The HIV and Sex Work Collection - Joint Programme Monitoring ...

AcronymsADBAsian Development BankIUDIntrauterine devicesAEMAsian Epidemic ModelKMRCKunming Red Cross SocietyAPNSWARTBCCBDSAsia-Pacific Network of SexWorkersAntiretroviral therapyBehavior Change CommunicationBlue Diamond Society, NepalKTVKunming CDCLGBTIMACKaraoke Chinese StyleKunming Center for DiseaseControlLesbian, Gay, Bisexual,Transgender and IntersexMalaysian AIDS CouncilCBOCCMDiCDJCommunity-Based OrganizationCountry CoordinatingMechanismDrop In CentreDisc JockeyMAPNACONACP-IIINAPFoundation-Migrant AssistanceProgramNational AIDS ControlOrganizationThe Third National AIDS ControlProgram, IndiaNational AIDS Program, MyanmarDMSC Durbar Mahila SamanwayaCommitteeFHI360 Family Health International 360NCASCNGONational Center for AIDS and STDControl, NepalNon-Governmental OrganizationGFATMHIVGlobal Fund to Fight for AIDS,Tuberculosis and MalariaHuman Immunodeficiency VirusNGUNFENon-Gonococcal UrethritisNon Formal EducationIBBSICTIDUIntegrated Biological andBehavioral StudyInformation CommunicationTechnologyInjecting Drug UserNHRCNMSOINational Human RightsCommission, NepalNari Mukti SanghaOpportunistic InfectionIECi/NGOInformation EducationCommunicationInternational / Non-Governmental OrganizationPACTPEPHOPact ThailandPeer EducatorPublic Health OfficePage 4

AcronymsPILPublic Interest LitigationTNCAThai National Coalition on AIDSPMTCTPRANPROTIRODHPSIRHRISACSPreventing Mother to ChildTransmission of HIVPacific Rainbow AdvocacyNetwork, FijiPromoting Rights of theDisadvantaged by PreventingViolence Against WomenPopulation Services InternationalReproductive HealthResearch and InnovationState AIDS Control SocietyUNAIDSUNGASSUNFPA APROUSAIDVAMPVCTWACJoint United Nations Programmeon HIV/AIDSUnited Nations General AssemblySpecial SessionUnited Nations Population Fund,Asia-Pacific Regional OfficeUnited States Agency inDevelopmentVeshya Anyay Mukti Parishad,IndiaVoluntary Counselling andTestingWomen’s Action for Change, FijiSANSurvival Advocacy Network, FijiWHOWorld Health OrganizationSANGRAMSHAKTISRHSampada Gramin MahilaSanstha, IndiaStopping HIV/AIDS ThroughKnowledge and Training InitiativeSexual Reproductive HealthYunnan PHBYunnan Bureau of Public HealthSTISexually Transmitted InfectionSWHASex Workers Living with HIVSWINGTBService Workers in Group,ThailandTuberculosisTGTransgendered PersonsTGSWTransgendered Sex WorkerTITargeted InterventionTOPTargeted Outreach Program,MyanmarPage 5

IntroductionContextA wealth of analysis exists on the natureand extent of HIV epidemics in Asia and thePacific in the context of sex work. These havehighlighted the progress and the challengesthat must be tackled 1 to realize the targetsto which governments have committed, 2 tobring an end to AIDS. Guidance on effectiveinvestment and responses is well articulated.For example, the UNAIDS Guidance Note onHIV and Sex Work expresses the need fora comprehensive response that prioritizesevidence- and rights-based HIV prevention,treatment and care programmes for keyaffected populations. Moreover it addressesthe factors that impede these efforts andresponds to the underlying causes ofvulnerability to HIV infection. 3Page 6

Key elements ofa comprehensive responseThe key elements of a comprehensive response to HIV in the context of sex work are:• community mobilization and organizationaldevelopment of sex worker-led organizations andnetworks;• peer outreach, and education 4 and drop-inservices, including linking or providing serviceswithin sex worker-specific programmes such asfor sexually transmitted infections (STIs), voluntarytesting and counselling (VTC), family planning;• promotion of and access to male and femalecondoms and water-based lubricants, includingstrategies to ensure demand, access, utilizationand supply — particularly in sites where sexwork takes place — community awareness andacceptance of condom use and empoweringsex workers to negotiate condom use;• access to the full range of sexual and reproductivehealth (SRH) services to meet the needs ofsex workers and their clients. This includesdiagnosis and treatment of STIs; the full range ofcontraceptive methods and counselling to preventunintended pregnancies; access to antenatal,delivery and post-natal care, including access toantiretroviral drugs for mothers and to preventvertical transmission;• access to alcohol and drug-related harm reduction,including needle and syringe programmes andopioid substitution therapy;• HIV voluntary testing and counselling;• access to HIV treatment, care and support;• preventing and addressing violence;• preventing and responding to stigma anddiscrimination, including in health care settings,through stigma reduction strategies, communitylegal education and access to legal services;• economic empowerment programming thatexpands choices for control over financialresources and generation of additional oralternative income;• advocacy and leadership building to reformlaws, policies and law enforcement practicesthat undermine rights and impede an effectiveresponse and to promote protective laws, policiesand practices that support effective responses. 5Page 7

There is considerable experience in this region about what works indelivering HIV prevention, treatment and care programmesThe elements of a comprehensive response are anelaboration of the three pillars outlined in the UNAIDSGuidance Note on HIV and Sex Work:• Pillar 1 — ensure universal access to comprehensiveHIV prevention, treatment, care and support• Pillar 2 — build supportive environments, strengthenpartnerships and expand choices• Pillar 3 — reduce vulnerability and address structuralissues.In addition, Investing for Results, Results for Peopleemphasizes the need to combine specific HIVprevention, treatment and care programmes withefforts to ensure investment in the ‘critical enablers’.This encompasses social enablers such as stigmareduction and supportive laws, and enabling policies,practices and programmes such as those withcommunity-centred design and delivery. 6There is considerable experience in this regionabout what works in delivering HIV prevention,treatment and care programmes combined withaddressing the factors that adversely affect theseefforts and responding to the underlying causes ofvulnerability to HIV infection. Yet there is a dearth ofdocumentation and analysis of this experience; whatworks and how these lessons should guide policy,programmes and resource allocations to ensure aneffective response in the region.Purpose and audienceThe purpose of this resource is to:• document and share programming and advocacy experiencefrom across the Asia-Pacific region that canguide programming and advocacy efforts to respondeffectively to HIV in the context of sex work;• provide detailed case studies that illustrate the waysin which programmes and advocacy interventionswere designed and delivered to address variouselements of a comprehensive response;• identify lessons learned, gaps and challenges andkey considerations for strengthening and scalingup comprehensive and effective responses in theregion.This resource provides insights into what is an effectiveresponse to HIV in the context of sex work in the Asia-Pacific region, and the manner in which programmaticand advocacy interventions have been carried out. It isenvisaged that it will be a valuable resource:• for programming managers, implementers andservice providers, including government, NGOs andsex worker organizations, in the design and deliveryof programmes;• to guide policy makers and development partners inplanning and allocating resources for strengtheningand scaling up effective interventions;• to advance advocacy efforts for a comprehensiveresponse that focuses on evidence and rights-basedinterventions.Page 8

