Grassroots-level advocacy by community organisations, collectives and networks has been central to AIDs awareness and control in India. The government too plays an important role. Yet, as Jo Krishnakumar discusses here, the government’s well-intended actions can sometimes be counter-intuitive and counter-productive, negatively impacting decades of carefully created awareness.
The AIDS discourse has professed that women in sex work are at greater risk to HIV infection than other categories of women. However, despite this opinion, as a category of people, they have been considered dispensable ~ National Network of Sex Workers India, 2019
A promotional film released by the Andhra Pradesh State AIDS Control Society (APSACS) in 2020 has caused a recent furore among sex workers in India. The short film (2 mins approx.), intended to challenge stigma and promote preventative measures against HIV/AIDS, ends up further stigmatising two AIDS-vulnerable groups: sex workers and truck (lorry) drivers. This is a particular blow to sex worker-led collectives working on the ground (Image 1) who have been disseminating critical health information for decades. M. Sivalakshmi (Amma Services and Development Society, Andhra Pradesh) put it succinctly (in Telugu; translated R. Meera):
Decades of work [has been] left unheard in one ad[vertisement].
India and HIV/AIDS Prevention Programmes
India’s approach to HIV/AIDS intervention is structured through a framework that operates at both national and state levels, aimed at preventing new infections, providing treatment and reducing stigma. Led by the National AIDS Control Programme (NACO), the programme is currently in its sixth phase. Phases 1 to 5 focused on scaling up prevention, regular testing and treatment services across the country — during these phases, lower HIV prevalence has been associated with safe sex practices employed by sex workers.
WHO guidelines from 2012 evidence that ‘early interventions in countries as diverse as Brazil, India, Kenya and Thailand have succeeded in reducing STI [sexually transmitted infection] transmission in sex work by increasing condom use, leading to improved health outcomes for sex workers and rapid control of HIV and STI epidemics’, indicating that where sex workers can negotiate safer sex, HIV risk and vulnerability can be sharply reduced. A key reason for this is stigma reduction, and for sex workers to feel safe to negotiate the terms of sex. For example, in Calcutta, condom use among sex workers rose from 3 per cent in 1992 to 90 per cent in 1999 due to early peer intervention in the Sonagachi Project, showing the dramatically positive effect on public health when sex workers are aware, and in control, of their sexual health.
Phase 6 focuses on a grievance redressal mechanism to address stigma and discrimination so that individuals affected by HIV/AIDS (the ‘key populations’ — sex workers, people suffering from drugs/substance abuse, men who have sex with men, transgender people, pregnant people, adolescent men and boys, and incarcerated people) are not marginalised in various settings, including healthcare and workplaces. Community empowerment is particularly associated with a significant increase in condom use and access to health services.
At the state level, interventions are meant to be tailored to address local epidemiological contexts and specific needs. State AIDS Control Societies (SACS) programmes involve partnerships with non-governmental and community-based organisations to deliver services like awareness campaigns (Photo 1), testing and direct care. Collectives that form the National Network of Sex Workers, for example, are a crucial part of these Targeted Intervention programmes and are the reason many key populations have direct access to the care to which each individual in the network has a right.
More Stigma than Prevention
It is in this wider context that APSACS has been producing short promotional films (2 minutes approx.) to raise awareness of different aspects of AIDS prevention and stigma.
One of these films, the subject of this post, is based on a truck driver and a sex worker’s conversation when he hires her services for the night. As the sex worker gets into the passenger seat and they make their way to the adda (a place to hang out), she reaches out to look at a photo of his daughter kept precariously on the dashboard, which he immediately pulls away from her (Image 2). This begins a conversation: the driver is portrayed as a man who ‘cares’ for her by asking her to consider not doing sex work after noticing a bruise on her hand; the sex worker responds by speaking of the emotional and financial distress her father put the family in when he had sex with multiple sex workers, leading to an HIV infection.
It is unclear whether the sex worker’s father is dead or whether he left the family. In any case, the sex worker mentions homelessness as the reason that drove her to start working. The film ends with the driver dropping her off in the middle of the street (unsafely, might I add) before reaching the adda as he is overcome with guilt looking at the picture of his daughter, and thus choosing not to engage in a sexual relationship that night.
There is a lot to unpack here. On Facebook, the film is accompanied by the phrase ‘Love needs responsibility, protection needs a condom! Safe relationships are the path to a healthy future. Prevent HIV and STIs by using a condom every time.’ The film, however, focuses much less on safety and prevention using condoms, relying instead on abstinence as the cure to HIV— an approach that has been critiqued by scholars and activists alike. According to R. Meera (WINS):
The narrative focuses on sex workers and truck drivers as key groups in transmission. The core message about safe practices is lost in debates over abstinence and moral judgments. The focus on abstinence, rather than more practical prevention methods (like safe sex practices), can indeed be counterproductive, especially when it fails to address the realities faced by at-risk populations. By giving a false sense of security to others who may be having unprotected sex with multiple partners (not sex workers and truck drivers). It is not at all focusing more on the health and prevention aspects. There’s a tension between addressing structural issues and concentrating on individual behaviour change.
What is also curious is that at the beginning of the film, a friend of the truck driver is seen teasing him because he will be seeing a sex worker, which lends the impression that he has been using sexual services for some time. This begs the question of why he is having this conversation and moral dilemma with this particular sex worker. The melodramatic juxtaposition of the driver with the sex worker’s father, and the sex worker with the daughter of the driver, frames both individuals as people who can surpass the risk of HIV as long as they abstain from sexual intercourse and are moral. The scene, as I mentioned before, ends with him dropping her off in the middle of the road. Bear in mind, street-based sex workers are some of the most vulnerablised communities. Sivalakshmi observes (in Telugu; translated R. Meera):
The awareness among sex workers is high. The advert ignores this fact and spreads stigma. It should have focused on correct scientific information. The way the story has been shown, it looks as though if a lorry driver meets a sex worker, he will get HIV because of the sex worker. This is wrong.
As Sivalakshmi says, the stereotypical view that sex workers are the primary cause of HIV is incorrect, and steeped in stigma. The majority of HIV infections in the country occur during unprotected heterosexual intercourse among the general population. In fact, HIV among women in sex work has been declining: in 2018, UNAIDS estimated that across India, over 91 per cent of sex workers used condoms, and no more than 1.6 per cent of Indian sex workers had HIV/AIDS, a drop from 2.75 per cent in 2013.
A film like this makes it seem that visiting a sex worker is the primary reason for the spread of HIV, and thus the destruction of families. A consultation with key populations portrayed in promotional films by an organisation that is meant to work for them could obtain a better result rooted in lived experiences. If the film moved on from melodramatic and moralistic imagery, it could have not just portrayed both professions with respect (aligned with NACO’s priorities in Phase 6) but also promoted safe sexual practices that address structural change, while not further stigmatising communities.
The 2012 WHO guidelines show that the decriminalisation and destigmatisation of sex work have a direct link to the reduction in HIV transmission and increased health services and human rights for sex workers. Moreover, one recommendation is to make sex workers’ groups and organisations essential partners in the designing, planning and execution of health services and any advocacy materials that talk about them.
One sentence in the film though does make sense — when the sex worker scoffs and says, almost as though reflecting the effect of a film like this on an already marginalised population, ‘[you are] acting as if you care about me!’
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Banner image © Amma Community Based Organisation (CBO) Peer Leaders during an HIV Intervention Programme, 28 May 2024, Kanchikacherla, NTR District, Andhra Pradesh; used with permission by Author.
