Their lives and liveli­
hoods are literally at the mercy of
political forces well beyond their
control.

At one entrance to Tangail brothel, 1998.

9S

SHAKTI, Bangladesh

ciated with them can work. Most
street sex workers are independ­
ent, in the sense that they decide
to work or not, as they need. A
minority is bonded to a dalal or
pimp, but many make use of
local men on the streets, e.g.
rickshaw pullers, hotel boys,
guards, tea-shop owners, and
others, to find them clients and
then pay them with cash or sex
for doing so. In addition, some
women have men who serve as
their protectors; they may find
them clients and, when needed,
help them avoid the police or
stand as their husbands to seek
their release from police custody.
Some sex workers even have
"station husbands", particular

Family life on
the streets of
Dhaka.

SHAKTI, Bangladesh

policemen who look after them
in exchange fo" sex.

Street sex won; must be seen as
one of the more lucrative street­
based occupations in Dhaka, a
crowded city of 10 million peo­
ple. Male and Transgender (hijra)
sex workers also operate in many
of the same contact venues as do
the
female
sex
workers.
Generally, it apoears the females
have the greatest client num­
bers, hijras next, and males fol­
lowing. In addition to thousands
of paper pickers, beggars, sellers
of flowers, tea, candies, fruits, or
magazines, the streets are the
home to many thousands of
homeless individuals, both single

adults and children as well as
whole families. Some have plas­
tic-covered "humpies" to sleep
and cook in, others do not. Slums
are packed with people and reg­
ulated by local politicians and
their fnastan gangs. Periodically,
the police are instructed to clean
up the streets and hundreds of
women, sex workers and others,
are arrested and placed in
vagrancy homes, where their
treatment is often abusive. Less
often, but more dramatically,
instructions are given to the
army to clear out slums, either by
fire or bulldozer. When this hap­
pens, or when a severe flood
drives thousands of people to
Dhaka from hopeless rural areas,
street sex work increases. About
half of the people in Dhaka live
on little over US$ 1 per day. The
situation is very dynamic and
unstable, creating an extremely
challenging
environment
in
which to carry out a sex worker
HIV intervention.

Relevance
Many Bangladeshis consider
their society to be sexually con­
servative. Perhaps for that rea­
son, among others, most AIDS
prevention
messages
have

97
u*—“

focused on the danger of going
to prostitutes. The number of
sex workers in brothels has var­
iously been estimated as 10 000
to
100000.
The
National
Behavioural Surveillance of
1998, however, surveyed all
brothels and found a total of
only 6584 (Jenkins, 1999a).
Floating sex workers, male,
female and transgender, are
now thought to total up to
100000 in the country as a
whole. One survey has provided
a national estimate of 12 000
hijras with 2000 in Dhaka, most
of whom also sell sex (Jenkins,
1999b). Several early efforts at
research
conducted
with
female sex workers demon­
strated poor knowledge of
STDs and inadequate utilization
of health services. These studies
documented their social isola­
tion and extreme marginaliza­
tion (Ahsan, et al., 1995; Khan
and Arefeen, 1995). CARE is an
organization
dedicated
to
working with the poorest and
most marginalized members of
society. Therefore, the project
was seen as relevant to both
the needs of poor, highly vul­
nerable women and the princi­
ples of CARE.

J

...

Brothel baseline studies
Tangail sex workers were dis­
trustful when first approached
by CARE, as other NGOs had
come, promised various services,
but were never seen again. CARE
personnel, on the other hand,
had never handled a sex worker
project and were uncertain and
nervous in dealing with highly
socially stigmatized women.
After an initial phase of site
selection during the first half of
1996, the project undertook,
with the aid of external consult­
ants, various types of formative
research, including a qualitative
assessment, a quantitative base­
line study on behaviour and
knowledge, and an STD survey.
The entire set-up phase covered
one year, during which advocacy
with those in the power struc­
tures and rapport building with
the sex workers were able to pro­
ceed. A two-room clinic, with
nurse and physician, was set up
at the brothel on land donated
by the Shamaj. Here STDs were
treated, as were other sicknesses.
Confidentiality was maintained
on all records. Those who volun­
teered for the baseline STD sur-

_ ___

.

SHAKTI, Bar idesh

SHAKTI, Bangladesh

Formative Stages

f

vey were given a standardized
clinical examination (n=296) and
tested for HIV, syphilis, gonor­
rhoea and chlamydia. PCR tech­
niques were available for gonor­
rhoea and chlamydia tests
through
collaborators
in
England, while the HIV and
syphilis tests were conducted at a
government facility and later
repeated at the national surveil­
lance laboratories. For blood
sampling, the survey recruited
466 sex workers out of a possible
593. The samples for HIV tests
were unlinked to identifying
information. Verbal consent was
required and cooperative sex
workers helped secure the coop­
eration of others by showing
them how the examination
would be performed, using a
speculum and a medical school
anatomical model. Women with
symptoms were treated.

Important issues were revealed
as a result of the formative
research, some of which the proj­
ect has been able to handle
while others remain unsolved.
First, the levels of clinical signs of
reproductive tract infections
were high, with 63% of the
examined women having cervical
9&

discharge and 32% having vagi­
nal discharge. A further 2% had
ulcers, 6% warts, and 26% had
lower
abdominal
pain.
Laboratory
tests
confirmed
somewhat lower rates, with 19%
positive by PCR for chlamydia,
20% for gonorrhoea, and 18%
for a current syphilis infection
(RPRD 1:8 and TPHA+). No
woman had a positive HIV test
(Sarkar, et al., 1998; Jenkins,
1999c). Tests were not conducted
for other possible causes of dis­
charge or abdominal pain. The
disparity between syndromic
clinical diagnosis/treatment and
the laboratory confirmatory tests
revealed that the standard syn­
dromic management strategy
would only correctly identify
about half (45%) of women with
chlamydia or gonorrhoea as the
others were asymptomatic. In
addition, one-third would be
overtreated because they would
receive treatment for pathogens
they did not have. Nonetheless,
without better treatment or
screening strategies, the brothel
clinic has had no option but to
follow standard syndromic man­
agement guidelines. This issue is
a problem for sex worker proj­
ects in most countries.