Overview of contentPart 1 provides a brief summary of the key lessonslearned and gaps and challenges in delivering andscaling up evidence and rights-based responses in theAsia-Pacific region. This analysis is largely drawn fromthe experiences, lessons and reflections identified inthe case studies, supplemented by a desk review ofrelated programming experience and research.Part 2 provides eleven detailed case studies onHIV and sex work interventions from seven countriesin the Asia-Pacific region — Bangladesh, China, Fiji,India, Myanmar, Nepal and Thailand. Each of these illustratesone or more elements of the comprehensiveresponse outlined above.All the organizations documented offer a range ofprogrammes. The case studies examine particular programmesand advocacy interventions for which thereis an absence of concrete guidance on approaches todesign and implementation and ways to achieve effectiveoutcomes. The table below summarizes the focusof each case study.Given the diversity of the interventions beingdocumented there are variations in the structure andanalysis of each case study. Broadly, they offer informationon the following:• a brief history of organization or intervention;• synopsis of the local HIV scenario;• the key interventions;• the rationale and programme principles that guideddesign and implementation;• the intervention design and implementation;• the accomplishments and challenges encounteredin design, implementation, monitoring and measuringresults;• ways that the intervention adapted to challenges andemerging needs;• means of monitoring and measuring results;• factors that contributed to progress and/or measurableresults;• lessons learned from the intervention;• gaps, challenges and future opportunities;Details about the methodology and processes for thedevelopment of this resource can be found in Annex atthe end of the regional analysis section (page 30).Page 9

Summary of case studiesOrganization Focus of documentation Country PageTOP/PSI (TargetedOutreach Programme,Population ServiceInternational)Dark BlueService Workers in Group(SWING)Lily Women’sWellness CentreVeshya Anyay MuktiParishad (VAMP) PlusUSHA Cooperative/Durbar MahilaSamanwaya Committee(DMSC)Durjoy Nari Sangha(Durjoy)Blue Diamond Society(BDS)Ashodaya AcademyEMPOWERSurvival AdvocacyNetwork Fiji (SAN Fiji)Scaling up an integrated approach to SRH and HIVprevention, testing, treatment and careHIV prevention, treatment and care for male andtransgender sex workersSex worker organizational development;Partnership with police to foster law enforcementpractices that protect rights and supports effectiveHIV programmingHIV prevention, treatment and care for ‘low fee’sex workersImproving access to HIV testing, treatment andcare for sex workers living with HIVEconomic empowerment: financialcooperative — savings and loansPreventing and addressing violence againstsex workersAdvocacy and leadership development for lawreform, programmes for legal education and legalservices for men who have sex with men andtransgender communitiesCommunity-to-community capacity building forsex worker- led HIV interventionsMeeting the needs of migrant sex workers: integratingHIV within holistic education programming;advocacy for labour rights andreform of laws and law enforcement practices.Addressing stigma and discrimination, improvingaccess to health servicesMyanmar 36China 48Thailand 57China 68India 78India 85Bangladesh 94Nepal 106India 116Thailand 129Fiji 139Page 10

Part 1:Lessons fromexperience in theAsia-Pacific regionThis section examines some of the key lessons that can bedrawn from the case studies and integrates an analysis ofrelated programming experience and research.Page 11

“ Community engagement is vital for advocacy, generating demand and ensuringaccountability for results. Civil society organizations play a vital role as enablers andmust have the resources and tools to play their role effectively over the long term.”Investing for Results. Results for People, UNAIDS 2012Community empowerment:The foundation of innovativeresponsesThe meaningful involvement of sex workers in theHIV response is often narrowly perceived as ensuringsex workers’ role as peer educators in HIV preventionprogrammes. This collection of case studies evidencesways in which community mobilization andempowerment builds sex workers’ social capital andprovides foundations for:• effective models for peer outreach, holistic educationand social mobilization, so that sex workers canaddress the challenges they face in their lives;• addressing the barriers to access HIV, SRH and otherhealth services, including addressing stigma anddiscrimination, building community demand andconfidence to access services;• encouraging innovative approaches to preventingand addressing violence against sex workers; tacklelaw enforcement practices that violate sex workers’rights and undermine effective HIV responses, andexpand choices for economic empowerment.The central principle that underscores most casestudies is the empowerment of sex workers to asserttheir human rights, control their domestic and workenvironment and improve their social conditions andhealth. While a focus on HIV prevention is a commonthread, these organizations concentrate on the broaderissues of health, development and well-being ofsex workers and their families.Community capacity development, organizationalstrengthening and leadership within sex workercommunities are essential elements of an HIVresponse in Asia and the Pacific. Many of theinnovative programmes that have been documentedare testament to the critical importance of highquality,flexible and appropriate technical supportfor sex worker-led organizations. Such technicalsupport improves organizational development, anddesign and implementation of effective programmesand develops sex worker community leadership.SWING (page 57), USHA Cooperative (page 85),Durjoy (page 94), TOP/PSI (page 36) andAshodaya Academy (page 116) exemplify the waysin which organizations have benefited from technicalassistance that is tailored to address the strategicpriorities of sex worker organizations, often sustainedover a considerable periods and is responsive to theirchanging needs. The technical support provided hascome from a variety of sources including the Asia-Pacific Network of Sex workers, the Global Networkof Sex Work Projects, international NGOs, researchinstitutions and United Nations agencies.“Community empowerment is when the community gains control of, andhelps to solve, the problems confronting it.”Terms of empowerment / exemplars of prevention: towards a theory of community psychology,Rappaport, J., American Journal of Psychology, 1987.Page 12

“ As a community, we all say NO to sex without condoms. We will not have sex withoutcondoms, even if it means we do not get clients for the day. This is one of our standardsfor ourselves and we follow this rule. This is why condom use among sex workers inMysore has been consistently high over the years.”Akram, male sex worker, Ashodaya AcademyPeer-based community outreachand educationPeer-based community outreach and education is vitalto reaching sex workers to provide access to preventioncommodities and develop sustained relationships thatencourage access to HIV programmes and services. Peeroutreach interventions have been shown to increaseHIV knowledge and condom use and reduce equipmentsharing among people who inject drugs. 7 Moreover,effective peer-based outreach and education is crucialin influencing community norms to promote ongoingsafer behaviours among sex workers and clients. 8Experience across the region demonstrates thecritical nexus between effective peer-based outreachand education and facilitating demand for and uptakeof HIV testing, STI diagnosis and treatment and HIVtreatment, care and support. Partnership between sexworker organizations and health care providers canreduce discrimination and improve health servicequality.Peers play a vital role in generating communitydemand and confidence to access services, and asa feedback loop to identify and address concerns inaccess to and quality of health services. 9The case study of Dark Blue in Tianjin, China(page 48), illustrates the ways that peer outreachcan reach highly mobile and ‘hidden’ groups of maleand transgender 10 sex workers. An innovative idea ofcreating virtual safe space through web-based radioand chat rooms is used as a vehicle for communityeducation and networking. This is used to promotehealth facilities of Dark Blue and the provincialgovernment. To achieve this, Dark Blue has investedconsiderable efforts in developing a strong partnershipwith the provincial health authority in Tianjin.In some instances, the socio-legal milieu foreffective peer outreach is complex and requiresalternative approaches, as demonstrated by LilyWomen’s Wellness Centre (page 68). Faced withcertain complexities for registration and organizationof non-governmental organizations in China, theCentre has adopted flexible approaches to reachsex workers — including through mobile phonetechnology, advocacy and partnership-building toimprove the environment for effective programming.The importance of scaling up peer-led HIVinterventions is highlighted in a case study on theAshodaya Academy (page 116). This programmehas institutionalized capacity building by formingan academy of sex worker leaders. The academyimplements training and mentoring of sex workersto equip them with the necessary skills to designand deliver community-led HIV interventions. Theprogramme has provided training and mentoringin India and eight other countries in the Asia-Pacificregion.Multiple benefits ofdrop-in-centresDrop-in-Centres (dics) are central to effectivecommunity empowerment, education and access tohealth services across the Asia-Pacific region. Theyassist in building social capital and fostering solidarity;both critical for sex workers to address personal andstructural risks that increase their exposure to HIV. 11Often dics are the only safe place where sex workerscan gather, interact with friends and peers, participatein different learning opportunities and social events,rest and relax, bathe, and be taken care of when theyare ill.TOP/PSI, Myanmar (page 36) has 18 dics acrossthe country, providing a wide range of activitiesincluding English classes, educational sessions on lifeskills and sexual health, social group meetings andentertainment. Their health services include VCT, STIdiagnosis and treatments and family planning adviceand commodities. Over eight years, 45 000 sex workershave registered at their dics — an estimated 75% of allsex workers in Myanmar. dics run by EMPOWER inThailand (page 129) support migrant sex workersacclimatising to a new culture, helping them gainlanguage skills, make friends, and learn about HIV andSTIs.Page 13

