UCL Discovery

Abstract

Background: Interventions targeting female sex workers (FSWs) are pivotal to HIV prevention in India. Societal factors and legislation around sex-work are potential barriers to achieving this. In recent years several high profile closures of red-light areas and dance bars in India have occurred. In this thesis I describe the effects of the demolition of Goa’s red-light area on the organsiation of sex-work, HIV risk environment, and implications for evidence-based HIV prevention. Methods: The pre-demolition phase was a detailed ethnographic study. The early post-demolition phase included rapid ethnographic mapping of sex-work in the immediate aftermath. The late post-demolition phase was a cross-sectional survey supplemented by an in-depth qualitative study. 326 FSWs were recruited throughout Goa using respondent-driven-sampling, and completed interviewer-administered questionnaires. They were tested for sexually transmitted infections (STIs) and HIV. Results: The homogeneous brothel-based sex-work in Goa evolved into heterogeneous, clandestine and dispersed types of sex-work. The working environment was higher risk and less conducive to HIV prevention. Infections were common with 25.7% prevalence of HIV and 22.5% prevalence of curable STIs. Women who had never worked in Baina, young women, and those who had recently started sex-work were particularly likely to have curable STIs, a marker of recent sexual risk. STIs were independently associated with young age, lack of schooling, no financial autonomy, deliberate-self-harm, sexual-abuse, regular customers, streetbased sex-work, Goan ethnicity, and being asymptomatic. Having knowledge about HIV, access to free STI services, and having an intimate partner were associated with a lower likelihood of STIs. HIV was independently associated with being Hindu, recent migration to Goa, lodge or brothel-based sex work, and dysuria. Conclusions: Tackling structural and gender-based determinants of HIV are integral to HIV prevention strategies. Prohibition and any form of criminalisation of sex-work reduce the sex workers’ agency and create barriers to effective HIV prevention.

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