One aim of the project has been
to reduce the time gap between
when symptoms are recognized
and when care is sought.
Generally, the women did not
wish to acknowledge current
STD symptoms for fear of losing
clients. At baseline, women with
symptoms waited an average of
7 days before seeking treatment
beyond their own home reme­
dies. When they did seek help, it
was from paramedics, traditional
healers, and medicine sellers,
some of whom do not have safe
injecting practices.
The project aimed at improving
levels of condom use. At base­
line, only 3% of women were
using condoms for all instances
of vaginal intercourse in the last
24 hours. Both oral sex and anal
intercourse were reported as
rare, but were probably underre­
ported due to their shameful
connotation. In the baseline sur­
vey, the women had an average
of 3.5 clients per day; in addition,
they had intercourse, on aver­
age, once a day with their lovers.
Numerous barriers to increased
condom use existed. First, the
women saw condoms as a family
planning device, and 45% had

Fl-t-'^

SHAKTI, Bangladesh

SHAKTI, Bangladesh

I

I

already adopted a mode of con­
traception. Others either wanted
a pregnancy or relied on men­
strual
regulation
(legal
in
Bangladesh) or illegal induced
abortion. At Tangail, 29.7% of
the women had never been
pregnant and, to those who
wanted children, infertility was a
problem. Second, 62% of the
women had lovers. While most
did not live under the same roof
with their private partners all the
time, the position of the lover
was like a husband and they saw
no need to use condoms in their
private relationships. Third, their
clients did not like condoms. The
sex workers feared that if they
asked these men to use condoms,
the clients would think that the
sex workers were infected with a
disease (Sarkar et al., 1997a).
Street-based sex worker
baseline studies
In late 1996 work began among
street-based sex workers in
Dhaka and by mid-1997, a base­
line study was conducted, with a
capture-recapture component to
estimate the population size. The
capture-recapture method yielded
an estimate of 4366 street-based
female sex workers found within

a two-week period (Sarkar et al.,
1997c). Many lived in slums
(37%) while others were home­
less (30%). Still others came into
Dhaka to work from nearby
areas, often during the day only.
More than half (60%) were
divorced or separated, while
21% were currently married.
Most of these women (80%) had
worked in other low-paying
occupations, such as in garment
factories, as domestic servants, in
hotels or restaurants; 20% had
been in brothels. The average
time they had spent in sex work
was 3.5 years (Abdul-Quader,
1997).

The STD study among these
women revealed much higher
levels of prevalence than among
those in the brothel. In a sample
of 247 tested in the same way as
the brothel sample, 48% had
chlamydia, 53% gonorrhoea, and
31% had current syphilis infec­
tions. None had HIV. Almost all
(90%) reported STD symptoms
and on examination, 69% had
vaginal discharge, 62% cervical
discharge and 11% had genital
ulcers. In the previous three
months only 54% of those with
symptoms had sought any treat-

ment at all, mostly from medi­
cine sellers. Most believed that
STDs were avoided by staying
clean.

Few of the women were using
condoms, mostly for prevention
of pregnancy. They reported an
average of 3.5 clients in the past
24 hours and only 14% used con­
doms for more than half of all
intercourse in the previous 24
hours. Only 10% had used con­
doms for all intercourse during
the past 24 hours, but overall
coverage was 18% of all vaginal
and anal sexual intercourse with
any partner the previous day. Ten
per cent of the women were
pregnant while working.

Implementation
Working strategies
The SHAKTI project has had four
major working strategies. These
are:
□ to raise awareness
□ to have repeated contact of
high quality with sex workers

□ to provide the means of
behaviour change (condoms
and STD treatment)

100

101
—*:r--

-J to create an enabling
environment
This approach required mobiliz­
ing support from the power
structures
surrounding
the
brothel, i.e. the local administra­
tion, the police, local opinion
leaders, clients that could be
reached. The project design did
not include training in negotia­
tion of condom use, creative
modes of safer sex or intensive
work with client groups. It never
anticipated the need for a strong
advocacy component, and skills
in this regard were not devel­
oped. As the project proceeded
and events unfolded, new strate­
gies were formed.

Peer education
Peer education has been the
main approach utilized by the
project. This began in August
1996 in the brothel and in 1997
among the street women. After
the mid-term review in 1998, the
manner of handling peer educa­
tion was altered in the direction
of greater sex worker manage­
ment of the project. During the
first few years, a total of 50 peer
educators were trained in the
brothel, with 28 actively working

. .

.... -J.

JS,

SHAKTI, Banaladesh

SHAKTI, Bangladesh

(a ratio of 1 to 20 sex workers).
They were each assigned zones in
the brothel. A zone was made up
of 10-14 apartments. Peer educa­
tors received 50 taka per day and
worked a half-day, once per
week. Their tasks were to visit the
women in their assigned zones,
discuss safe sex, HIV knowledge
and STD treatment, and ask
about condom use in the previ­
ous 24 hours. They also collected
the condom package covers.
Rubbish bins for condom disposal
were first placed in strategic loca­
tions, but later in each room.
Used condoms in the bins were
counted, but somewhat irregu­
larly. These data were recorded
with colour codes on a monitor­
ing map, according to zone and
room, by the peer educators.
Then, the results were summa­
rized on a monitoring board in
the brothel. The process of peer
education reached about 70% of
the women. The remaining 30%
were resistant. As these sex work­
ers were not monitored, they
were not included in the number
who were using condoms at the
first follow-up survey.
On the streets of Dhaka, drop-in
centres were established, a few

at first, then more,-'and by the
end of 1999 there were 8 drop-in
centres at which women could
rest, bathe and access STD treat­
ment, as well as simple general
health care. Peer educators were
paid when they were at the
brothel and assigned spots
around the city at which about
35-40 sex workers could be
reached per peer educator.
The trainers of peer educators,
called field trainers, wore white
laboratory coats and a badge
around the brothel, while the
peer educators themselves wore
a badge and blue apron when
working. This applied to the
street-based peer educators as
well and was copied from the
Sonagachi project in Calcutta.
The field trainers felt they
needed these uniforms to distin­
guish themselves from sex work­
ers, so that clients would not
approach them for sex. While the
peer educators have enjoyed the
status these uniforms give them,
the uniform marked them as
somehow different and distinct
from the other sex workers. The
peer educators in both arms of
the intervention were privileged
with more attention, small

nr.

amounts of cash and other
rewards, such as lessons in liter­
acy. Several made repeated trips
overseas and were often asked
to represent the project at vari­
ous AIDS meetings. Jealousy
among the non-peer educator
sex workers began to grow. The
first step taken to address this
was to drop the use of the blue
uniform at the brothel. On the
streets, the women were able to
use the status symbolized by the
uniform to protect themselves
from police arrest and did not
wish to give it up. Gradually
these
markers
have
been
dropped, and well-trained peer
educators were elevated to out­
reach workers and given small
daily salaries, while a new cadre
of volunteer, unpaid peer educa­
tors was developed.

larly. At the brothel, 21 outreach
workers, 102 peer educators as
well as 29 peer lover educators
were trained and continue to
work under the new scheme. The
number of CARE staff at the
brothel was drastically cut from
14 to 5 with the aim of decreas­
ing reliance on CARE staff and
increasing sex worker manage­
ment of the project.