contact increased condom use by clients. 29 Echoingthese findings, Durjoy (page 94), USHA Cooperative(page 85), and SWING (page 57) found thatsocial marketing strategies, combined with repeatedoutreach contact with sex workers and their clients,have the greatest impact on consistent use of condoms.Another positive outcome of these condom socialmarketing programmes is that they provide flexibleresources for community-based organizations. Forinstance, from an initial capital investment of US$ 100,SWING’s (page 57) revolving fund from this programmetotalled more than US$ 13 000 by June 2009. 30During 2010–2011, USHA Cooperative (page 85)made a profit equivalent to US$ 19 500. Such profitshave been used to fund activities that do not receivedonor support.Effective linkages between HIVand sexual and reproductive healthfor sex workers 31The rationale for improving sexual and reproductivehealth (SRH) for key affected populations and linkingSRH and HIV services is well documented. 32 In June2011, Member States of the United Nations agreed toachieve bold new targets including:• reducing sexual transmission of HIV by 50% by 2015and• eliminating new HIV infections among children. 33To realize these targets in this region, linkages betweensexual and reproductive health (SRH) and HIV servicesto address the SRH needs of sex workers are crucial. Forfemale sex workers, ensuring effective linkages willreduce unintended pregnancies and improve accessto antenatal, delivery and post natal care includingaccess to the antiretroviral drugs both for the mothers’own health and to prevent infection to their childduring pregnancy, delivery and breastfeeding.However, programmatic experience in doing so islimited. 34 Realizing these synergies in practice makes‘people sense’ and ensures effective use of availablefinancial and human resources.There has been considerable progress in eliminatingnew HIV infections through integrating Preventionof Mother to Child Transmission (PMTCT) withinmaternal child health (MCH) services. However, thishas led to a focus on HIV testing of pregnant womenwho attend MCH services, and often female sex workersat higher risk HIV are not accessing MCH services.Criminalization of sex work and high levels of stigmaand discrimination undermines sex workers’ access tohealth services including MCH. 35 This underscore theimportance of HIV testing within HIV programmes forsex workers and the need to provide effective referralto MCH/PMTCT for pregnant sex workers living withHIV.Moreover, there are serious gaps in familyplanning counselling and access to the full rangeof contraception for sex workers. 36 The provision ofcondoms alone as protection against HIV, STIs andpregnancy does not address the realities of femalesex workers’ lives, as workers and women given:• low condom use among non-commercial partners; 37• high rates of abortion, indicating unmetcontraceptive need; 38• condoms are less effective in preventing unwantedpregnancy compared with other contraceptivemethods; 39• high levels of sexual violence; 40A number of case studies indicate that improvingsex workers’ understanding of their sexual andreproductive health rights is a focus of their educationefforts. However, very few focus on delivering SRHrelated services or building referral networks withgovernment and private providers of SRH services,beyond STI diagnosis and treatment.Page 18

Consistent condom use and exposure to mass media andoutreach (number of respondents in brackets)100 per cent798789929698No exposure(442)1+contact andmass media(229)2+contacts andmass media(119)3+ contacts andmass media(95)4+ contacts andmass media(73)5+ contacts andmass media(56)Note: All statistically significant compared with no exposure p < .05Source: Using Formative Research to Promote Behavior Change among Male Clients of Female Sex workers in Vietnam,Ngoc K V, et al, Cases in Public Health Communication & Marketing 2011.TOP in Myanmar (page 36) and Lily Women’sWellness Centre in Kunming, China (page 68), aretwo such examples that illustrate linking SRH and HIVprogrammes can successfully deliver both HIV preventionand reproductive health outcomes.TOP (page 36) started providing a wide range ofSRH services in 2005, as part of their dic clinic servicesfor female sex workers in Yangon. This includes familyplanning counselling, access to the full range of contraceptivemethods including contraceptive pill, injectables,IUDs and pregnancy test kits. They alsoprovide cervical cancer screening. TOP’s work demonstratesa strategic focus in delivering aspects of theSRH services that can best be delivered in dics suchas family planning and pregnancy planning linked toa network of quality private providers to meet a rangeof SRH needs for sex workers. This approach couldbe applied to improving sex workers’ access to SRHservices located within public health systems.Likewise, through on-site clinic services at their dic,Lily Women’s Wellness Centre (page 68) providesa similar range of SRH services for female sex workers.Accompanied referrals to offsite SRH services are alsoprovided, wherein partnerships have been formedwith government doctors in Kunming.There is a pressing need to ensure that theselessons are applied more broadly in the region. Greaterfocus is required to ensure SRH and HIV services meetthe needs of female sex workers, to reduce unintendedpregnancies and improve access to antenatal, deliveryand post natal care including access to antiretroviraldrugs for mothers and to prevent vertical transmission.The work of Dark Blue in China and BDS in Nepal,are illustrative of efforts to improve the sexual healthPage 19

