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Photo: Nick Rain for ESCAP
Far from society – close to HIV:
Working with Uzbekistan’s sex workers
(Sabo Tashkent City Women and Children Centre,

   Central Asia is credited with the dubious distinction of having the world’s fastest-growing
   HIV/AIDS epidemic. In 2001 the number of documented HIV cases in Kazakhstan and
   Uzbekistan increased three-fold in comparison with the year 2000, and according to unoffi-
   cial estimates, the number of people living with HIV/AIDS in the five Central Asian countries
   – Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan – was about 35,000 in
   2002.1 A severe lack of government resources has prevented countries in this subregion
   from implementing prevention measures for HIV/AIDS, especially for high-risk groups. In
   addition, a cultural reluctance to openly address issues such as drug abuse and changes in
   sexual norms, perpetuates and compounds the HIV/AIDS problem.
   Uzbekistan is the most populous of the five Central Asian Republics. Reports indicate that in
   2002 between 1,000 and 2,000 people were HIV-positive.2 A sudden surge is paving the way
   for an imminent epidemic, unless urgent action is taken immediately.
   Founded in 1998, Sabo Tashkent City Women and Children Centre focuses on HIV/AIDS
   prevention programmes and social and health services for youth and high-risk women,
   particularly for sex workers. With the help of peer educator volunteers, Sabo provides
   information, education and counselling programmes, legal aid, and contraceptives.

A burgeoning epidemic: The state                    epidemic with the majority of drug users and
                                                    sex workers in the subregion aged under 30.3
of HIV/AIDS in Central Asia                         At the same time, the proportion of sexually
                                                    transmitted infections (STIs) such as syphilis
Central Asia is perfectly situated for a mas-       and gonorrhoea, have increased 100-fold
sive HIV/AIDS epidemic.         The explosive       since 1991 – presenting increased risks for
growth of HIV experienced by many of the            HIV infection.4
Central Asian Republics is unfolding against
a complicated backdrop of political upheaval,
economic crisis, rapid social change, increas-      Uzbekistan: Nascent spread of HIV
ing unemployment and poverty, and changes
in sexual norms. The surge of injecting drug        The spread of HIV in Uzbekistan is at an
use and a growing sex industry are major            early stage. As in many neighbouring Central
drivers of the epidemic across the subregion.       Asian countries, HIV prevalence among the
Young people are particularly hard-hit by the       adult population in Uzbekistan has not yet

 40                              HIV/AIDS Prevention, Care and Support: Stories from the Community
exceeded the rate of 0.1 per cent.        Yet,    through unprotected sex. Some sex workers
evidence is mounting that the country is ripe     report every third client refusing to use a
for a full-blown epidemic: In the first six       condom.9 With the number of sex workers
months of 2002, 620 new infections were           estimated to be between 10,000 and 15,000
registered – almost as many as the total          in Tashkent alone, the cause for concern is
number for the previous decade. The highest       great.10
number of cases has
been      identified in                                                  A ray of light
Uzbekistan’s capital,       Oksana* can’t afford safer sex  11
Tashkent, the coun-                                                      and an open
try’s largest city.5
                            Young, bright-eyed and hopeful, Oksana       door
                              came to the western city of Nukus, a rap-
Injecting drug use ac-        idly growing city of the autonomous republic    Today, Sabo is a busy
counts for 71 per cent        of Karakalpakstan, three years ago to study     community centre with
of new HIV infections         at the university. However, her application
                                                                              20 staff members and
                              was rejected. In the desperate economic
in Uzbekistan.6 Par-          climate, she was unable to find employ-
                                                                              20 volunteers. Sabo
taking in drugs and un-       ment. She has been working as a sex             began as a small-
safe sex seems to be          worker ever since.                              scale project. The
an integral part of the                                                       founders, among them
                              “I came here from a remote village, and I       doctors and teachers
subculture       among        have only recently learned what AIDS is
young people between          and how it is transmitted,” she said. “I        experienced in social
15 and 29 years of            don't know if I have this disease, but I'm      and education work,
                              too scared to go for an HIV test. Not one       had almost no fund-
age, who comprise
                              of my clients has ever practised safe sex.”     ing.
more than one-fourth
of the population.7 At        Oksana is not alone. Doctors at the Nukus
                                                                              “But we had extensive
the same time, igno-          branch of the Centre for Reproductive
                              Health have concluded that the majority of      life experience and the
rance about how to            sex workers are at extremely high risk, as      desire to change soci-
contract HIV and other        their clients are not using condoms. Many       ety for the better,” re-
STIs is relatively high,      of them know nothing about the symptoms         calls Tadjikhon Saidi-
particularly     among        of sexually transmitted infections or ways to
                                                                              kramova, chairperson
youth. According to a         prevent the infections.
                                                                              of Sabo’s coordination
2001 survey, one-third        Sex workers in Nukus fear that potential        council. At first the
of young women aged           clients will pay much less if they insist on    group provided sexual
15 to 24 had never            condom use. As the going rate for one
                              session can be as little as US$ 3, the sex      and         reproductive
heard of AIDS.8               workers are not inclined to further lower       health        education
                              their prices.                                   and HIV/AIDS-related
Condoms are                                                                   knowledge      to   stu-
                              * not her real name                             dents, housewives or
important!                                                                    people entering mar-
Condom use is uncommon in Uzbekistan,                  riage. Soon Sabo staff identified the need to
including among sex workers.          Conse-           focus on HIV/AIDS prevention efforts, particu-
quently, a high proportion of sex workers              larly for sex workers because they are among
contract sexually transmitted infections. Up           those most at risk and most marginalized in
to 30 per cent of sex workers also inject              Uzbek society. The centre now serves over
drugs. For sex workers and their clients,              400 sex workers per month with medical
the biggest risk of contracting HIV is                 service, counselling or outreach work.