J

Zk' -J

Hijra peer educators at World AIDS Day
ceremonies. 1998.

Health care
The brothel clinic was staffed by
a female doctor and two nurses,
one male and one female.
Although the doctor was dedi­
cated to helping the sex workers,
she had no specific training in
STD management. In early 1999
she undertook short training
with a clinic group in Dhaka and
later in the year went abroad
for a clinical training course.

By mid-1999, 55 outreach work­
ers and 171 volunteer peer edu­
cators were working on the
streets of Dhaka. These women
reached about 3200 sex workers
on a regular basis for both group
and individual discussions. In
addition, 6 hijra peer educators
and 3 outreach workers were
trained and through them at
least 100 hijras are reached regu-

103

SHAKTI, Bangladesh

SHAKTI, Bangladesh

T_he.5lin'C 'S °peri 5 days a week
HIV and STD recognition and
in the morning from 9:00 to
treatment, but require consider­
13:00. The women were free to
ably more attention. They are
bring their family members for
known to give unnecessary intra­
any illness. STD drugs were given
venous injections of saline or
free, but drugs for other illnesses
other fluids.
were bought elsewhere, with a
prescription provided by the
In Dhaka, CARE's partner, the
clinic. Immunizations were pro­
Marie Stopes Clinic Society, sup­
vided for children by the govern­
plied services for the drop-in cen­
ment health service and special
tres from the earliest days of the
immunization campaign days
intervention,
---------Problems arose
were held. Clients did not have
repeatedly regarding the way in
access to the clinic, but the proj­
which the clinic doctors treated
ect opened the clinic in the
the sex workers. Some covered
evenings to the sex workers'
their
mouths
when
they
lovers. Eventually, technical sup­
addressed the women; others
port for clinic supervision was
were curt and obviously unwill­
accessed through a partner clini­
ing to touch them. The sex work­
cal NGO. Sustainability of the
ers were very sensitive to these
brothel clinic is a major concern
slights and often complained. In
for the sex workers. Through a
addition, the clinic hoped to
workshop, the district health
regain some of the cost of medi­
administration assured them
cine, but it soon became clear
that, if required, they would
that many women were too poor
assign a doctor to the brothel on
to be able to afford the fees.
a routine basis. Plans have been
Repeated meetings with the
made to equip the sex workers
Marie Stopes directors gradually
with skills necessary to manage
led to a deeper understanding of
their own clinic, including an
the needs of these women. The
insurance scheme to cover costs.
fee schedule was altered so that
women now pay only 10 taka to
Medicine sellers, whom the
gain a clinic membership card
women often consult, were
and all other treatment costs are
given four training sessions on
free. As the street-based sex

worker
organization
gained
strength, it has been able to
address the doctors more directly
and this has helped improve doc­
tor-patient interactions. Now
many of the clinic activities are run
by the sex workers themselves.
Empowerment: in the brothel
The baseline survey identified a
number of concerns of the
brothel sex workers and the proj­
ect has attempted to address
these. They were:
J economic stability and
savings
J education, literacy

□ medical services
J freedom of movement
outside the brothel

□ welfare of children

social acceptance, including
burial in Muslim cemeteries

Economic stability has not been
addressed directly. Outreach
workers are paid a small amount
and have voluntarily opted not
to take clients for the few hours
per day that they work as educa­
tors. For a variety of reasons, in

I

104
as

105

1998 Tangail sex workers claimed
that the number of clients had
dropped. It was suspected that
the
high
visibility
SHAKTI
brought the brothel, and the
large number of visitors (nearly
200 in 1997) who wished to see
the intervention, may have con­
tributed to a decreased number
of clients. Project management
stopped all unnecessary visiting,
and from mid-1998 to mid-1999
the brothel was visited only 17
times by outsiders.

Skills training in alternative
modes of supplementing income
began in February 1998. Several
associated local NGOs began to
provide training in embroidery
and sewing to 20 women, with a
view to the sale of goods pro­
duced by the women. Such activi­
ties as sewing, however, cannot
be expected to replace or even
supplement a sex worker's income
and most of the women are little
interested in this approach.
Many women had hired private
tutors prior to the coming of
SHAKTI. Literacy and education
are highly appreciated. Early in
the project SHAKTI initiated a
programme of literacy with the

SHAKTI, Bangladesh

shakti, Bangladesh

peer educators. Forty women
attended but 12 dropped out.
Literate peer educators began
teaching literacy to 60 other sex
workers, but the women lost
interest due to the inappropri­
ate nature of the curriculum. A
new curriculum was developed
through consultation with 8 lit­
erate sex workers and several
project staff, and now includes
issues such as women's rights. A
sub-contract was signed with a
local NGO to run the education
programme as of October 1999.
Most importantly, literacy educa­
tion was made available to all
the sex workers and not just the
peer educators.

The sardanis, bariwallis, and
police exercise considerable con­
trol over the sex workers, espe­
cially
over
the
chhukris.
Independent sex workers are
supposed to ask permission to
leave the brothel and not to
wear shoes or sandals. Chhukris
are never allowed to leave until
their period of indenture is com­
pleted. Chhukris are also not
allowed to have lovers as such an
attachment would diminish the
number of clients they would be
willing to take. Gradually, the
>

peer educators (who are not
chhukris) gained more freedom
to wear shoes out of the brothel.
In the early days of the project,
regular meetings were held with
the gatekeepers of the brothel
and attempts were made to
encourage them to alter some of
their practices. In a few instances,
for example on World AIDS Day,
many women appeared in public
wearing shoes.

the next year, without con­
frontation, they simply appeared
in the activities and nothing was
said. Because considerable fear
still exists that the police, local
politicians or fundamentalist
groups will close the brothel if
the women offend local society,
progress has been slow in chang­
ing the social climate around the
brothel.