Lessons learned acrossthe region providea compelling case forscaling up condomsocial marketing as aneffective strategy for:• promoting condom use among male clients;• creating supportive social norms for condomuse, both within the sex industry and widercommunity;• a sustainable, cost-effective approachto availability of high-quality affordablecondoms and lubricants;• generating flexible resources for communitybasedorganizations.needs of MSM and transgender people, includingsex workers. For example, Dark Blue addressthe sexual health of MSM and transgendersex workers through ensuring access to STI diagnosisand treatment services and psychosocialsupport to increase self-esteem and improvehealth seeking behaviour.Effectively addressing the sexual healthneeds of MSM and transgender sex workersincludes ensuring:• taking a sexual history that includes attentionto anal sex, particularly to include this in history-takingfrom men who may not appear tobe having male-to-male sex• counselling about safer sex, including effectiveapproaches to couple counselling for marriedMSM• sensitivity to MSM and TG — particularly important forTG who have experienced rejection, humiliation anddiscrimination in health services• psychosocial support to increase general health, selfesteemand general capacity to reduce risk of acquiringor transmitting HIV and other STIs• attention to sexual health beyond HIV/STIs — includinganal health, penile and prostate cancer screeningand hormone treatment and care for transgenderpeople. 41Improving access and uptake ofVCT and HIV treatmentGood quality HIV VCT is important so that people canmake an informed decision to test, know their status,reflect on risk reduction strategies for themselves and/or others, and identify their preferred course of actionshould their test result be positive.Country-specific data reveals a need to improveuptake of HIV testing among sex workers in manycountries in the region. The median reported coveragein 2010 was 34% for female sex workers (range4%–79%) in 20 countries reporting data. 42 Countrydata show strong efforts are still required in manycountries in the region. For example, the percentage ofsex workers who had an HIV test in the last 12 monthswas 43.8% in Viet Nam and 38.2% in China, 50.4%among venue based workers and 65.2% among malesex workers in Thailand and 54.6% among femalesex workers in Nepal. Indonesia at 79.4% in Indonesia,71% in Myanmar showed better results. Indonesiaand Myanmar indicate better results; 79.4% and 71%respectively. 43To improve sex workers’ access to VCT, and HIVtreatment should they require it, there is a need tocomprehend the factors that undermine access, andlook to the ways these barriers are being addressed.For example, it is well established that stigma is animpediment to testing. It reduces quality of care,Page 20

delays testing and hinders adherence to treatment. 44Concerns regarding mandatory or forced testing andbreaches of confidentiality have been widely reportedby sex workers in the region, including that disclosureof HIV positive results can lead to sex workers losingtheir job. 45 These infringements undermine people’swillingness to test. 46SAN Fiji’s innovative work in developing a play asa tool to explore the barriers sex workers face inaccessing health services has been a catalyst for sexworker and health care provider engagement. Thereare indications that this has resulted in reducingdiscrimination, evident in the significant increase inthe number of sex workers accessing health services.Moreover it has provided a strong impetus for creatingnon-discrimination policy in health care settings.Community-based VCT: rapid,confidential and accessibleCommunity-based VCT is one of the most effective andinexpensive service delivery models. 47 Experience inthe region shows a combination of factors help increasesex workers’ uptake to VCT in community settings.These include availability of rapid testing; providingservices during hours and in locations that areconvenient to sex workers; deploying professionallytrained community counsellors; and a demonstrationof commitment to confidentiality in service design.In Dark Blue’s experience (page 48), sex workersprefer rapid testing delivered by community counsellors.Introduction of this approach into the programmecontributed to a doubling HIV testing among male andtransgender sex workers over two years — from 2 163people testing in 2009 to 4 501 in 2011.TOP (page 36) provides pre- and post-test counsellingin all their dic. They provide rapid testing infive sites but rapid test kits are not widely availablein Myanmar. For all other sites, TOP transports bloodsamples daily to the nearest cooperating clinic forscreening. Once the results are returned, within oneto two days, community counsellors at the dic providethe post-test counselling. In 2011, of the 12 107 peopleaccessed VCT services in Myanmar, about 40% weretested through the TOP program. 48Designing and implementing community-basedVCT programmes has fostered working partnershipswith local public health services. Such linkageshave assisted access to rapid tests kits and laboratoryservices, ensured that community counsellors areprofessionally trained and that diagnostic facilitiesmeet quality assurance standards. 49 This underscoresthe vital role of the public health system in makingHIV treatment and care services a ground reality forsex workers.EMPOWER’s experience in implementing an HIVprevention programme funded through Global Fundresources, sounds a note of caution on the difficultiesof applying appropriate performance targets inthe context of broad programmes seeking to protectthe rights of sex workers and deliver more effectiveholistic programming. In this case, the target set forVCT was 1 600 sex workers recruited and tested in oneyear “…although more than this came for counselling,only 500 sex workers went on to have an HIV test. It ledto problems because we were not able to ‘meet’ GlobalFund to Fight AIDS, Tuberculosis and Malaria (GFATM)VCT indicators…Ultimately, we were judged to be noteffective…” Noi, EMPOWER. Sex workers’ decision totest for HIV must be voluntary and this should notbe undermined in order to meet numerical targets.Among the 500 sex workers that decided to test for HIV,30 tested positive and needed immediate follow-upsupport for treatment and care. 50 However, as fundingwas only linked to the testing element, there were noresources for the kind of support that was needed toensure those testing positive had access to treatment,care and appropriate support.Page 21

“Because of fear of discrimination, many sex workers do not want to take HIV test. MyCD4 count was 71 when I got HIV tested for the first time; with the right treatment andthe support I have received from my friends and community members, it is now 930.Improvements in my health status is a testimony of the positive impact of HIV testingand treatment.”Shantamma Gollars, Outreach Worker, VAMP PlusMaking HIV treatment and carereal for sex workers living with HIVOverall antiretroviral therapy coveragein the Asia-Pacific region is only 44%,lower than global average of 54%for low-income and middle-incomecountries.Source: Together we will end AIDS, UNAIDS, 2011.For people living with HIV, timely access toantiretroviral therapy not only saves lives and sustainsgood physical health, fully effective therapy preventsnew HIV infections. This provides a compellingcase for challenging the barriers to HIV testing andtreatment. 51 The vast majority of people living withHIV who are eligible for treatment are not receivingit. Sex workers are particularly disadvantaged inthis regard. Unfavourable conditions in health caresettings, usually stemming from stigma, threaten theiraccess to HIV treatment. 52VAMP Plus has developed a service delivery modelthat delivers continuity of care, improving access toboth VCT and HIV treatment for sex workers who testHIV positive. Their peer-based outreach and educationprogramme encompasses HIV testing and treatmentrelated literacy, pre- and post-test counsellingon HIV and accompanied referral for HIV testing. Allof the outreach sessions are individualised, focusingon one-to-one personal interaction, the benefits oftesting and consequences of results and accompaniedreferral to VCT centres. This has proved effective in improvinguptake of VCT. The key strength of VAMP Plusis their community centered, peer led approach thatfacilitates understanding of and access to HIV testingand access to HIV treatment, care and support for thosewho need it.Two key challenges were identified in the courseof documentation: Often there is a disconnectbetween HIV prevention and treatment services.This disconnection can be exacerbated by theway programmes are funded. HIV preventionprogrammes are commonly funded to includecondom programming, peer outreach and education,STI diagnosis and treatment and VCT. Organizationsthat implement HIV prevention programs often do notreceive funding support for follow-up support requiredto facilitate access to HIV treatment for sex workers.Programmes such as VAMP Plus have developed toaddress the reality of sex workers lives, having madea decision to test for HIV, yet too often unsupportedin accessing HIV treatment and care when the resultis positive. The kind of support required, as the VAMPPlus exemplifies, requires considerable time andskills — individual counselling and psychosocialsupport, accompanied referrals, treatment literacy,support with treatment adherence and engaging withhealth services to address stigma and create communityconfidence to access services. Disincentives to HIVtesting mean that sex workers living with HIV oftenonly discover their HIV status when they are alreadyseriously ill and the efficacy of treatment is reduced.Efforts to improve sex worker communities’ knowledgeabout the value of timely HIV treatment will encouragesex workers to test for HIV.Experience in the region indicates that there isinadequate attention to funding this work, a vitalconnection between sex workers and the healthsystem. Yet, it is precisely this kind of approach that canensure sex workers living with HIV have access to HIVtreatment and care. Community-based interventionsthat build sex workers’ understanding of and facilitateaccess to HIV treatment and care should be funded asintegral part of HIV treatment scale up.Page 22

