In Mumbai, also known as 'Maximum City' where 20 million people live, female and transgender sex workers face limited access to healthcare, social discrimination, uncertain income and police harassment.
Ahead of the Women Deliver conference in Kuala Lumpur (28-30 May), members of the Aastha community are speaking out about the need to improve access to HIV and sexual and reproductive health services.
Female and transgender sex workers are highly vulnerable to HIV and other sexually transmitted infections (STIs) due to multiple factors, including high numbers of sex partners, unsafe working conditions and barriers to the negotiation of consistent condom use.
The Aastha project, which was funded by the Bill and Melinda Gates Foundation, is part of a community effort to prevent sex workers contracting HIV and other STIs. Devata works with sex workers based in brothels and explains how women and girls are lured to Mumbai city and sold into the sex industry. A brothel owner is known as a 'gharwali' and purchases girls at a high price. This cost is then passed on to the girl as a ‘loan’, which she has to pay back to the brothel owner.
Devata recalls: “In earlier days, the gharwali could force the girls to have sex without a condom and the incidence of infection was high. The gharwali would not allow the girls to access health services, and if any services were provided the girls were overcharged and this money was added to her loan amount."
Sex workers rarely able to prioritise their health needs and are often not aware of the importance of preventive healthcare. Illness is therefore common, from HIV, STIs ,and TB to malaria, coughs, fevers, aches and pains. Devata said: "In the past we did not pay attention to our health, we did not realise that without good health we will not be able to work."
She suggests there should be a door-to-door healthcare facility, so that all sex workers can access services. Providing healthcare for common ailments such as fevers and aches could also be an entry point to encourage sex workers to access HIV and sexual and reproductive health services.
Devata added: "Female sex workers work through the night and go to sleep around 6.00am. It is not possible for them to be at the health clinic at 8 am to queue for registration papers. There must be more flexible healthcare hours."
A recent UNAIDS study shows that female sex workers are 13.5 times more likely to acquire HIV than all other women aged 15-49 years.
Seema is a community development officer also involved with the Aastha project and works with street-based sex workers, she said: "If we want to see real change at the ground level to improve the health of sex workers, it is essential that we work with local politicians, pimps and police. Once we involve them they are more ready to help."
Involving decision-makers is also important when it comes to addressing the criminalisation, legal and policy barriers which play a key role in the vulnerability of transgender people to HIV. Same-gender sexual activity is currently illegal in more than 75 countries and transgender people lack legal recognition.
The 'hijra' transgender community in Mumbai is tightly knit. Chandana, a transgender woman involved in the Aastha project, describes the transition process. She said: "The hijra undergoes castration surgery called 'nirvan', which means rebirth. It involves the complete removal of the penis and testes and is an essential process in transforming men to women. The wound is allowed to bleed, as this is seen as the bad 'male' blood."
This procedure is against the law in India and as it is done behind closed doors there are no medical guidelines. Due to bad surgical procedures adopted by unqualified medical practitioners, many hijras develop complications after the operation, especially urological problems.
Devata, Seema, and Chandana make a compelling case for stronger integration of HIV and sexual and reproductive health services, which would lead to more user friendly and cost effective programmes targeting those most in need.