Of the 580 sex workers from brothels of four different districts of West Bengal, who participated in the study, 488 (84%) were from India, 51 (9%) from Nepal, 40 (7%) from Bangladesh, and only one from Bhutan. Overall, the rate of HIV seroprevalence was 12% (n=68) among the participants. Figure shows the distribution of the study participants with their country of origin and corresponding seroprevalence of HIV among them.
Country-wise distribution of studied sex workers (n=580) with HIV status
The figure shows that sex workers from Nepal had the HIV seroprevalence rate of 43%. Sex workers of Indian origin had an HIV seroprevalence rate of 9%, and Bangladesh had an HIV seroprevalence rate of 7%. The lone sex worker from Bhutan was infected with HIV.
The commonest age-group was 21–30 years (51%; n=296) with the mean age of 29.8 years. The studied participants aged 20 years or less were 9% (n=50). The seroprevalence of HIV was the highest (24%) among sex workers aged 20 year or less. The same was 10% in the age-group of 21–30 years and 12% in the age-group of 31–40 years. The seroprevalence of HIV was the lowest (2%) among participants aged over 40 years (Fig. ). The mean number of clients entertained daily by sex workers aged 20 years or less was the highest (3.66 clients/day) compared to that of the 21–35-year age-group (2.67 clients/day) and above 35-year age-group (1.65 clients/day).
Age distribution of studied sex workers (n=580) with corresponding HIV status
Forty-six percent of the participants started sex work at the age of 16–20 years. This was followed by 25% of them initiating at the age of 21–25 years. About 10% initiated their sex work at the age of 15 years or below. The overall mean age of initiation of sex work was 21.2 years.
Thirty-two percent of the subjects had sex work for a duration of 1–5 year(s); about 28% had sex work for a duration of >5–10 years; about 11% had it for a duration of one year or less; and 7% had it for a duration of more than 20 years. The mean duration of sex work among all the study participants was 8.6 years. The majority (58%) of the sex workers entertained 1–2 client(s) daily, followed by 3–4 clients (34%). Only 1% entertained seven or more clients, whereas the remaining 7% entertained 5–6 clients daily.
The majority (68%; n=397) of the sex workers joined the profession voluntarily and primarily due to poverty. About 24% found themselves cheated and were forced by somebody to join the profession against their will. These were the girls who were trafficked and brought into sex work. The remaining 8% were forced to join the profession directly or indirectly by their spouses or family members. It has also been observed that 46% of 50 sex workers aged 20 years or less had the experience of trafficking compared to 30% (n=160) of older sex workers aged over 20 years having a similar experience.
Results of the study showed that violence was faced more by the trafficked sex workers, including those sold by their families (57%) compared to those who joined voluntarily (15%). The seroprevalence of HIV was 13% (n=24) among the trafficked sex workers, including those sold by their families compared to those who joined the profession voluntarily (10%; n=40).
Table shows that 63% (n=105) of the sex workers who faced violence (n=166) in their early professional sex work were victims of trafficking. On the other hand, 37% (n=61) had the history of violence despite joining the profession voluntarily. This difference was statistically significant (odds ratio [OR]=7.4; confidence interval [CI] 95% 4.8–11.3).
Violence and trafficked victims
Of the trafficked victims, 66% were assured with jobs, and 27% were assured of better quality of life. Promise of marriage was assured to about 4% of the study participants, whereas 3% of those who did not join the profession voluntarily (n=183) had a single recruiter (88%; n=161), and 12% had two recruiters (n=22).
About 29% (n=166) of the sex workers faced violence during the early phase of their profession. The seroprevalence of HIV was 20% (n=33) among those who faced violence during the initial phase. The same was 8% among those who did not face violence during the similar period.
Of the 166 sex workers who faced violence, 15% faced physical violence, 55% had sexual violence, and 30% had both. Both clients and brothel owners or their representatives committed physical and sexual violence in most cases. About 16% (n=92) of the participants were forced to do sex against their will initially as part of sexual violence. Recruiters, brothel owners, or their representatives were involved in most cases. Pimps and customers were also associated with 13% and 6% of the cases respectively. The seroprevalence of HIV was 23% (n=32) among sex workers who faced sexual violence initially compared to 8% (n=36) among those who did not.
Ideal time of negotiation for condom-use appears to be better after taking the client on bed, when client begins to be intimated with sex workers. Acceptance of condom-use appears to be better at this phase for unwilling clients. However, in this study, only 38% of the participants had practised it at that phase, i.e. after taking them to bed. The majority (55%) of the sex workers did it during price-fixing, which appeared to be less effective compared to the former approach. The seroprevalence of HIV was less (9%; n=20) among sex workers who negotiated after taking them to bed compared to those who did not (13%; n=44).
Most (86%; n=499) sex workers asked their clients to use condom as a routine practice. Regarding the assessment of negotiating skill, sex workers were asked about condom-use with their most recent two clients. If the response was ‘yes' with any one of them, the respondent was asked again whether it was with or without negotiation as some clients used condoms voluntarily and did not require any negotiation. In total, 566 participants responded to this question. In total, 292 and 258 sexual acts took place with condoms with the first client (most recent) and the second client respectively. Of the 292 sexual acts using condoms with the first client, 125 clients used condoms voluntarily and did not require any negotiation. So, actual scope of negotiation for condom-use with the first client was (566–125) 441. Of the 441 clients who did not have any intention to use condoms, the sex workers negotiated successfully with 167 clients. This gives rise to a rate of 38% (167 of 441) as their successful condom negotiation rate. In this way, the rate was 38% with their second clients. So, the overall successful condom negotiation rate was 38% (rounded up) among the studied participants (Fig. ).
Negotiated condom-use rates with most recent two clients (n=566)
Most (97%; n=563) sex workers did not have any formal training on negotiating skill; only 4% participated in some kind of training on negotiating skill organized by local NGOs.
In total, 321 (55%) of the 580 subjects had the history of consumption of alcohol. Of the 321 alcohol drinkers, 233 (73%) consumed it in varying quantity and frequency before entertaining their clients. Cost of alcohol was borne by the clients for most (74%; n=238) sex workers. Negotiation for condom-use seemed to be affected, at least to some extent, when sex was offered with prior alcohol intake.
Univariate analysis was done considering HIV as an independent variable and younger age of less than 20 years, trafficking, violence, sexual violence, forced to perform sex against will, timing of negotiation, etc. as dependent variables. HIV was associated with younger age (20 years or less) (OR=2.6; CI 1.2–5.6), trafficking (OR=1.9; CI 1.1–3.3), violence faced during early phase (OR=2.6), sexual violence (OR=3.2; CI 1.8–5.7), and forced sex against will (OR=3.0; CI 1.6–5.5). HIV was not, however, associated with negotiation for condom-use during entry or price-fixing. In multivariate analysis, sexual violence was found to be associated with HIV infection (OR=2.3; 95% CI 1.2–4.5) (Table ).
Univariate and multivariate analyses showing factors associated with HIV