“ …a structural intervention must grow from a strong collectivisation process andtransformations in sex workers’ relationship with local partners in responding to rapidlychanging contexts and addressing multiple risk factors simultaneously”.Sex worker-led structural interventions in India: A case study on addressing violence in HIV prevention throughAshodaya Samithi collective in Mysore, Indian J Med Res, 2012Addressing causal factors thathinder effective HIV responsesA feature common to most of the interventionsdocumented is the development of leadership amongsex workers. They amply illustrate that investingin sex worker empowerment leads to innovativeresponses which have become vehicles for socialchange — challenging inequality, social exclusionand marginalization and tackling law enforcementpractices that undermine sex workers’ access tohealth services. A concrete outcome of these effortsin the region is the many examples of strategic andinnovative efforts to address the causal factors forsex workers’ vulnerability to HIV infection.Structural interventions often missing incomprehensive responseRights-based, evidence-informed, and community-ownedprogrammes that combine biomedical, behavioural,and structural interventions, and are attentiveto the specificities of communities, will havethe greatest sustainable impact on reducing new infections.53, 54 This is often referred to as ‘combinationprevention’. And yet, according to a number ofreports, national programmes seldom include robustsupport for structural interventions to change policiesand social norms that block the AIDS response, andexisting efforts are insufficiently grounded in humanrights or integrated with the broader developmentagenda. 55 Renewed investment approaches to AIDS emphasizethe need for better allocation of national resourcesfor structural interventions to be included aspart of comprehensive responses to HIV prevention. 56In 2009, of all external investments in HIV in the Asia-Pacific region, only 4% was directed to addressing theenabling environment. 57Recognizing and harnessing sex worker communitiesas active agents of change — as opposed topassive recipients of services, Ashodaya Academy inIndia (page 116), SWING in Thailand (page 57),and TOP in Myanmar (page 36), for example haveadopted approaches which respond to the underlyingcauses of sex workers’ vulnerability to HIV infection.They provide impetus for scaling up structuralinterventions as an essential part of a comprehensiveresponse.Preventing and responding to violenceThere is a plethora of evidence about the nature andextent of violence against sex workers and the impactit has on their lives, including on their ability toprotect themselves from HIV infection. 58 Violence hasbeen found to be significantly associated with sexualhealth risk, including reduced condom use andincreased risk of STI/HIV. 59 Efforts to address violenceagainst sex workers have demonstrated:• significant reduction in violence 60• increased condom use among sex workers and theirclients, reductions in STIs, improved access to HIVprevention and treatment services 61• better health and social outcomes for sex workers. 62In Bangladesh, Durjoy Nari Sangha’s anti-violenceprogramme (page 94), Promoting Rights ofDisadvantaged by Preventing Violence AgainstWomen (PROTIRODH), is multifaceted and seeks to:• prevent violence by mobilizing and buildingcapacities of sex workers and community partners,including clients, police, local business men, goons 63and religious leaders;• mitigate violence by ensuring that sex workers whoexperience violence can access legal, health andprotection support services; and• respond to violence by tackling barriers to reportingviolence, enhancing access to legal support andimproving responsiveness of law enforcement andjudiciary systems.Page 23

Percentage of sex workers receiving an HIV test in the last12 months and know the results, 2007–2011Afghanistan20094FSWBangladesh*2010438MSMCambodia**201082China201138Indonesia20117789Lao PDR201122Malaysia200920Myanmar200871Nepal***20115565Pakistan201169Philippines2009Papua New Guinea2010194744Thailand2010Viet Nam2011445051100 per cent* 2006–2007 data for female sex workers** Female entertainment workers who have more than 14 clients per week*** Kathmandu Valley, 2009 for female sex workersSource: www.aidsdatahub.org based on Global AIDS Response Progress Reports 2012and UNGASS Country Progress Reports 2010Page 24

In the Asia-Pacific region, and across world, there are too many examples of countrieswith laws, policies and practices that punish, rather than protect, people in needs of HIVservices. Where the law does not advance justice, it stalls progress.HIV in Asia and the Pacific: Getting to Zero, UNAIDS 2011 p.88.PROTIRODH demonstrates the numerous benefitsof integrating an anti-violence programme. Theseinclude reduction in incidence of violence, increasedunderstanding of rights among sex workers, increasedreporting of violence and improved access to legal andhealth services and social systems. 64Ashodaya Samithi’s work on addressing violence 65revealed an 84% reduction in the incidence of violenceover five years. Empowerment across social contextswas central to this transformation, particularly innegotiating with police, boyfriends, lodge owners andclients. A concrete outcome was more support andprotection from police.Features of effective anti-violenceprogrammesExperience in implementation of anti-violenceinterventions demonstrates several features that makethem effective. These are:• space for community discussions to understandpeople’s experiences of violence, exchange protectivestrategies and problem solve according tocontext;• partnerships between sex workers and key stakeholdersat local level, including police, venue andbrothel owners, community leaders, long-termpartners and clients of sex workers, lawyers, humanrights institutions, and health care service providers;• capacity development of sex workers to case manageincidences of violence, including counselling andreferral;• mechanisms to document incidents of violence andprovide and/or refer individuals to services requiredto address a range of their needs including:––health, including emergency contraception, postexposureprophylaxis (PEP) and diagnosis andtreatment of STIs and counselling––legal assistance––individual and group psychosocial support––shelter• implement community-based education that addressesstigma, exclusion and marginalization ofsex workers. 66Tackling laws and policing practicesStigmatization, and in many cases criminalisation, ofaspects of sex work perpetuates an environment thatexposes sex workers to violence. This results in theireconomic and social exclusion, preventing them fromaccessing essential HIV prevention and care services. 67Almost all countries in the region currently criminalisesome aspect of sex work. 68The Global Commission on HIV and the Law undertook18 months of extensive research and consultation,releasing their landmark report in July 2012. 69The Commission found that an epidemic of bad lawsand human rights abuses is stifling the global AIDSresponse. The report states that despite the plethora ofscientific breakthroughs and billions of dollars of investments,over the past three decades that have ledto the remarkable expansion of lifesaving HIV preventionand treatment—benefiting countless individuals,families and communities—many countries squanderresources by enacting and enforcing laws that underminethese critical investments. 70The Commission stated that countries must reformtheir approach towards sex work, by ensuring safeworking conditions and offering sex workers andtheir clients’ access to effective HIV and healthPage 25