Far from society – close to HIV: Working with Uzbekistan’s sex workers                           41
                                                       HIV/AIDS and other infections (see box,
   “Uzbek laws are undefined regarding sex             page 65).
   work and liability for engaging in sex work
   is not clearly established. But public opinion           “We have won the trust of sex workers”,
   is clearly established, condemning women                 says a Sabo volunteer, acknowledging
   for frivolity with men and blaming them for              that this serves as a precondition to
                                                            effective counselling and subsequent re-
   Tadjikhon Saidikramova, Sabo                             ferral to medical care.

                                                       Sabo also offers sex workers important and
                                                       valuable social services. They can consult,
The stigmatization that sex workers fre-               confidentially and for free, a gynecologist,
quently face often forces them into secrecy,           psychologist, immunologist or a lawyer. Sabo
making them difficult to reach and mistrustful         offers workshops about methods of protection
of people who try to help them. Given this             from pregnancy and STIs, including HIV, and
climate, mutual trust between Sabo and sex             about their legal rights. The centre also runs
workers grew slowly.       But once a sex              a counselling hotline and distributes informa-
worker visited the centre and benefited from           tional materials, syringes and condoms.
medical, psychological or legal aid, she
helped to bring more of her peers to the
centre.                                                   “In ancient Uzbek, ‘sabo’ means ‘morning
                                                          freshness’ and calls to mind a brighter fu-
      “They know that Sabo accepts them for               ture. In contemporary language it's a
      who they are. We don’t judge them.                  female's name. We decided to name our
      Our goal is solely to lower behaviour               organization after one of those whom we
      risks,” explains Tadjikhon Saidikramova.            wanted to support in her hard times.”
                                                          Sabo, Uzbekistan
A six-month needs assessment project ex-
tended Sabo's ideas about the needs of
women working the streets and revealed a
clear overlap between sex workers and drug             At present, the extent of the project's suc-
users. Some drug users turn to sex work                cess on HIV prevention has not yet been
out of financial necessity to support their            determined. However, Sabo is working hard
drug habits. Sex workers use drugs to seek             to assist the number of women who come to
an escape from their harsh lives. One may              its centre for STI treatment. A recent report
also lead to the other. The desperate ex-              indicates that 10 per cent of sex workers
change of sex for drugs or “drug money”                examined by Sabo health workers were diag-
was identified as a high-risk encounter that           nosed as having syphilis and half of the
reduces appropriate judgment around safer              women had gonorrhea or trichomoniasis. A
sex behaviours.    The sharing of unclean              contributing factor to the STI problem is lack
needles and syringes is a well-documented              of access to medical care for sex workers.
mode of HIV transmission.      Consequently,           Many of the women who were diagnosed by
Sabo has included harm reduction informa-              Sabo had previously been diagnosed with
tion about injecting drug use in its                   STIs but had been denied treatment in pri-
programmes and has introduced a needle                 vate clinics because they did not have the
and syringe programme for the distribution of          money to buy the medication to treat their
sterilized needles and syringes to prevent             infections.12

 42                                  HIV/AIDS Prevention, Care and Support: Stories from the Community
Achievements and challenges
                                                         Treating STIs aggressively reduces
Sabo programmes have helped to educate                   HIV infection risk13
and empower sex workers, and contribute to
their health and well-being. Many of these               The presence of sexually transmitted infec-
women have constantly had doors closed on                tions magnifies the risk of HIV transmission
them. At Sabo, the light has remained on and             during unprotected sex since the infection
the doors kept open for them. Sabo is giving             creates additional entry points for the virus
many of these women an opportunity to try to             or facilitates viral replication.
live safer and healthier lives. The programme
                                                         Many STIs – including the four most com-
has been so inspiring that some sex workers
                                                         mon ones: syphilis, gonorrhea, chlamydia
have joined as volunteer counsellors.                    and trichomoniasis – can be cured relatively
                                                         easily with antibiotic treatment. But lack of
The high number of users has also served                 services, poor availability of drugs, limited
as an effective measure to continue the                  access to diagnosis, and disparaging atti-
programme with the possibility of expanding              tudes by service providers are barriers to
the HIV/STI preventive education outreach.               more effective detection and treatment of
However, financial sustainability is one of the          STIs, as part of HIV/AIDS prevention.
most difficult challenges. Currently, the Neth-
erlands Organisation for International Devel-            These problems are surmountable, even in
opment Cooperation (NOVIB) as well as the                resource-poor settings. Research in low-
Open Society Institute Uzbekistan/Soros                  and middle-income countries has confirmed
Foundation      serve   as   the     community           the effectiveness of syndromic management.
                                                         This involves recognizing clinical signs and
organization’s main sources of funding while
                                                         patient symptoms (or syndromes) and pre-
Sabo continues to explore new avenues for
                                                         scribing treatment for the major causes of
financial support.
                                                         that syndrome. Syndromic management en-
                                                         ables health workers who lack specialized
Sabo has accepted yet another challenge:                 skills and access to sophisticated laboratory
meeting the needs of a growing population of             tests to effectively treat most symptomatic
HIV-positive people who have begun to fre-               infections during a patient's first visit.
quent the centre. Sabo is now exploring
additional ways to formally meet their care,
treatment and support needs.
                                                      Sabo has taken action to combat the lack of
Sabo is also stepping up its advocacy work.
                                                      knowledge about STIs, including HIV/AIDS, in
The centre is planning to work with the me-
                                                      Uzbek society. But Uzbekistan, and Central
dia to address the urgent necessity for public
information about HIV prevention, and care            Asia as a whole, require more HIV prevention
and support for people living with HIV/AIDS.          programmes – both governmental- and civil
So far, the state media has not been forth-           society-based – that address the needs of
coming on this issue, and has often taken a           vulnerable groups. The time frame for action
harsh stance on HIV/AIDS – sometimes even             is short. Collective national, subregional and
blaming sex workers, men who have sex with            regional efforts that emphasize prevention
men, and drug users for “bringing it upon             and harm reduction programmes related to
themselves”.     These attitudes, frequently          drug use are most urgently needed. The
shared by the general public, further the im-         development of such programmes can help
portance of collaborating with the media to           prop open the window of opportunity for Cen-
address the stigma and discrimination that            tral Asian countries to avert a full-scale epi-
fuel the spread of HIV/AIDS.                          demic.