The project began with a conflict
resolution model (as opposed to
one that focuses on the rights of
sex workers) in order to convince
those in the surrounding com­
munity (e.g. religious and politi­
cal leaders) that it was not
encouraging illicit sex, only
attempting to increase its safety.
Numerous formal as well as
informal meetings were held
with these groups. This process
was also monitored with indica­
tors and a quarterly assessment.
For the first few years, the proj­
ect carefully avoided taking a
strong stand in favour of the sex
workers. In 1996, sex workers
were blocked by the local
administration from participat­
ing in World AIDS Day activities.
Protests were not lodged, but

After the mid-term review
revealed continuing disagree­
ments about condom
use
among the women, meetings
were held at which the women
were asked what they could
agree upon. They all stated they
wanted to wear shoes out of
the brothel, but the sardanis
did not like this. Although it
altered the non-confrontational
stance SHAKTI had taken ear­
lier, the women were advised to
go out in groups of five with
shoes but without make-up, to
report what happened to the
sardanis, and to wait a few days
to see if the police came to
threaten the sardanis or them.
Within a few months, over 200
women had gone out of the
brothel with shoes without any
mishap and eventually all have

106

107

done so. Now they state they
never realized that the proscrip­
tion against shoes was not a
real law, but was only in their
minds. Staff members had
known there was no legal
aspect to the taboo, but had
never considered it wise to tell
the women, lest they offend the
local society.
In India and Bangladesh, chil­
dren are a major issue in broth­
els. Women want their own or
adopted children, partly to
ensure an income when aged as
well as to satisfy their own emo­
tional needs for nurturing and
attachment. Some sex workers
have been able to educate their
children by sending them away
from the brothel, but most are
unable to do this. SHAKTI has
initiated
coordination
with
another NGO to provide a nonformal elementary school for
brothel
children.
Currently
about 45 children are enrolled.
The partner NGO has purchased
land on which it hopes to build a
training centre for the brothel
children.

Numerous events have taken
place in which selected peer

SHAKTI, Bangladesh

SHAKTI, Bangladesh

educators have made public
presentations about the proj­
ect, both in Bangladesh and in
other nations. Several sex work­
ers
attended
the
Fourth
International Asia-Pacific AIDS
Conference in Manila in 1997
and the Twelfth World AIDS
Conference in Geneva in 1998.
Both sex workers and brothel
keepers (owners and sardanis)
attended the First National Sex
Workers Conference of India in
November, 1997 and the First
Meeting of the Asia-Pacific
Network of Sex Workers in
March 1998. On other occa­
sions, sex workers from Tangail
have attended meetings with
sex worker organizations in
Calcutta, and Calcutta women
have visited Tangail. Picnics,
parties and other gatherings
held by CARE for sex workers
and CARE staff are other
instances in which sex workers
are given a small opportunity
to feel less stigmatized. These
are, however, inadequate to
meet the needs of all the
women in the brothel and
much larger structural changes
to community attitudes and
control will be required before
a sex worker in Bangladesh i

108

could feel equal to any other
woman.

1998 World AIDS Day play performed by'
Tangail brothel sex workers, with their
children.

A small committee of sex workers,
known
as
Mukti Shangho
(Freedom
Committee),
was
formed. The spirit of full participa­
tion, however, was compromised
by the appointment of its leader
by CARE personnel. Eventually, it
became apparent that the com­
mittee was stagnant and unsup­
ported by the sex workers. It was
modified, renamed Nari Mukti
Shangho
(Women's Freedom
Committee), the sex workers
elected the woman they wanted
as leader and the organization
began the process of becoming
formally registered as a social wel­
fare organization. The committee
collects 50 taka as a monthly sub­

scription from its growing mem­
bership, receives 10 taka from
each woman who registers at the
clinic (donated by the partner
NGO which supervises the clinic)
and makes a small profit on con­
dom sales. Meetings are held reg­
ularly at which sex workers can
participate in making decisions
about matters important to their
lives. Leadership, however, contin­
ues to be problematic as the
woman elected was later arrested
and sent to jail. As the brothels of
Bangladesh are nodes of political
contention and local politics can
easily turn violent, growth of the
self-run sex worker organization
continues to be erratic. As of
November 1999, membership
stood at 230.
Empowerment: on the
streets of Dhaka
Many of the problems of street­
based sex workers were quite
different from those of the
brothel women. Many had no
place to bathe, wash their
clothes or even to sleep; others
expressed that their greatest
problem was police harassment.
The barriers to becoming skilled
in practising safer sex included
high levels of mobility, serious

repeated legal problems, moving
in and out of the trade, a large
influx of new women, significant
levels of violence, as well as con­
cerns for their children, health
care, income stability and safety.
Their social status is at least as
low as the brothel women, if not
lower, and their self-esteem
reflects their stigmatization.
However, those who survive
beyond a few years on the
streets are tough and smart.
They are not threatened by sarda­
nis and all-encompassing power
structures, as many are in the
brothels. These women took the
lead and in early 1998 formed the
first street sex worker organiza­
tion,
Durjoy Nari Shangho
("Undefeatable Women's Club").
They began to mobilize street
workers, particularly in a local
fight to re-open a previously
closed brothel in Dhaka City.
From the beginning they saw
their purpose as one of creating
a collectivity strong enough to
demand their rights. These
include legal rights, burial rights,
rights to shelter, education for
their children, rights to safety
from violence, particularly at the
hands of the state, and the right
to make a living. Gradually

109

.. ..-SPA.

.... aJK&SI

SHAKTI, Bangladesh

jj’

<

!

Durjoy formed 6 area commit­
tees with representation to a
central one. They began register­
ing their organization as a social
welfare group. They opened a
bank account into which they
deposit the 50 taka collected
monthly as membership dues.
They took on the distribution of
food, water and medicine during
Dhaka's severe flood of 1998, to
sex workers and their families, as
these women found it very diffi­
cult accessing relief goods at the
regular sites. With the selling of
condoms, the organization also
accrues some earnings.
By
November 1999, membership
had risen to 950 women. Sex
workers manage many of the
drop-in centres that can now
provide space for some women
to sleep, rest and bathe, as well
as to undertake specific types of
training. Both street and brothel
sex workers have received some
basic training in their legal
rights, and several dozen street
workers have received training in
the martial arts as well.

