As with other studies of sex-trafficked women and girls in South Asia [3
] the present study documents a substantially high seroprevalence of HIV (45.8%) in this population of predominantly Karntakan women and girls released from sex trafficking and receiving assistance at Odanadi. Furthermore, narratives illustrate how the context of sex trafficking heightens HIV risk. Specifically, experiences with extreme sexual violence as a tool to initiate individuals into sex work (i.e. gain compliance), the inability to refuse sex or negotiate condom use, and the inability to obtain health care appeared to place these women and girls directly at risk for HIV. The narratives also suggested the importance of substance use, both in the form of forced consumption as well as a means of coping with the sexual and physical violence they were made to endure; substance use may further heighten HIV vulnerability among victims of sex trafficking.
Given the confluence of fear, violence, and lack of autonomy described within the context of sex trafficking, it is questionable whether HIV prevention strategies relying solely on the ability of FSWs to negotiate and demand condom use with male clients are effective among sex-trafficked women and girls [13
]. In addition, HIV prevention strategies that depend upon brothel owner enforcement of condom use among male clients may be similarly limited based on the current data. Central to the success of such approaches is engagement with brothel owners to convince them of the value and profits associated with keeping FSWs healthy and free of disease [17
]. However, in the case of sex-trafficked women and girls, brothel owners may be more concerned with associated costs, which include having to pay nearly double the rate to “buy” younger girls from traffickers in response to the demands of male clients for younger girls [18
]. Thus, to fully profit from their “investment,” brothel owners may place the interests of paying male clients above the health of FSWs [19
], a situation likely exacerbated in cases of trafficked girls. Attempts to engage brothel owners in focusing on longer-term profit goals that can be derived from preserving the health of FSWs must also overcome the steady supply of young trafficking victims reported in this region [14
] and the relatively low risk of prosecution for forcibly prostituting such individuals [18
]. Further research related to development of HIV prevention programming in this context is needed.
Consistent with previous work with young, debt-bonded FSWs in Southeast Asia [20
], sex-trafficked women and girls in the present study faced obstacles from brothel managers in obtaining access to health care. Considering the illegal nature of sex trafficking, brothel managers are likely to ensure that sex-trafficked victims remain hidden from authorities, including healthcare professionals [21
]. Thus, existing HIV-focused interventions and programming (e.g. VCT clinics, NGO-led support groups) that may be successful among general populations of FSWs (i.e. those with relatively more personal freedom) may be inaccessible to sex-trafficked women and girls because of restrictions on movement outside of brothels [23
]. These restrictions are likely to pose barriers to accessing health programs even in situations where attempts are made by public health professionals to build rapport with brothel owners, as documented among young, debt-bonded FSWs in Cambodia [20
]. This inability to obtain treatment may place trafficked women and girls at greater risk for HIV infection.
The findings of the present study are best considered in the context of the following limitations. This work is limited by the small sample size of case records, thus results may not be generalizable to the larger population of sex-trafficked victims from either Karnataka or other Indian states. Nonetheless, the themes gleaned from case narratives are consistent with the few studies that have been conducted with younger and/or debt-bonded populations [11
], as well as prior hypotheses concerning HIV vulnerability in the context of sex trafficking [8
]. In addition, case records were reviewed from only one NGO, and women and girls cared for by other organizations may report different experiences. However, the sample includes women and girls who were trafficked to multiple destinations (e.g. Mumbai, Delhi, within Karnataka). Data were abstracted from case narratives that recorded the testimony of the sex-trafficked survivors at the time of intake into Odanadi. Thus, data may have been subject to error via caseworker detection or survivor recall. Moreover, the case narratives were not originally intended for research purposes, and were often recorded in the third person. Future research should seek to quantitatively corroborate the themes presented in this qualitative work.
Despite these limitations the current work provides critical insight into how the context of sex trafficking (e.g. violent initiation, lack of control over condom use) may place trafficked women and girls at high risk for HIV infection and potentially explain the high prevalence of HIV reported in earlier studies. While further research is needed to clarify these observations, current findings have several important implications for HIV prevention and intervention. These include broadening existing FSW-focused public health programs via development and implementation of HIV prevention strategies that can reach this highly vulnerable and hidden population. Also of paramount importance is increasing condom use among male clients, since reliance upon trafficked women and girls to negotiate condom use is likely to be ineffective and be met with violent repercussions.
Our qualitative findings also highlight the need for increased efforts to prevent sex trafficking in South Asia, including the release of women and girls who are forced into prostitution. Currently, the majority of such enterprises are conducted by antitrafficking NGOs, in conjunction with police operations. Another emerging model is FSW self-regulatory boards to monitor sex trafficking cases, without police involvement [25
]. To date, neither approach has been formally evaluated regarding their ability to reduce trafficking. Development of effective and large-scale approaches to prevent sex trafficking is urgently needed to avert the brutal violence that is inflicted upon these women and girls and to minimize their risk for HIV infection.