Far from society – close to HIV: Working with Uzbekistan’s sex workers                               43
                                                        7    Kozlova, Marina (2002, April 15). Uzbekistan
1    United Nations Office for the Coordination of           faces HIV epidemic.      United Press Interna-
     Humanitarian Affairs (UNOCHA) (2002, July 9).           tional. 18 February 2003 <
     Central Asia: HIV/AIDS growing rapidly.                 news/upi/2002/UP020402.html>
     IRINNEWS Newsletter.                               8    UNAIDS/WHO (2002).
2    Joint United Nations Programme on HIV/AIDS         9    Saidikramova, Tadjikhon (2002, Fall).         A
     (UNAIDS) (2002). Report on the Global HIV/              brighter future for sex workers, Harm Reduction
     AIDS Epidemic.       Geneva: UNAIDS; and
                                                             News, 3, p. 14.
     UNOCHA (2002, November 29). Uzbekistan:
                                                        10   UNOCHA (2002, Novemver 29).
     Focusing on the growing AIDS threat.
     IRINNEWS Newsletter.                               11   Adopted from the Institute for War & Peace
3    The United States Agency for International De-          Reporting (2002). Central Asia Report, 140. 14
     velopment (USAID) (2002). Central Asian Re-             February 2003 <http://www.diplomaticobserver.
     publics Regional Program. 10 February 2003              com/others/20020826_01.html>
     <   12
     eande/caregion.html>                                    International Harm Reduction Development
                                                             (IHRD) (2002). Sex Worker Harm Reduction
     USAID (2002).                                           Initiative Mid-Year Report. A Guidance to Con-
5    UNAIDS/World Health Organization (WHO)                  tacts and Services in Central and Eastern Eu-
     (2002). AIDS Epidemic Update. December                  rope and the Former Soviet Union. Budapest:
     2002. Geneva: UNAIDS.                                   IHRD.
6    USAID (2002).                                      13   UNAIDS (2002).

    44                                HIV/AIDS Prevention, Care and Support: Stories from the Community
Social mobilization in the era of HIV:
India’s sex workers fight against HIV/ AIDS
(Durbar Mahila Samawaya Committee and the All-
India Institute of Hygiene and Public Health, India)

   India has around 3.97 million people living with HIV/AIDS, making it the most seriously
   affected nation in the Asia-Pacific region, and the second most impacted in the world
   following South Africa. India's socio-economic status, social mores, cultural myths on sex
   and sexuality and a vast population of marginalized people, make its population highly
   vulnerable to HIV/AIDS, resulting in one of the most serious development problems the
   country has ever faced.
   Throughout the country, the epidemic continues to shift towards women and young people,
   with about 25 per cent of all new HIV infections occurring in women.1 Adverse gender
   discrimination such as poor access to education, and low economic and social status,
   undermine women's ability to negotiate for equality in sexual relations. In addition,
   women’s biological vulnerability increases their risk of contracting HIV.
   Heterosexual sex has been identified as the chief mode of HIV transmission in India, ac-
   counting for roughly 80 per cent of reported HIV/AIDS cases. This makes sex workers and
   their clients a significant reservoir for spreading sexually transmitted infections (STIs), includ-
   ing HIV.2
   The Sonagachi District in Kolkata, known as having the oldest, largest and most-storied
   “red-light” district in the city, has been the breaking ground for a multilateral cooperative
   partnership between the Durbar Mahila Samawaya Committee (DMSC), Asia’s first organiza-
   tion of sex workers, and the Indian Government's All-India Institute of Hygiene and Public
   Health. Their HIV/AIDS project, which was launched by the Indian Government and 18 non-
   governmental organizations in 1992, remains one of the largest community-run intervention
   projects in the world. The Government continues to support the programme. And the results
   are promising – compared to a 30 per cent HIV infection rate among sex workers in
   Sonagachi less than a decade ago, today, 9 per cent of the roughly 6,000 sex workers tested
   HIV positive. This can be compared to a 60 per cent HIV-infection rate in similar communi-
   ties in Mumbai.3
   In partnership, these groups have worked together to develop the STI/HIV Intervention
   Programme (SHIP) in Kolkata and West Bengal. This pioneering initiative is empowering sex
   workers and providing them with an innovative HIV/AIDS prevention programme that offers
   a safer environment in which to live and work.