4 turning point
A crucial event occurred in July
1999 that galvanized street and
brothel sex workers alike, and

also shifted the stance of the
SHAKTI project. A young sex
worker named Jesmin at Tan
Bazar brothel was beheaded by a
fake client, an act facilitated by
political forces that were work­
ing to close the brothel. The
police
and
Social
Welfare
Department were mobilized to
help close the brothel in the
name of a rehabilitation pro­
gramme. Violence and gross dis­
regard of human rights ensued.
This brothel and another nearby
named Nimtoli, also similarly
affected by these events, repre­
sented nearly 30% of all brothel­
based sex workers in Bangladesh.
Brothel sex workers throughout
the nation were frightened.
Womens' rights groups and legal
rights NGOs gathered their
forces to defend the brothels.
Both Durjoy and Nari Mukti
Shangho joined, leading the sex
worker contingent, and staged
numerous public demonstrations
and made press releases. Within
a short time, about 80 different
human rights and women's
organizations joined to form a
group called Solidarity to stand
with sex workers against the
government. They met with the
Prime Minister, but she would

1

shakti, Ba^niadesh

not alter the government's plans.
She stated that she believed the
only option for sex workers was
rehabilitation, even though the
women stated clearly that they
did not want to be rehabilitated.
The case went to court.
CARE's stance was simple and
direct. It supported the sex work­
ers in their fight for basic human
rights, and began a stronger
approach to working with gov­
ernment, UN agencies and other
NGOs to bring this about. In addi­
tion to numerous local groups, the
International Network of Sex
Work Projects, Amnesty and
other international agencies
were alerted to the serious prob' ■Jd*'**'*

For weeks in mij-1999 newspapers
carried stories abcut Solidarity, sex
worker groups and \'GOs collectively
seeking protection of sex workers’ human
rights. (Photo: AKM '-lohsin, reprinted
with permission frem the Daily Star?

lems in Bangladesh and rallied
support.

In March 2000, all who worked
on advocacy and networking
among the sex workers and
other concerned groups experi­
enced an astounding victory.
The High Court of Bangladesh
declared that sex work was not
illegal and that the women had
a right to make a living. It fur­
ther declared that state agen­
cies responsible for evicting
women from the brothels had
themselves acted illegally. The
women were instructed that
they could petition the lower
courts to re-open their brothels.
While it is not known how these
events will impact on the future
of the project, the court deci­
sion clearly gives a signal that
human rights, and particularly
the constitutional right to work,
will be protected for sex work­
ers. This decision strengthens
the HIV prevention options for
all concerned.

Condoms
Male condoms were purchased
from a single source by the proj­
ect and given out free by peer
educators. At the brothel, not all

m

SHAKTI, Bangladesh

SHAKTI, Bangladesh

the women accepted condoms,
reportedly because they did not
like being asked how many clients
they had the previous day and
how many condoms were used.
Those who did were supposed to
receive
as
many
as they
requested. However, shortages
and an attempt to control scarce
resources led to complaints by sex
workers that they were not
receiving the number they
needed. In mid-1998 the street­
based intervention only gave out
3 condoms per day to the women,
i.e. the average number of clients
reported during the baseline sur­
vey, and the brothel intervention
gave out 4 per day. Problems had
arisen when the condom distribu­
tor had a labour strike and no
condoms were available. The gov­
ernment would not supply family
planning condoms to these inter­
ventions at the amounts needed.
The future sustainability of the
condom supply was in question.

Eventually, condoms were avail­
able again from the main source
and by October 1998, three con­
dom depots were set up in the
brothel at which women could go
freely to take as many as they
wanted. This alleviated the pres-

sure to ask questions and the 30%
of sex workers who had been
resistant began taking condoms.
Records were kept at the depots
of how many condoms were
taken, but this took the monitor­
ing out of the hands of the peer
educators. By December 1998,
free condoms ceased to be avail­
able at the brothel. By a decision
of the small sex worker-run
organization,
Nari
Mukti
Shangho, a system was set up to
purchase the same condoms at
trade price from commercial
depots in Tangail and sell them
through the peer educators with
a small profit divided between
the sales women and the organi­
zation. Meanwhile, government
condoms began appearing at the
shops around the brothel at prices
lower than those bought by the
sex worker organization. As they
also were better lubricated, sex
workers began purchasing them
directly and to sell to others. Sales
of condoms increased, but with
the variety of possible modes of
access, it became more difficult to
monitor. Figure 1 shows all sex
worker sales monitored.

Among the street sex workers,
sales began and free condoms

stopped being distributed in
February 1999. The street-based
sex worker organization, Durjoy,
was, by that time well organized
and sales increased monthly, ris­
ing from 23 385 in Febuary to
62 900 in August. A small profit
was made by the peer educators
or outreach workers who sold
the condoms and also by Durjoy.
With this money, among other
activities, they set up a trust
fund for the poorest group of
sex workers.
I

Figure 1. Growth in condom sales by sex workers
80
70

□ Brothel

T 60
h

■ Street
______

o 50
u
s 40
a
n 30
d
s 20
10

0
l

6o>

Q

112
~r

During 1998, female condoms
were introduced to both groups
of sex workers on a trial basis
and found generally useful,
especially among the street
women. Due to their high cost
and encouraging reports of safe
re-use with washing, re-use with
washing was also tried, but fears
of misuse prevented project
managers from proceeding fur­
ther with this option. Larger tri­
als are planned after further
research and training takes

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SHAKTI, Bangladesh

place. In addition, a general
demand for water-based lubrica­
tion has led to the development
of a locally-produced product
which is also under trial.

I.

Clients, non-clients and
lovers
From the beginning,
little
emphasis was placed in the
SHAKTI project on the clients of
sex workers. At the brothel these
include traders and other busi­
nessmen, students, truckers, con­
struction workers and others. In
Tangail two AIDS information
centres were set up at a bus sta­
tion and a court in the town of
Tangail, but no targeted pro­
grammes for clients were devel­
oped. Working with the clients
while they are in the brothel is
difficult as they do not wish to be
seen or recognized when enter­
ing the brothel. For this reason
the
brothel
has
several
entrances. The brothel sub-cul­
ture is set up for profit and the
protection
of
clients
and,
although brothel keepers have
stated they are concerned about
the loss to business that a rise in
HIV would bring, concrete solu­
tions to these issues have not
emerged. Discussions with the

SHAKTI, Bangladesh

brothel keepers, as well as
selected other stakeholders, i.e.
religious leaders and municipal
personnel, have continued. To
date, only awareness workshops
have been held with some client
groups.