An epidemic of bad laws and human rightsabuses is stifling the global AIDS responseGlobal Commission on HIV and the Law — Risks, Rights andHealth, July 2012services and commodities. Among the Commissionrecommendations were the following:• repeal laws that prohibit consenting adults to buyor sell sex, as well as laws that otherwise prohibitcommercial sex, such as laws against ‘immoral’earnings, ‘living off the earnings’ of prostitution andbrothel-keeping;• complementary legal measures must be taken toensure safe working conditions to sex workers;• take all measures to stop police harassment andviolence against sex workers;• prohibit mandatory HIV and STI testing. 71Sex worker organizations including EMPOWER(page 129), Ashodaya Samithi, SWING (page 57),Durjoy (page 94), DMSC, together with the Asia-PacificNetwork of Sex Workers have been at the forefrontof advocacy efforts to ensure legal recognition ofsex work as work, with equal labour rights and occupationalhealth safeguards. The International LabourOrganizations’ Recommendation Concerning HIV andAIDS and the World of Work, which recognizes sexwork as work, provides an important advocacy tool forlobbying governments and employers. 72EMPOWER (page 129) has advanced labour rightsfor sex workers by ensuring their access to the ThaiNational Social Security Scheme. Their communityledresearch documents the negative effects of antitraffickingraids by police on sex workers and findingssuggest that sex workers in Thailand who have notbeen trafficked are routinely arrested and imprisonedin such raids. 73 The findings are being used toadvocate for a review of anti-trafficking laws and lawenforcement practices to ensure that they are not usedto target consenting adult sex workers. 74In Nepal, the Blue Diamond Society’s work(page 106) is a powerful example of combining community-ledHIV programming among men who havesex with men and transgender people, with high levelpolitical and grass roots advocacy to create an enablinglegal, policy and social environment for sexual andgender variant minorities. Using a blend of advocacy,leadership building, legal education and test case litigationhas contributed to increased social, legal andpolitical recognition of rights of Lesbian, Gay, Bisexual,Transgender and Intersex (LGBTI) people in Nepal, includingsecuring a range of civic entitlements fortransgender people.SWING’s partnership with the police in Pattaya,Thailand (page 63), provides valuable insights intoways of overcoming police violence by simultaneouslyworking on two courses of action. The first is buildingup sex workers’ knowledge of their rights and skills tonegotiate with police. Secondly, SWING has been cultivatingdefenders of sex workers’ rights within thepolice service. This approach has had a positive impacton curbing abusive law enforcement practices andsupporting HIV efforts.Economic empowermentThe UNAIDS Guidance note on HIV and Sex Workrecommends a range of approaches to economicempowerment. This includes expanding choicesfor control over financial resources, generationof additional or alternative income, and access toeducation and vocational skills training.Efforts to improve the economic security ofsex workers and their families are reflected in a rangeof case studies. The most striking example is USHACooperative (page 85)— steered by Durbar MahilaSamanwaya Committee (DMSC), whose work has led toa sustainable economic empowerment intervention,with minimal start-up costs. Realizing that financialinsecurity is one of the reasons why sex workerscompromise on health and safety, DMSC identifiedthe need to address sex workers’ lack of access tofinancial institutions, leading to the eventual creationof the USHA Cooperative. The Cooperative providessecure savings and loans to over 16 000 members andinnovative income generation programmes throughsocial marketing strategies. The battle to registerUSHA as a cooperative of and for sex workers hadPage 26

wider ramifications. Ultimately it led to reform in theCooperatives Law that now recognizes sex work as anoccupation.Another innovative sex worker’s enterpriseis Ashodaya Samithi’s restaurant and apartmentrental service entirely managed by the sex workercommunity. Both ventures are an employmentsource for sex workers, the profits of which are keptas special fund for specific situations such as medicalemergencies. 75Lily Women’s Wellness Centre (page 68)has a range of strategies to advance the economicsecurity of sex workers including developing financialliteracy and monetary management skills; referralsto cooperating banks to enable sex workers toopen savings accounts and make investments; andproviding vocational training on marketable skills togenerate additional income.Importantly, several of the organizations runningeconomic empowerment programmes noted thatprogrammes designed to expand livelihoods optionsmust be based on a sound understanding of businessviability and the demand for skills in which people arebeing trained.For the most part, approaches to economicempowerment in the region appear to be piecemeal,small in scale and there is limited evidence aboutwhat is effective. HIV programmes should not beimplemented in isolation and better synergies betweenHIV-specific efforts and development are needed,including access to social protection, education andpoverty reduction. 76 Much more needs to be doneto ensure that programmes to address economicempowerment meet the needs of and are accessible tosex workers, rather than expecting HIV programmes todeliver on all aspects of a comprehensive response.All three of the case studies discussed abovedemonstrate ways that financial security benefits thewell-being of sex workers and their families. Theyprovide insight into how economic empowerment cancontribute to supporting HIV prevention and improvehealth outcomes for sex workers living with HIV. Forexample, acquiring skills in money management,opening bank accounts and having additional sourcesof income are activities that gesture being in commandof one’s situation. This has the cumulative effect ofbuilding sex workers’ capacities in other areas, such asto negotiate for safer sex and safe working conditions.For sex workers living with HIV, financial securityincreases quality of life in several measurable ways;enabling regular and continued health monitoringand treatment, balanced nutrition and a healthierlifestyle.Page 27

Summary of key themes• Partnership between sex worker organizations andhealth care providers can reduce discriminationand improve health service quality and uptake.• Peer outreach and education plays a vital role ingenerating community demand and confidenceto access services, and act as a feedback loop toidentify and address challenges in access to andquality of health services.• dics are central to effective communityempowerment, education and access to healthservices. They build social capital and fostersolidarity, both critical for sex workers to addresspersonal and structural risks that increase theirexposure to HIV.• There is an urgent need to better understand theuse of ICT by sex workers, and ways it can be usedeffectively as a tool for health promotion.• There is a compelling case for scaling up condomsocial marketing as a sustainable, cost effectiveapproach to availability of high-quality affordablecondom and lubricants. This promotes condomuse among male clients, and creates supportivesocial norms for condom use, both within the sexindustry and the wider community.• Effective linkages between SRH and HIV servicesfor sex workers make ‘people sense’ and ensureeffective use of available financial and humanresources. More attention is required to addressthe SRH needs of female sex workers.• A combination of factors help increase uptakeof VCT in community settings. These includeconvenient hours for sex workers, trainedcommunity counsellors, commitment toconfidentiality and the availability of rapid testkits.• Community-based interventions that build sexworkers’ understanding of and facilitate accessto HIV treatment and care should be funded asintegral part of HIV treatment scale up.• Greater investment in structural interventionsis urgently required, to address the factorsthat hinder effective HIV programmes and theunderlying causes of vulnerability to HIV infection.• Community capacity development, organizationalstrengthening and leadership within sex workers’communities are central to an effective responseto HIV.• Greater investment in financial and technicalresources is required to ensure high-qualitymonitoring and evaluation, particularly forinterventions where there is limited evidence.This will help to build the evidence base aboutwhat works in responding to HIV in the contextof sex work to ensure the most effective use ofresources.• Greater understanding of what approachesare effective to achieve greater economicempowerment for sex workers is needed, includinghow to improve access to social protection,education and poverty reduction programmes.Page 28

AnnexMethodologyThe development of this resource was led by UNFPAAsia-Pacific Regional Office (APRO), Asia-PacificRegional Support Team of the Joint United NationsProgramme on HIV/AIDS (UNAIDS) and the Asia-PacificNetwork of Sex Workers (APNSW).Criteria for selecting case studiesThe regional partners identified seven countries to bepart of an in-country process to identify and agree oncase studies for documentation. These countries werechosen because of their creditability in responding toHIV in the context of sex work, and their diverse rangeof HIV and sex work programming. A combination ofthese factors, it was felt, would offer a rich sample ofthe range of programmes in the region.The regional partners developed criteria and achecklist to guide case study selection at the countrylevel. The criteria determined that the organization orintervention:• demonstrated meaningful engagement of sexworkers;• applied evidence and rights-based approaches indesign and implementation;• demonstrated innovative approaches, strongprogress and/or achieved results; and• demonstrated interventions which engendered theelements of comprehensive approach, where documentationcould provide guidance for others incertain areas including economic empowerment;preventing and responding to violence; integrationof SRH and HIV for sex workers.Regional and country selection processesA participatory process took place in the selectedcountries to identify and decide on case studies fordocumentation:UNAIDS country offices convened relevant partnersincluding government, sex worker organizations andUnited Nations agencies to discuss the criteria, applythe checklist and nominate case studies for inclusion;The nominated case studies together with thechecklists were submitted to the regional partners,who made the final selection using the above criteria.Case study development methodsThe methods for developing selected case studiesincluded:• semi-structured interviews over telephone, Skypeand personal interviews with key informantsincluding management and programme staff, 77members of sex work communities and programmepartners;• extensive follow up with organizations in-country togather programme design documents, research data,evaluation reports and other published and unpublishedmaterials;• provision of draft case studies and feedback to organizationsfor review and fact checking; and• revision of case studies in light of feedbackresponse.Page 30