Social mobilization in the era of HIV: India’s sex workers fight against HIV/ AIDS                   45
Behind the red lights: Sex workers                       Sonagachi boasts of a long tradition in the
                                                         sex trade industry, with a regular influx of
in Sonagachi                                             young girls from remote places.      A large
                                                         number of sex workers from different parts of
Sonagachi is a red-light district that has been          India, Bangladesh, and Nepal have congre-
around for nearly a century. The area con-               gated here. Their ages range from 13 to 45,
sists of three- and four-story crumbling                 and income varies from US$ 4 to US$ 47 per
houses overlooking a chaotic din, where sex              night.5 Most of the sex workers are illiterate
workers, hawkers, revellers, bicycles, scoot-            and joined the sex industry due to poverty
ers, and rickshaws jostle for space in narrow            and deprivation.
congested lanes. An estimated 6,000 sex
workers reside here in nearly 370 houses.                The sex workers may operate independently
Another 1,500 “floating” sex workers can be              or under the control of madams. Pimps act
found in the vicinity. The community is finan-           as middlemen and collect one-fourth of the
cially dependent on the 20,000 or so men                 earnings, while madams take 50 per cent
who visit Sonagachi monthly.4                            (known as the adhia system). In addition,
                                                         the sex workers are also expected to pay
Sonagachi consists of five areas, namely                 their rent daily or monthly for the small floor
Sonagachi, Rabindra Sarani, Jorabagan,                   space that they occupy.
Rambagan and Sethbagan. Each tenement
building houses several brothels in which the            Most of the sex workers average three to
numbers of rooms vary from five to twenty-               four customers a day. When the project be-
five. Accommodation is diverse, ranging from             gan in 1992 a survey of 450 sex workers
a cramped, badly lit cubbyhole to a spacious             indicated that 45 per cent took precautions
air-conditioned room. Not surprisingly, sanita-          against pregnancy, with only 27 per cent
tion and civic amenities are in deplorable               taking precautions regularly.  In addition,
conditions in many locations. Instances of               while 69 per cent of the sex workers knew
four to six sex workers sharing a room parti-            about STIs, only 31 per cent had heard
tioned by curtains are common.                           about HIV/AIDS.6

               Probable source of infection of reported HIV/AIDS cases in India
                            (n = 20304) May 1986 – March 2001


                                                                   Blood & Blood Products
                                                                   History not available

                            7.5%   4.2%    4.0%   1.8%

   Source:   NACO (2002).

 46                                  HIV/AIDS Prevention, Care and Support: Stories from the Community
Empowerment brings change!                             ber 1994, 79,420 condoms were distributed.
                                                       In 2000, over 100,000 condoms were distrib-
The above indicators, combined with the ris-           uted monthly.9
ing STI and HIV prevalence rates, motivated
                                                            Raising awareness is just the beginning
the All-India Institute of Hygiene and Public
Health, along with 18 NGOs, to initiate the            In addition to its awareness raising compo-
STI/HIV Intervention Programme (SHIP).                 nents, SHIP has given sex workers (both
The objective of this programme was to pro-            male and female) information and access to
vide sex workers with prevention education             health services, education, and policy activi-
and services. Right from the beginning, the            ties. The creation of DMSC has given the
programme involved female sex workers as               sex workers their own organization, managed
peer educators and programme coordinators.             by a board comprised of some of the older
By 1997, the sex workers of Sonagachi                  sex workers. They have managed a literacy
were sufficiently empowered to establish               programme and an immunization programme
their own organization, the Durbar Mahila              for their children. They have created the
Samawaya Committee (DMSC), which now                   Usha Multipurpose Cooperative Society, which
facilitates the local HIV/AIDS project in              provides loans to sex workers, keeping loan
Sonagachi.7                                            sharks at bay. And they have established a
                                                       commercial market. Formerly the sex workers
Initially, a group of 12 peer educators were
                                                       had to depend more on their pimps and
selected, trained, and sent to the field for
                                                       madams, as they were discouraged from go-
direct association with the sex worker com-
                                                       ing out to shop, and therefore paid higher
munity. Today, the number of peer educators
                                                       prices for goods. Now, with the help of their
has increased to 430.8 Since the sex work-
                                                       organization, these women can shop freely at
ers themselves act as peer educators, the
                                                       their local cooperative and avoid being over-
response has been quite positive. The peer
educators, who are trained for a period of six
weeks, visit the tenements and distribute              Although originally funded by the Norwegian
condoms free of charge. The female sex                 Agency    for     Development    Cooperation
workers report that they find it easy to relate        (NORAD), World Health Organization (WHO)
to their fellow sisters. They attend lectures          and the National AIDS Control Organisation
on HIV prevention and get free treatment for
STIs and examinations in project-run centres.
Even male clients are involved – they are
                                                                                                        Photo: WHO/P. Virot

educated about the importance of condom
use during evening education sessions. The
peer educators informally try to verify the
extent of condom use by different methods.
They inquire about the total number of cli-
ents, the number of clients who refuse to use
condoms, and the number of clients who
have been motivated to use them.