The study provided the project with infor­
mation on types of clients, as well as other
data, and gave the sex workers insight
into the practice of research. It clearly
demonstrated that illiterate women could
conduct valuable research themselves,
with minimal technical supervision.

Street sex worker clients were
enumerated in a study carried
out in November-December 1998
by sex workers themselves. At 22
locations around Dhaka on one
different day each week (during
7 successive weeks), thirty mem­
bers of the Durjoy Nari Shangho
interviewed five sex workers per
day (every second one they met).
Responses were recorded on a
pictorial sheet. In total, for 923
sex workers, data were collected
about 4654 different clients. The
proportions of men in different
occupations are shown in Figure
2. Rickshaw pullers were the most
frequent, followed by a category
called "service holders" which, in
Bangladesh, means men who
hold wage jobs, such as govern­
ment and private sector posi­
tions, and students. In this study,
police were listed as clients but
either paid nothing or very little,
as they were often simply given
sex in exchange for protection.

Figure 2. Clients of street-based sex workers in Dhaka, 1998

114

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The sex workers' long-term lovers are
important men in the brothel. Although
some are abusive and exploitative, most of
the women value their relationships with
these men. Many of the lovers pay the
rent, buy them food and clothing, and

115

'-•NK

SHAKTI, Bangladesh

SHAKTI, Bangladesh

help with their children. In
February 1998, a study was carried
out, showing that, among 233 of
these men, 14% were permanent
residents of the brothel and 56%
visited for only one or two days at
a time. About 30% of women in
the brothel had claimed they did
not need to use condoms as they
took no clients and remained
faithful to their lovers, but project
staff disputed this. The study,
however, seems to corroborate
this, with 28% of the men stating
their women took no clients. In
the three months prior to the sur­
vey, 16% of lovers reported hav­
ing had sex with another sex
worker in the same brothel and
16% with a sex worker outside
the brothel. In addition, 60% had
wives. If it is true that about 30%
of sex workers were really taking
no other clients than their long­
term lovers, it is also true that
these sex workers, as well as the
others, were at risk from their
lovers' multiple sex partners.

Street sex workers have long­
term boyfriends or husbands too
but they also are often coerced
into giving sex in exchange for
protection. Pimps, guards, rick­
shaw pullers, police and mastans,

among others, demand sex from
these women. According to the
survey in October 1999, 36% of
women gave sex in exchange for
protection (or some other favour)
without pay the previous week,
while 61 % had had sex with their
own private partners. Condom
use differed accordingly, with
32% of sexual acts covered
among the casual or coercive
partners and only 18% covered
with longer-term, private part­
ners. Overall, 23% of sex acts the
previous week had been covered
by condoms with men who were
not paying clients.
Another survey among these
women in 1998 revealed that
13% had at some time injected
drugs, as had 24% of their main
partners, far higher levels than
among brothel women and their
men (Jenkins, 1999a). In addition
these women more often sold sex
to men in groups, either for serial
or simultaneous group sex, than
did the brothel women. In most
cases, group sex is riskier because
the woman's capacity to control
her safety is reduced and the men
may be exposed to the semen of
other men as well. In both 1998
and 1999, about one-quarter of

116

the women sampled had hired
themselves out to a group (aver­
aging about 4 men) the previous
week, and over half had done so
the previous month.

Monitoring and
Evaluation
During the first few years of
SHAKTI, peer educators con­
ducted most of the monitoring of
changes in knowledge, intent,
trial and use of condoms. After
the mid-term review, other modes
of data collection were added.
Biannual surveys conducted by
independent interviewers were
put in place, and, after condom

Figure 3. Harassment of street sex workers, Dhaka (average
proportion harassed weekly, 1998-1999)

16 T' !

14 12 -

%

8 6 -

4 ' i
2

0

‘

n Police
□ Mastan
□ Client

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10 -

I

ii
Beaten

I

Raped

J
Robbed

117
'SHT’’"'

sales began, the number of con­
doms sold was monitored. In mid1998, new indicators on violence
among street-based sex workers
were developed. Data on the pre­
vious week's harassment were col­
lected at 444 group education ses­
sions among 4,750 women in the
drop-in centres between Sept
1998 and October 1999. With con­
tinuing collection of these data,
shown in Figure 3, such an indica­
tor could demonstrate a reduc­
tion (or increase) in violence over
time and any impact the project
might have on securing greater
safety for sex workers through
advocacy and better communica­
tion with street mastans.

J
Violence

S!

---- MgULJI

SHAKTI, Bangladesh

SHAKTI, Bangladesh

■

■

The SHAKTI project has always
devoted much effort to monitor­
ing its own activities. Although
at times changes were made that
make comparisons difficult, over­
all the sampling and attention to
accuracy, data management and
analysis were adequate to pro­
duce a clear picture of changing
behaviour, major barriers to
greater success, and the impact
of attempts to break those barri­
ers. One area in which monitor­
ing was not fully adequate was
the changing composition of the
target groups, a lesson for the
future. Nonetheless, the atten­
tion to monitoring and research
has made it possible to docu­
ment the project very well, pro­
ducing numerous presentations
at international meetings and
several useful publications.

I
4

4

28% to 64% and the trial of a
condom within the last 24 hours
rose from 12% to 59% (Sarkar et
al., 1997b). Self-reported 'consis­
tent' condom use rose from
about 14% to 28% (consistency
was interpreted as 50% or more
of all intercourse with clients
during the previous 24 hours).

80
70

■ with clients
last 24 hrs
□ with private
partners
last week

60
50

Surveys conducted in 1998 and
1999 separated questions about
sex with clients and private part­
ners more precisely than had
been done earlier, using both the
previous day and the previous
week as recall periods. These
showed a clearly rising trend in
condom use. Figure 4 illustrates
the trend in condom use among
the women at Tangail.

%

US
• ■■ -

.