Limitations and lessons from the processAs outlined above, one criterion for case studyselection was ‘demonstrated innovative approaches,strong progress and/or achieved results’. The broadnature of this criterion was deliberate. At the outset,it was not possible to determine the extent to whichprogrammes had demonstrated results until detaileddocumentation had been done. Secondly, it is difficultto measure the impact of advocacy, such as for lawreform or reducing stigma in health care settings, andattribute the contribution of these efforts on improvingaccess to services. This is not a challenge unique to theprogrammes documented in this resource. 78Nevertheless, considerable effort was made duringdocumentation to gather and analyse data that highlightedresults. The case studies of Durjoy (page 94),Dark Blue (page 48), TOP/PSI (page 36), LilyWomen’s Wellness Centre (page 68) and USHA Cooperative(page 85) provide important insights intoways data was analysed and findings used to improveprogramming. Hence they are able to demonstrate theextent to which specific programmes have achievedresults.This resource reveals varying degrees of organizationalinvestment in assessing the results of interventions.It underscores the need to allocate financial andtechnical resources for high-quality monitoring andevaluation. This is critical to building the knowledgebase, particularly in areas where evidence is scant, sothat decision makers and development partners canensure effective use of available resources.One notable gap has become apparent throughthe documentation process. None of the case studiesindicate that they provide and/or refer sex workerswho use drugs to drug-related harm reduction programmes,including needle and syringe exchange andopioid substitution therapy. 79 There is evidence thatsex workers who inject drugs are at greater risk of HIVinfection. 80 Addressing this is critical. Sex workerswho inject drugs are at dual risk of HIV infection andthere indications that overlapping networks of populationsare at higher risk of HIV infection. 81With respect to the scope of this resource, many moreinterventions worthy of documentation and analysisexist in the region. Clearly the human and financialresources available for this work was a necessaryconsideration when deciding how many case studiescould be documented.Page 31

Behavioural and Structural Strategies to Reduce New HIV Infections:A UNAIDS Discussion Paper, September 2010.54 Shahmanesh M.et al., Effectiveness of interventions for the preventionof HIV and other sexually transmitted infections in female sex workersin resource poor setting: a systematic review. Trop Med Int Health, 13:5,2008.55 Combination HIV Prevention: Tailoring and Coordinating Biomedical,Behavioural and Structural Strategies to Reduce New HIV Infections:A UNAIDS Discussion Paper, September 2010. p.8; UNFPA, UNAIDSand APNSW, 2011; Building Partnerships on HIV and Sex Work: Reportand recommendations from the first Asia and the Pacific RegionalConsultation on HIV and Sex Work, March 2011; HIV in Asia and thePacific: Getting to Zero, UNAIDS 2011 p. 119.56 Investing for Results. Results for People: A people centred investment tooltowards ending AIDS, UNAIDS 2012.57 Cited in HIV in Asia –Transforming the agenda for 2012 and beyondReport of a Joint Strategic Assessment in ten countries Final Report,Godwin P, Dickinson, June 2012. The Commission in AIDS in Asiarecommended that 11% of national resources should be allocated toaddressing the enabling environment, in addition to specific fundingto address structural barriers to HIV prevention programme for KAPs.The New Investment Framework makes the case that high investmentin ‘critical enablers’ will lead to the need for reduced investment overtime — 35% in the first year, compared with 15% in 5th year.58 Sex Work and Violence: Understanding Factors for Safety & Protection DeskReview of literature from and about the Asia-Pacific region, UNFPA, UNDP,APNSW, P4P 2012.59 A profile of HIV risk factors in the context of sex work environmentsamong migrant female sex workers in Beijing, China, Yi, Huso et al,Psychology, Health & Medicine 15:2 2010; Violence victimization, sexualrisk and sexually transmitted infection symptoms among femalesex workers in Thailand. Decker, M. et al, Transmitted Infections Vol.86, 2010; Violence against female sex workers in Karnataka state,south India: impact on health, and reductions in violence following anintervention programme. Beattie, T. et al, BMC Public Health Vol. 10,2010.60 Ashodaya Samithi’s programme to address violence demonstrated an84% reduction in the incidence of violence over the five years since theprogramme was introduced. Reza-Paul S, et al., Sex worker-led structuralinterventions in India: a case study on addressing violence in HIVprevention through the Ashodaya Samithi collective in Mysore, Indian JMed Res 135, January 2012.61 The Power to Tackle Violence: Avahan’s Experience with Community-ledCrisis Response in India, Bill & Melinda Gates Foundation, 2009.62 Reza-Paul S, et al., Sex worker-led structural interventions in India:a case study on addressing violence in HIV prevention through theAshodaya Samithi collective in Mysore, Indian J Med Res 135, January2012; Gupta GR et al., Structural approaches to HIV prevention, Lancet2008; Gielen AC et al, Intimate partner violence, HIV status, and sexualrisk reduction. AIDS Behav Vol 6, 2002.63 Goon — a bully or thug.64 Bangladesh Institute of Development Studies (BIDS), Final EvaluationPROTIRODH Project, CARE Bangladesh, 2010.65 Ashodaya Academy is documented in this resource, as AshodayaSamithi’s anti-violence work has already been documented. See Reza-Paul, S. et al., Sex worker-led structural interventions in India: A casestudy on addressing violence in HIV prevention through AshodayaSamithi collective in Mysore, Indian J Med Res, 2012.66 Tackling HIV-Related Stigma and Discrimination in South Asia, WorldBank, July 2010. This resource provides key findings and lessonslearned from 26 Stigma Reduction Innovations in South Asia includingprogrammes to reduce stigma and discrimination against sex workers.67 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA,October 2012; Global Commission on HIV and the Law – Risks, Rightsand Health, July 2012; Report of the Asia-Pacific Regional Dialogue of theGlobal Commission on HIV and the Law, 2011; UNAIDS Guidance noteon HIV and Sex Work 2009, Annex 1 — The legal and policy environmentand the rights of sex workers.68 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA, October2012.69 Ibid. p. 9.70 Media Release: Independent high-level commission finds that anepidemic of bad laws and human rights abuses is stifling the global AIDSresponse, Global Commission on HIV and the Law, July 2012.71 Global Commission on HIV and the Law — Risks, Rights and Health, July2012 p. 9. A full list of recommendations in relation to sex work can befound on p.43.72 ILO Recommendation Concerning HIV and AIDS and the World of Work2010 (No.200); Provisional Record 13 (Rev) of the International LabourConference 99th Session, Geneva, 2010.73 Hit & Run: Sex workers’ Research on Anti-Trafficking in Thailand, EMPOWER2012.74 This is consistent with recommendations in the UNAIDS Guidance Noteon HIV and Sex Work, UNAIDS 2009, updated March, the findings of thereport Sex Work and the Law in Asia and Pacific, UNDP and UNFP 2012 andthe Global Commission on HIV and the Law – Risks, Rights and Health, 2012.The conflation of human trafficking with all forms of sex work has ledto police raids and crackdowns indiscriminately targeting sex workersincluding that conducted by consenting adults, undermined the rights ofsex workers and hindered access to services.75 This information was gathered in the course of documenting AshodayaAcademy, a programme of Ashodaya Samithi, but is not detailed in thecase study.76 Investing for Results. Results for People, UNAIDS 2012.77 Many staff members were sex workers.78 Roadmap Towards and expanded response to HIV Stigma andDiscrimination, ICRW, 2010 www.icrw.org/publications/roadmap-towardexpanded-response-hiv-stigma-and-discrimination.79 For a description of the component elements of harm reductionprogrammes see Technical guide for countries to set targets foruniversal access to HIV prevention, treatment and care for injectingdrug users, WHO, UNODC and UNAIDS, 2009.80 For example, a study in Ho Chi Minh City found one quarter of the city’s12,000 street-based sex workers injected drugs and were between 3.5and 31 times more likely to be infected with HIV, as compared with thosewho did not inject. National Institute of Hygiene and Epidemiology,Vietnam Ministry of Health and FHI 2005–2006, IBBS Vietnam.81 Where sex work, drug injecting and HIV overlap: Practical issues forreducing vulnerability, risk and harm, AIDS Project Management Group,Sydney Australia, unpublished, 2005.Page 34