The demand for condoms by sex workers
has been increasing steadily. During the first
month of the project’s inception in 1992,              SHIP helps sex workers protect themselves from
3,592 condoms were distributed; in Decem-              HIV infection.

Social mobilization in the era of HIV: India’s sex workers fight against HIV/ AIDS                  47
(NACO), DMSC is now funded not only
through continuing assistance from these
organizations, but also through local chari-          Condom usage among sex workers
table donations, on-going contributions from
the All India Institute of Hygiene and Public
Health, the United Kingdom’s Department for
International Development (DFID), UNDP and           80
several other major aid agencies. Activities
                                                     60                                  Overall
are also funded through members' dues and
profits from their cooperative.                      40
Furthermore, once the community was con-
vinced that SHIP was not going to upset their         0
                                                          1992       1993      1998
self-interests, or the sex industry, they ex-
tended a willing hand. Such an interaction
has given the programme a more supportive            Source:   Biswas, Ranjita (1998).
environment in which to continue.

Achievements and challenges
                                                  However, more Sonagachi women have be-
The SHIP programme has made striking              gun refusing clients who are reluctant to use
progress in Sonagachi.     Sex workers are        condoms, despite the higher amount paid.
more conscious of their health needs and          Some pimps and madams intervene when
requirements. A 1998 survey of sex workers        clients refuse to use condoms. Many brothel
in Sonagachi found that more than 94 per          owners realize that it is easier to keep a sex
cent knew how HIV/AIDS spread, and how to         worker healthy than to keep looking for new
prevent it from spreading. In 1992, only 1.6      workers. More importantly, infected workers
per cent of sex workers said they were using      keep clients away. The realization of this
condoms regularly; by 1998, more than 80          economic advantage to keeping sex workers
per cent were using condoms often (see            healthy has made many madams/brothel own-
figure, this page).10                             ers advocate condom use and safer sex
                                                  practices. Although this is still not a conven-
Despite the high condom use and the training      tional practice among all brothels and sex
of over 430 peer educators in the community,      workers, it is becoming more common.11
infection rates hover around 9 per cent (al-
though this is much lower than similar areas
in the rest of the country). According to sex
workers, this is because most clients still do
                                                     “When a customer comes, I take the
not want to use condoms. Many sex workers
                                                     money first and then let him in my room.
continue to face high-risk situations, because       Then I ask whether he'll use a condom. If
of their client's willingness to pay more for        he says no, I keep the money and show
sex without condoms. With some willing to            him out”
pay double or triple the amount, sex workers,
who need the money desperately, unhappily            Priya Begum, 23, Sonagachi sex worker12
agree to forgo the use of the condom.

 48                             HIV/AIDS Prevention, Care and Support: Stories from the Community
Programme participants and peer educators              The organization of sex workers is now ac-
have noted the change in their lives since             tively involved in preventing girls under the
working with SHIP. Many feel they have                 age of 18 from entering the sex work profes-
gained self-respect, dignity, and a new social         sion. Initial results of this activity are encour-
identity. They have an increased sense of              aging, indicating an increase in age of entry
self-esteem and authority. Initially, the sex          into sex work. This has tremendous signifi-
                                                       cance for the sex workers’ lives and HIV
workers could not muster the courage to
                                                       prevention efforts, as police and other state
speak to anyone. Now they can communicate
                                                       powers have often kept control of the broth-
with other sex workers as well as negotiate            els, and dis-empowered sex workers, through
more effectively for safer sex with their cli-         raids carried out in the name of rescuing
ents.                                                  underage girls from sex work.13

The sex workers of Sonagachi have estab-               DMSC is a model of what grassroots social
lished their own financial cooperatives. They          mobilization can achieve when coupled with
are becoming literate with the implementation          empowerment and human dignity initiatives.
of a literacy campaign that has, as a                  It is also an example of multi-sectoral part-
                                                       nerships and how early government actions
secondary effect, helped raise awareness
                                                       such as the above programme, in partnership
among sex workers about STIs, including
                                                       with NGOs and community-based organiza-
HIV, and increased their knowledge about
                                                       tions, can develop long-term and sustainable
their rights. They have advocated for the              programmes that can shift the outcomes of
prevention of child abuse, sexual exploitation         HIV/AIDS infection in India, Asia and the rest
and police harassment. As a result of their            of the world.
literacy and advocacy programmes, many sex
workers aspire for a better work and living            For the women of Sonagachi, it is no longer
environment.                                           enough just to survive and live on the periph-
                                                       ery of society. It is now the right to self-
Today, Sonagachi's success has been pro-               determination and having a say in the way
                                                       they work and live that has become the main
jected as a role model for other areas.
                                                       agenda. With these changes in Sonagachi,
DMSC has attended national conferences
                                                       the lives of women such as Priya, are set to
and is working towards official recognition as         keep on improving.
a labour union under the Government’s
labour law. They have also extended their
outreach to other states of India and
neighbouring countries, such as Bangladesh                 National Aids Control Organisation (NACO)
and Nepal. Sonagachi's latest project is an                (2002). Combating HIV/AIDS in India 2000-
                                                           2002. 10 February 2003 <http://www.naco.nic.
awareness campaign and treatment of tuber-
culosis among members, particularly among
                                                       2   NACO (2002).
the most poverty stricken who live in
                                                       3   Biswas, Ranjita (1998).      The red lights of
cramped rooms.
                                                           Sonagachi. Positive Nation. 10 February 2003
The principles of the Sonagachi project have               features/feature6/feature6_1.htm>
been replicated in a very short time in Bang-          4   Jana, S. (1995). Three Years at Sonagachi.
ladesh, demonstrating that the lessons
                                                           International Symposium on AIDS in India. 10
learned from the project are replicable and                February 2003 <
adaptable to other organizations and areas.                education/conferences/India/India-1995-6.html>