40
30
20
10

0

Jun 96

J

Jun 99

Nov 98

shifts in the resident population as
well as reliance on syndromic man­
agement in a group of women
with high STD prevalence, pro­
duced no significant reduction in
STD levels at the time of the mid­
term evaluation in April 1998.
Figure 5 shows some changes in
the composition of the brothel
through time. The number of
bonded sex workers (chhukris)
continued to rise until 1999, as did
the number of those under 18. A
survey started in July 1999 was sus­
pended for a month and finished
in September due to trouble in the

Changes in composition of the
brothel population continued over
time. For several years the number
of young women under 18
increased, until 1999, when a
severe crackdown took place in a
nearby brothel and panic spread.
Towards the end of 1999, the gov­
ernment announced that all
brothels would be closed and the
women rehabilitated. While it may
be doubtful that this goal will be
accomplished, the combination of

Effectiveness
The peer educators collected
monitoring data that showed,
after 14 months (as of October
1997), knowledge that STDs can
be prevented through the use of
condoms rose, as did intent, trial
and reported condom use.
Knowledge of the value of con­
doms rose from 36% to 87%. The
intent to use condoms rose from

t

Figure 4. Trends in condom use (proportion of acts)
in Tangail brothel, 1996-1999

brothel. Violence at nearby broth­
els as well as at Tangail evoked
police raids and some arrests.
Results of the survey showed that
the number of bonded women
had been reduced, young sex
workers were fewer and, accord­
ingly the number of clients on the
previous day was seriously dimin­
ished. Nonetheless, clients still pre­
ferred the bonded young women.
At that time, 52% of independent
sex workers had been without
clients the previous day, while only
11% of chhukris had had no
clients.

U9

SHAKTI, Bangladesh

SHAKTI, Bangladesh

Figure 5. Changing composition of residents atTangail brothel

monitoring the changing composition of
the street-based sex worker population
ever evolved. The prevalence of current
syphilis (TPHA+ and RPR=>8) did not shift
between surveys in 1997 and 1998, with
32% and 34% respectively. It is difficult
to understand if this was because the
clinic work and condom use really failed
to reduce the prevalence of syphilis or if
the women accessing the clinics were
constantly changing.

45 Yl
40 35 -

■ <18 years old

30 -

%

i

25 -

I

20

i
j
i

bonded
no clients
yesterday

1

15
10

The earliest survey estimated about 4,300
street-based sex workers in Dhaka but
continued estimates have not been

0 Jun-96

Apr-98

Nov-98

Jun-99

Among the Dhaka street sex workers, the
baseline survey did not question use with
non-paying partners in a clear manner,
but between 1998 and 1999 condom use
with private and other non-paying part­
ners improved. Results of surveys over
time show a clear improvement in use
with all types of partners. Figure 6 illus­
trates these trends.

While the average age of those sampled
remained about 22 to 23, the proportion
under 18 dropped from 25% to 14%, and
the average number of clients per week
rose between 1997 and 1999 from 13 to
18. The sex workers reported many new
women appearing on the streets during
the 1998 floods and again after the Tan
Bazar brothel was closed. No method of

120

Figure 6. Trends in condom use, 1997 to 1999 (proportion of
acts) among street-based sex workers in Dhaka
60

50

with clients last
24hrs

40

D with private
partners last week

30

I

20

10
0

Jan-97

Nov-98

Oct-99

121

SHAKTI, Bangladesh

SHAKTI, Bangladesh

J.

f

made. The situation is very fluid,
with many women shifting from
hotels to streets, or from city to
city, and in and out of the trade.
The actual number visible at any
one time appears to be highly
influenced by police activity, but
it is clear that the women either
find new venues or remain inac­
tive for a while when police
activity is high. Poverty, illiteracy,
lack of remunerative options and
high rates of abandonment by
husbands place many women at
risk of turning to the street sex
trade for sustenance. Despite
their many levels of vulnerability,
street sex workers associated
with the SHAKTI project have
demonstrated remarkable capac­
ity to take control of their sexual
health.
Efficiency
The excellent infrastructure of
CARE, Bangladesh, CARE'S largest
mission, has certainly played an
important role in facilitating the
operation
of
the
project.
Nonetheless, the project suffered
in efficiency largely due to the
lack of experienced personnel at
all levels and the continued need
for training. SHAKTI was the first
targeted intervention with a

i

well-conceived
.^behavioural
change model specifically for sex
workers in Bangladesh. Training
of staff improved through the
years with the addition of a
newsletter, a journals club and
increased access to reading
materials translated into Bangla.
Nonetheless, repeated distur­
bances created by local politics
and shifts in management were
major factors that limited effi­
ciency. Scaling up to cover all the
nation's brothels through part­
nerships with other NGOs had
been planned but lack of fund­
ing, expertise, and, in the end,
government's threats to close all
brothels, have worked against
this plan.

Ethical soundness
Sound ethical procedures were
put in place during the extended
period of formative research.
Confidentiality, non-coercive and
informed consent processes and
de-linking of HIV samples were
practised. All treatable infections
diagnosed during STD surveys
were treated. However, in the
case of some STDs, results were
slow to reach the brothel due to
sending the samples overseas for
processing. Better collaboration

122

with local laboratories has solved
this problem.

Planning for the needs of HIV­
positive sex workers has also
arisen as an issue that the project
never clearly considered in its
early phases. A small support
group for positive people has
evolved within the framework of
the SHAKTI project, and plans to
support its growth have been
made.
Replicability and
sustainability
Throughout the life of the proj­
ect, the AIDS programme of the
Government of Bangladesh has
been associated with SHAKTI in
numerous ways. The Tangail
brothel and the street sex worker
clinics have been included as sen­
tinel sites in the National HIV
Serosurveillance.
Replicability
through other NGOs will, how­
ever, require investment on the
part of donors or government.
Sustainability specifically of
SHAKTI's sex worker interven­
tions is considered achievable
through the enhancement of
skills among the sex workers
themselves. Investment for the
last year of the project is aimed

123

at building capacity within the
self-run organizations of sex
workers for leadership, manage­
ment, and monitoring. Continued
aid to these organizations will
certainly be
required,
but
increasing numbers of functions
have been taken over by sex
workers.

Lessons Learnt
One of the most important les­
sons learnt in this project has
been that, even in a very con­
servative society, sex workers
can be reached with a sexual
health intervention in a nonjudgmental way with previously
inexperienced staff. A step-bystep approach to behavioural
change, with condoms sold
by the sex workers them­
selves, has worked to improve
condom use. Monitoring of con­
dom use and sales by the sex
workers has contributed to their
involvement in the outcome of
the project. SHAKTI was a welldesigned project, informed
by theory and epidemiology,
a factor which has helped hold it
together through several changes
of management and personnel.
Considerable investment in

SHAKTI, Bangladesh

SHAKTI, Bangladesh
I

monitoring and documenta­
tion has paid off in numerous
ways for the project.

