The Sonagachi Project has achieved worldwide recognition for its innovative approach to public health,26,27
including World Health Organization funding and coverage in The New York Times.28
The project organized an international meeting of sex workers in 2001 that mobilized thousands of sex workers in the Millennium Mila Mela Conference, demonstrating its impact as a social movement. However, there were few previous empirical data on which to evaluate the efficacy of this intervention.
Although it involved only 2 communities, the Sonagachi intervention resulted in significant increases in condom use in a relatively short period that were sustained for 16 months. Consistent condom use was demonstrated by an additional 40% of sex workers, a figure that was sustained over 3 assessments over 16 months. Fewer than 5% relapsed over that period in the intervention community. Comparable increases were not found in the control communities.
It is important to note that knowledge of STD- and AIDS-preventive methods were high prior to implementing the intervention. However, condom use was not similarly high. The rate of STDs was so low (<1%) that it was not feasible to demonstrate reductions in STD infection over the 16 months.
This is a relatively low-cost intervention that has benefits that extend beyond HIV prevention. The most significant cost is the establishment of a clinic that is available to provide treatment of STDs and training of sex workers to deliver prevention messages and promote condom use. Yet, there were significant increases in condom use once these resources were established in a community far removed from the initial intervention site in Calcutta. More than half of the sex workers had a regular sexual partner, a “babu.” Although we did not assess changes in communication between marital partners or babus, there were spontaneous reports that the intervention helped sex workers communicate and be assertive with their spouses, babus, and stakeholders. In addition to the treatment of STDs for sex workers, the health clinic also provided free health care to their families, clients, and other persons living in the red light areas. Having access to these resources may increase the perception of one’s status, as well as the status of sex workers in the community.
As this intervention was mounted over a very long period in Calcutta, a set of social entrepreneurial programs became attached (e.g., a micro-savings and lending cooperative, literacy programs, cultural programs, schools). Over the 16-month period, sex workers in the local sites had only just begun to build these resources, prioritizing services and education for their children and literacy for sex workers. However, with a forum for community dialogue and the experience of sex worker peer organizers from Calcutta, benefits accrued over time and continue to be implemented.
Notwithstanding our findings, the study had several limitations. First, only 2 communities were included, which limits the generalizability of our results. Nevertheless, we found significant differences in consistent condom use, suggesting the effectiveness of the Sonagachi intervention among sex workers in the 2 communities and other locales in India. It would be helpful, however, to increase the number of communities within India, and to test the intervention in locales outside of India, so as to increase external validity.
While steps were taken to avoid contamination, the research team noted some movement back and forth between the 2 communities and an awareness of the existence of an enhanced intervention among some sex workers in the control community. However, we still found significant differences in condom use across the sites. Given the inclusion of only 2 communities, it is also possible that differences in these communities, other than the intervention, contributed to differential rates of condom use. However, efforts were made by the research team, working in concert with members of the Calcutta-based team, to ensure parity across the selected communities in terms of size, language, religion, and other sociodemographic factors.
An additional limitation is that condom use was by self-report only. While we implemented VDRL testing at baseline and in subsequent waves as an independent marker of sexual risk, STD rates were too low to be of use in documenting sexual risk behavior. To reduce social desirability, separate teams of interviewers and intervention staff were maintained, interviewers were trained to remain nonjudgmental, and participants were identified by a code number only for the assessment and assured of confidentiality. Additionally, while not intended as an outcome measure for this study, the Calcutta-based team kept monthly records of the number of condoms sold (at a nominal, subsidized price) outside the clinic; the records indicate increases in condom sales over time and higher numbers of condoms distributed in the intervention community from the second wave onward as compared with the control community. While we cannot be assured that these condoms were used, condom supply measures tend to corroborate the self-reports of condom use among the sex workers, thus increasing our confidence in the results.
Lastly, the implementation of a control site that did not receive the enhanced intervention against STDs and HIV raises ethical dilemmas. However, efforts were made by the research team to address the ethical concerns. First, the provision of a free, accessible health clinic for sex workers in both of the sites was an improvement over the usual standard of care. Second, there was no guarantee that the intervention would be effective. And most importantly, in discussions between the U.S.-based research team and the Calcutta-based Sonagachi intervention team, it was agreed that at the end of the study period the control community would cross over; the Sonagachi team moved into the control community after the study period to provide the enhanced intervention.
Too often, effective interventions are conceptualized based on theories of social change and launched by university researchers. This intervention was designed by the community,29,30
is sustained by the community, and is taken to new communities by sex workers. In this replication, the mounting and design of the intervention were controlled by the Calcutta team of sex workers from the Sonagachi Project. The research team only conducted the evaluation of a project conceived and refined over time by the community. Greater emphasis must be placed on interventions arising from communities if HIV prevention programs are to be sustained and broadly implemented.