Social mobilization in the era of HIV: India’s sex workers fight against HIV/ AIDS                  49
5    NACO (2002).                                             news_updates_archive/sep20_02/india_aids_
6                                                             project.html>
     Jana, S. (1995).
                                                         9    Jana, S. (1995).
7    World Bank Group (1999, December 3). Spot-
                                                         10   Biswas, Ranjita (1998).
     light on India's AIDS control efforts: Grassroots
     projects key to success. Development News.          11   Biswas, Ranjita (1998).
     10 February 2003 <>        12   Basu, Paroma (2002, September 18-24).
8    Basu, Paroma (2002, September 18-24). Giv-          13   Personal communication with Dr. S. Jana,
     ing AIDS the red light.  Village Voice. 10               former project coordinator, Sonagachi project.
     February 2003 <               March 2003.

    50                                HIV/AIDS Prevention, Care and Support: Stories from the Community
Getting in tow about HIV/AIDS:
Education for Bangladeshi rickshaw pullers
(Nari Unnayan Shakti, Bangladesh)

   Bangladesh is a South Asian country recognized for its low HIV/AIDS prevalence rate.
   UNAIDS estimated in 2001 that some 13,000 people in Bangladesh were living with HIV/
   AIDS.1 Despite the low prevalence rate, many high-risk behaviours in place suggest that
   HIV/AIDS is likely to spread rapidly in the near future.
   One report noted that 60 per cent of long-distance truck drivers in the country have sexual
   relations with sex workers about twice a month, without any basic knowledge of how to
   prevent HIV/AIDS.2 Studies of the sex industry have also identified over 100,000 sex workers,
   whose customers represent all socio-economic segments of society.3 Female sex workers
   have an average of two to five clients a day, most of whom do not use condoms. At risk are
   the sex workers, their clients, which total about half a million men a day,4 and the clients'
   partners and families.
   In recognition of a potentially looming HIV/AIDS crisis, Nari Unnayan Shakti (NUS) is work-
   ing in poverty-stricken districts in Dhaka, implementing HIV/AIDS education and advocacy
   programmes that have currently reached approximately 10,000 people. Based in Dhaka,
   NUS's main projects address capacity building, poverty reduction, sustainable livelihood, HIV/
   AIDS and sexually transmitted infection (STI) prevention, general health care promotion,
   advocacy for gender equality, and the protection of women and children from trafficking,
   sexual exploitation and other forms of abuse.
   This is a story about one of their most innovative HIV/AIDS prevention programmes, which
   worked with 3,000 rickshaw pullers and their families in the Dhaka slums of Khilgaon and
   Shabujbag Thanas.

Life as a rickshawala                                The rickshaw is to Bangladesh, what the tuk-
                                                     tuk is to Thailand: an inexpensive form of
The streets of Dhaka come alive every morn-          transportation that is available any time of
ing as hundreds of thousands of human-               day or night. However, the rickshawala, who
powered rickshaws fill the streets in their          peddles his three-wheeled cycle throughout
colourful finery. They battle traffic with cars      the city, earns much less than his Thai coun-
and vans, vying for a piece of the road to           terpart, with daily earnings amounting to less
get passengers to their destinations.                than US$ 1.5

Getting in tow about HIV/AIDS: Education for Bangladeshi rickshaw pullers                       51
Rickshaw pullers are one of the largest                     The NUS survey showed that more than 84
groups that patronize sex workers. Their par-               per cent of the wives and daughters of these
ticipation in high-risk behaviours such as un-              rickshaw pullers were aware of HIV/AIDS and
protected sex and injecting drug use6 serves                what preventive measures should be taken.9
as a significant bridge between populations,                This group of women, however, differed con-
and threatens the spread of HIV between                     siderably from general surveys in Bang-
                                                            ladesh, which indicated that men were better
sex workers, and the clients’ wives and fami-
                                                            informed about HIV/AIDS than women.10
lies. A 2002 NUS survey, prior to the start
of their HIV/AIDS programme, found that out                 This meant that despite the high level of
of 1,000 rickshaw pullers and their families,               knowledge among wives, husbands still con-
more than 80 per cent of men admitted to                    tinued to infect the family because of their
not knowing what high-risk sexual behaviour                 high-risk sexual behaviour, and because of
caused HIV/AIDS to spread and what preven-                  gender      inequalities which    compromised
tive measures could be taken to avoid be-                   women’s and girls’ ability to negotiate condom
coming infected.7                                           use and to adopt safer and healthier prac-
                                                            tices. Further compounding women and girls’
                                                            vulnerability are prevalent social norms that
                                                            limit their access to economic opportunities.