The basic approach of the
SHAKTI project is clearly replica­
ble, with adjustments. There is
now a vision of sustainability
through a sex worker-run
project that has evolved due to
the efforts of the sex workers
themselves to band together for
strength and safety. Protecting
the human rights of sex
workers has galvanized staff
and sex workers alike and
helped them to understand the
conditions needed to ensure
long-term HIV prevention. Their
empowerment has become a
principal aim of the project
because it is clear that sustain­
able operation of clinical services
and an outreach programme will
be best motivated by the women
themselves. Skills in advocacy
have emerged as a much-needed
capacity when working with
highly marginalized groups.

The lack of evidence for a drop
in STD prevalence illustrates the
need for regular monitoring
of the changing composition
of a dynamic target group

124

and the value of an indicator
■that will measure the frequency
of contact with the intervention.
It may also reflect the lack of
adequate training for service
providers and the inadequacy
of syndromic management
alone in a group with high lev­
els of STDs. It surely also reflects
the continued lower level of
condom use with ’regular part­
ners, a serious issue requiring
sensitive approaches and better
interactions with the men
associated
with
these
women.

!
I

The SHAKTI project illustrates
many of the problems faced by
sex worker interventions in most
nations and a flexible, sex
worker-focused approach to
solving them.

The problems faced by the
SHAKTI, project emphasize the
need for developing expert­
ise among staff through con­
tinued training and practice.
As environmental, social and
political conditions are con­
stantly changing, the project has
had to be flexible to survive.
Meeting the needs of sex work­
ers could not be accomplished by
a single project, but has required
the building of alliances with
partners that have won victo­
ries for sex workers far
beyond
the
immediate
expectations of the project.

125

fl

I

SHAi^i i, Bangladesh

SHAKTI, Bangladesh

j

References
1997 Abdul-Quader, Abu.
Women in Need: Street-based
Female Sex Workers in Dhaka
City. CARE, SHAKTI Project
Report, July 1997.

■
■

I

1999c Jenkins, C. Resistance to
condom use in a Bangladesh
brothel. In: Caldwell, J, Caldwell,
P, Anarfi, J, Awusabo-Asare,
K, Ntozi, J, Orubuloye, IO,
Marcke, J, Cosford, W, Colombo,
R, and Hollings, E. (eds.)
Resistances to Behavioural
Change to Reduce HIV/AIDS
Infection in Predominantly
Heterosexual Epidemics in Third
World Countries. Health
Transition Centre, Australian
National University, Canberra,
1999, pp. 211-222.

2000 Azim, T, Bogaerts, J, Mian,
M, Islam, M, Sarker, M, Fatteh,
K, Simmonds, P, Jenkins, C,
Chowdhury, MR, and Mathan,
VI. Prevalence of HIV and
syphilis among high risk groups
in Bangladesh. AIDS 14(2) 210211.
1999a Jenkins,C. Sex workers in
Bangladesh - Results of the
National Behavioural
Surveillance 1998.
Paper presented at the 5th

I

i

1999b Jenkins, C. Hijras and HIV
Risk: Transgender Communities
in Bangladesh. Abstract of paper
presented at the 5th
International Conference on
AIDS in the Asia Pacific Region,
Kuala Lumpur, Oct.

1995 Ahsan, RM, Ahmad,
N, Eusuf, AZ and Roy, J.
Prostitutes and their
environment in Bangladesh:
A geographical perspective.
Seminar proceedings:
Commercial Activity, Women
and Ecology. International
Geographical Union/Bangladesh
Geographical Society. Nov 1994,
Rajendrapur, Centre for
Development Management,
Dhaka: Grafosman.

&

(
I

International Conference on
AIDS in the Asia Pacific Region,
Kuala Lumpur, Oct.

1995 Khan, ZR and Arefeen, HK.
The Health Status of Prostitutes
in Bangladesh. Study Report.
Dhaka Centre for Social Studies,
University of Dhaka.

j

I

I

I

I

I
1

I

I
I

I
I

I

I
I

1997a Sarkar, S, Durnadin, F,
Jana, S, Hassan, R, Hoque, E,

126

I
j

Quddus, MA, and Islam, N. A
community-based survey of
commercial sex workers (CSWs)
in a brothel of Bangladesh on
knowledge, intent, trial, and
practice for use of condom.
ASCON VI (Sixth Annual
Scientific Conference,
International Centre for
Diarrhoeal Disease Research),
Bangladesh. Programme and
Abstracts, Special Publication No
57, p. 37.

city of Dhaka in Bangladesh.
Proceedings of the 4th
International Congress on AIDS
in Asia and the Pacific, Manila,
Oct, Abst. # A(P) 071, p. 184.
1998 Sarkar, S, Islam, N,
Durandin, F, Siddiqui, N, Panda,
S, Jana, S, Corbitt, G, Kipper, P
and Mandal, D. Low HIV and
high STD among commercial sex
workers in a brothel in
Bangladesh: scope for
prevention of a larger epidemic.
International Journal of STD and
AIDS 9:45-47.

1997b Sarkar, S, Durnadin, F,
Quddus, MA, Chowdury, FK,
Islam, N, and Mandal, D.
Preliminary results on
effectiveness of peer outreach
intervention on condom use
among commercial sex workers
(CSWs) in a brothel of
Bangladesh. Proceedings of the
4th International Congress on
AIDS in Asia and the Pacific,
Manila, Oct, Abst. # C(O) 060,
p. 118.
1997c Sarkar, S, Durnadin,
F, Quader, AA, Hoque, E,
Mandal, D, Ahmed, YH, and
Islam, N. Estimation of number
of street based female
commercial sex workers (CSWs)
and their HIV situation in the

127

The Joint United Nations Programme on HIV/AIDS (UNAIDS) is the leading advocate for global
action on HIV/AIDS. It brings together seven UN agencies in a common effort to fight the
epidemic: the United Nations Children’s Fund (UNICEF), the United Nations Development
Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations
International Drug Control Programme (UNDCP), the United Nations Educational, Scientific and
Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Bank.
UNAIDS both mobilizes the responses to the epidemic of its seven cosponsoring organizations
and supplements these efforts with special initiatives. Its purpose is to lead and assist an
expansion ofthe international response to HIV on all fronts: medical, public health, social,
economic, cultural,political and human rights. UNAIDS works with a broad range of partners governmental and NGO, business, scientific and lay - to share knowledge, skills and best practice
across boundaries.

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