                                                            As a result of the survey findings, NUS em-
       Potential spread of HIV from
                                                            barked on a major initiative to educate and
         high risk groups to the                            promote behaviour change among rick-
         Bangladesh population,                             shawalas, which encouraged safer sex
           Central Bangladesh8                              practices. Launched in November 2001, and
                                                            financed by UNDP, the project aimed to
                                                            create an enabling environment for HIV/AIDS
                                                            prevention work, increase rickshaw pullers'
                                                            knowledge of sexually transmitted infections
                                                            including HIV, and increase safer sex
                     Rickshaw pullers                       behavioural practices.
                      (76% married)

                          69% visit                         Going to the garages


                                        34% (46%

                                        Visit married)      Extremely long days and nights on the

            IDU     33%     FSW FSW                         streets of Dhaka leave the rickshawalas

           (40%     Visit    (9%
          married)  FSW married)
                                                            exhausted with little free time to attend
                                                            classes or workshops on subjects that would
              2 Percent are IDU
                                                            improve their well-being. Besides, attending
                        1 Percent are IDU                   a class would take away time that could be
                                                            spent earning another fare. To address this
                                                            constraint, NUS developed an innovative one-
                                                            on-one outreach programme.            Eight staff
                                                            members from NUS were sent out to speak
   FSW = female sex worker
   IDU = injecting drug users                               to the rickshaw pullers individually, or in small
   MSM = men who have sex with men                          groups, when they were resting in the
                                                            garages – a time when they were more open
                                                            to instruction and advice. Close to 8,000

 52                                       HIV/AIDS Prevention, Care and Support: Stories from the Community
mini-meetings were held that addressed               work. The garages serve as homes for most
sexual health needs and priorities, relation-        rickshawalas – it is here that they eat, sleep
ship problems and the consequences of not            and bathe. It is also where many of their
getting treatment for STIs. The outcomes             sexual encounters take place, in close
resulted in greater awareness of STIs, includ-       proximity to other rickshaw pullers. The dor-
ing HIV, and a greater number of rickshaw            mitory-style accommodation means that there
pullers seeking medical treatment.                   are no partitions between people; sexual
                                                     intercourse is not necessarily a private affair.
In order to expand its outreach, NUS incorpo-        Thus, rickshaw pullers put on condoms and
rated peer education training into its pro-          have sex in the presence of other rickshaw
gramme. In 2002, NUS trained 64 new peer             pullers, with many commenting on each
educators. Peer educators were identified as         other’s prowess or weakness.
those who were in positions of influence and
were willing to learn and spread key mes-
sages about HIV/AIDS. The programme in-

                                                                                                     Photo: Hoque, Muhammad Towhidul (2002). Amori Bangladesh
corporated the following strategy: For three
days participants were given information
about HIV/AIDS transmission and prevention
methods, as well as issues that impact HIV/
AIDS, such as gender inequalities, and how
to improve communication skills. In addition,
104 peer educators who were trained under
a separate health education project in 2001
were invited, and given refresher courses on
HIV/AIDS issues.

At the end of the training course, evaluations
indicated that the participants could explain
at least three methods by which HIV/AIDS
could be spread (e.g., sexual relations, inject-
ing drug use, contaminated blood) and three
ways to help prevent transmission (e.g.,
abstinence, monogamy, condom use).             In
addition, many peer educators felt more
empowered to help raise awareness about
STIs, including HIV, and the importance of
safer sexual behaviour, including condom
use. They also valued their roles in the
community as peer advisors who could pro-
vide reliable information to their colleagues.

    Expanding alliances
                                                        “Even if I am now tired, I try to get a
                                                        condom and use it … I know it will help to
NUS recognized that even more allies and                save my life and my family and I can
partners were needed within the community               continue to send more money to my wife.”
to help strengthen HIV/AIDS prevention
efforts. Accordingly, they targeted the owners          Mohammad Abdul Habib, rickshaw puller11
of the garages where the rickshaw pullers

Getting in tow about HIV/AIDS: Education for Bangladeshi rickshaw pullers                         53
To increase stakeholder participation, NUS         The other link: Increasing access
staff and peer educators strategically edu-
                                                   to health care
cated and recruited the owners of the
rickshaw garages and mobilized them into
                                                   NUS recognized that prevention education
action. As a result, condoms supplied by
                                                   without health care and support would be
NUS were made more easily available for
                                                   highly ineffective. Once rickshaw pullers were
distribution among rickshaw workers.       The
                                                   educated about sexually transmitted infections,
alliance of the garage owners helped break         many would wish to seek medical assistance.
barriers, stigma and misconceptions about          Consequently, in order to address the health
condoms being “unmanly”12 and helped               concerns of rickshaw pullers and provide them
address some of the rickshaw pullers’ com-         and their families with access to primary
plaints that they lacked privacy in putting on     health care, counselling and information and
condoms or in carrying them.                       education materials, NUS established a medi-

In order to reach a wider range of

                                                                                             Photo: Hoque, Muhammad Towhidul (2002).
                                                                                                                  Amori Bangladesh
people, NUS also organized 31
video shows for rickshaw pullers
and slum dwellers in 2002. Before
and after the show, health educa-
tors interacted with the audience
to respond to any concerns or
questions. Each video discussed
HIV/AIDS, with key messages reit-
erated by the staff educators at
the end of the show. This me-
dium was highly effective.      Not
only did it provide entertainment to
the rickshaw pullers and increase
community participation, it also
made many of the rickshaw pull-
ers seek more information on how
to prevent HIV/AIDS.13                             cal care programme where rickshawalas and
                                                   their families could receive treatment for STIs
In addition, NUS organized five meetings with      and other general health problems. In 2002,
community leaders in the slum districts.           more than 330 persons were treated for STIs,
These meetings addressed issues such as            and another 1,209 were treated for general
HIV/AIDS, family and social violence, as well      medical problems. The facility also distributed
as communication strategies to improve             free condoms to the rickshaw pullers, and
people’s decision-making and negotiation           their wives and partners.
skills in matters related to their sexual and
reproductive health. These workshops and           Achievements and challenges
policy discussions have gone a long way in
getting the community leaders to accept that       The NUS programme with rickshaw pullers
education and community-driven initiatives         highlights the importance and value of highly
were needed in preventing HIV/AIDS.                targeted and focused advocacy and education

 54                              HIV/AIDS Prevention, Care and Support: Stories from the Community
efforts and partnerships.     The rickshawala        once only suffering, stigmatization and a
programme has trained 168 peer educators             lonely road to death, there is now hope for a
and set up a medical facility to treat patients      longer and happier life, peddling on the
with STIs and other health problems. Rick-           streets of Dhaka.
shaw pullers and their families, slum dwellers
and garage owners have all been educated
about the importance of safer sex practices          1    Joint United Nations Programme on HIV/AIDS
and modifying sexual behaviour.                           (UNAIDS) (2002). Report on the Global HIV/
                                                          AIDS Epidemic. Geneva: UNAIDS.
When the programme began, more than 50               2    Islam, Tabibul (1997, September 2). Bangla-
per cent of rickshaw pullers were not using               desh – AIDS: Waking up to the AIDS disaster.
condoms among the NUS target group.14 In                  Interpress News Service. 10 February 2003
response, NUS organized regular visits to the             <
garages and conducted education courses for               html>
garage owners in order to mobilize the power         3    Bangladesh.    Ministry of Health and Family
structure into full action and support. From              Welfare, Directorate General of Health Serv-
September 2001 to the end of the                          ices, National AIDS/STD Programme (2001).
programme in September 2002, a survey at                  HIV/AIDS in Bangladesh: Current situation. 1
the medical facility indicated that more than             April 2003 <
one out of every three rickshaw pullers used
                                                     4    Bloem, Maurice (1999). HIV/AIDS and female
a condom during his last sexual encounter,
compared to none at the start of the                      street-based sex workers in Dhaka city: what
                                                          about their clients.? Resistances to Behav-
                                                          ioural Change to Reduce HIV/AIDS Infection.
                                                          Canberra: National Centre for Epidemiology
At the end of the programme, NUS had                      and Population Health, Australian National Uni-
reached over 10,000 rickshaw pullers and                  versity (ANU).
their families, who are now aware of HIV/            5    Rickshaw pullers in city not aware of HIV/AIDS
AIDS and how to prevent its spread.16 In                  (2002, February 4). Bangladesh Observer.
addition, their communities were mobilized to        6    Bloem, Maurice (1999).
create a greater enabling environment for STI        7    Nari Unnayan Shakti (NUS) (2002).     Final
and HIV/AIDS prevention efforts.
                                                          Report on STD/HIV/AIDS Prevention Program
                                                          for the Rickshaw Pullers and their Families.
Despite the programme’s success, it has not               Dhaka: NUS.
been renewed by the Ministry of Health and           8    Monitoring the AIDS Pandemic (MAP) (2001).
Public Welfare, which distributes the UNDP                The Status and Trends of HIV/AIDS/STI Epide-
funding for it.     The Ministry is presently             mics in Asia and the Pacific. Melbourne: MAP.
utilizing the UNDP funds for other projects.17       9    NUS (2002).
NUS is thus presently seeking funds to
                                                     10   UNAIDS (2003, February 3-4). Accelerating the
continue with its rickshawala project.
                                                          Momentum in the Fight against HIV/AIDS in
                                                          South Asia. UNAIDS South Asia High-Level
It is still a long road ahead in getting all              Conference, Kathmandu.
rickshaw pullers in Bangladesh to change             11   Bloem, Maurice (1999).
their sexual behavioural patterns, but increas-
                                                     12   Rickshaw pullers in city not aware of HIV/AIDS
ingly, projects like the one run by NUS are
helping to make a big difference in the life of           (2002, February 4).
the common rickshawala. Where there was              13   NUS (2002).

Getting in tow about HIV/AIDS: Education for Bangladeshi rickshaw pullers                           55
14   Anti-AIDS initiatives in the doldrums (2002, No-   16   NUS (2002).
     vember 22). The Independent Bangladesh             17   Anti-AIDS initiatives in the doldrums (2002, No-
15   NUS (2002).                                             vember 22).

 56                                   HIV/AIDS Prevention, Care and Support: Stories from the Community

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