Part 2:Case studycollectionPage 35

Case Study1Scaling upHIV preventionand Sexual andReproductive Healthamong sex workers:TOP, MyanmarThe map indicates locations of TOP drop-in-centresSource: TOP / PSI MyanmarPage 36

Populations Services International (PSI) Myanmarlaunched the Targeted Outreach Programme(TOP) in 2004. The two main objectives wereto make HIV prevention and treatment servicesaccessible to sex workers and men who have sex withmen and to promote safer behaviour and healthylifestyles. TOP has four components: peer outreach,clinical services for STI, tuberculosis (TB) andopportunistic infection (OI) management and referralfor HIV treatment, drop-in-centres (dics) and HIV careand support. Advocacy, mentoring and support areoverarching aspects of all four components.TOP has become the single largest provider of HIVprevention services in Myanmar. In 2007 it accountedfor 50% of services reaching sex workers and allservices for men who have sex with men. 82 It hasemerged as an example of effective community-ledservice delivery for HIV programmes in Asia and thePacific. TOP’s success lies in community participation,empowerment and community ownership. Usinga ‘learning-by-doing’ approach, programmes havebeen adapted and informed by lessons learnt throughthe active participation, knowledge and wisdom ofthese communities. In 2011, TOP had establishedcentres in 18 cities across Myanmar, reaching over 45000 sex workers and 58 000 men who have sex withmen. Out of its 350 staff members, 95% are sex workersand/or men who have sex with men. 83 “TOP’s strength isour ability to care and protect our community people.We believe in empowering ourselves and empoweringeach other. And that’s why we have achieved so muchso quickly,” says Kaythi Win, the Programme Managerof TOP Programme and PSI staff member, and formersex worker who joined TOP as a peer educator eightyears ago.This case study documents the experiences ofTOP in scaling up its HIV prevention and treatmentprogramme for female sex workers in Myanmar.Context: HIV and sex work inMyanmarIn Myanmar, the adult prevalence is less than 1% andnew HIV infections are declining. The epidemic isconcentrated among key affected populations: sexworkers with prevalence estimated at 10%, men whohave sex with men (8%) and people who inject drugs(22%). 84The number of female sex workers in Myanmar isestimated at 60 000. 85 There has been a steady declinein HIV prevalence among female sex workers from 33%in 2006 to 9.4% in the 2011 reporting period. 86 Stigmaand discrimination and the criminalisation of sexwork remain significant impediments to accessibilityof HIV prevention, treatment and care services forsex workers. 87Key components of the TOPprogrammeTOP services are delivered through peer-led outreachand drop-in-centres (dic). These ensure preventionservices are accessible to female sex workers andmen who have sex with men at all times. Althoughservices for both groups are similar, they are deliveredseparately in dics. Four prevention components workin tandem.Peer outreach and educationPeer-led outreach is the backbone of TOP’s work. Itreaches marginalized and hidden communities andeffectively expands the community base. Hot-spots aremapped to identify the geographic spaces that peopleoccupy. This data is continually updated and informsdesign outreach and dic intervention strategies.During mapping exercises, peer workers establishtrust and friendship with community members.After this, intervention sites are divided into zones tomaximize reach. Peer workers distribute IEC materials,male and female condoms and lubricants. Theydiscuss HIV, STIs and other health issues, and informpeople of dic services. Home visits and assistingPage 37

TOP Strategic approachesPeer outreach activities• Friendship/community building• Education and communication• IEC materials distribution• Condom and lube sales• Information about DiCDiC based activities• Socialising• Entertainment / recreation• Information / educational activities• Peer support groupsClinical services• VCT• SRH services including STI diagnosisand treatment, family planning,contraception, pregnancy testing,cervical cancer screening• Referral to ARTHIV care and support• Trained volunteer “buddies” providesupport and care• Saturday Club• National network of sex workers PLHIVpeople with ill health to access mainstream healthservices is an integral part of outreach. By the end of2010, the cumulative number of female sex workersreached by outreach was approximately 196 500,representing a significant proportion of the overallestimated population of these groups. 88 In 2010 alonethe outreach programme made contact with 47 215female sex workers of the 60 000 in Myanmar. 89TOP follows a peer-progression model 90 to enrolcommunity members as volunteers and staff. Staffand volunteer performance is continually monitored.Promotion results from good performance and thisencourages leadership from within the communities.Currently, almost all field and core staff members areeither men who have sex with men or sex workers,with the exception of technical specialists. The peermodel provides vital material and emotional support.Peer educators are paid approximately US$ 30per month to cover transportation and expenses. Theyare trained twice a year on peer education, interpersonalcommunication skills and technical knowledge relatedto HIV, STIs and SRH, including social marketing ofcondoms and VCT.Drop-in-centres (DiC)A primary attraction of the 18 dics is the ambience;they are a safe space for socialising and entertainment.All activities play a significant role in the process ofcollectivisation and self-help group formation andare conducted in response to identified needs. dicsoffer daily, weekly, monthly activities and annualevents and clinical services for female sex workers andmen who have sex with men. Daily activities includewatching TV and video, providing space for bathingand grooming, sessions on sexual health, and condomand lubricant demonstrations. Weekly activitiesconsist of spoken English classes, small social gatherings,counselling and medical treatment. Discussingmovies, sharing experiences and information fromreadings, health discussions and problem solving aresome of the activities. Monthly activities include lifeskills education and large social meetings with entertainment.Annual events such as World AIDS Day, theWater Festival and Valentine’s Day provide a platformfor advocacy. Over eight years, the registration offemale sex worker across all dics has grown exponentially,with more than 45 000 female sex workers registeredand regularly participating in activities. Thisamounts to approximately 75% of the total estimatedpopulation of female sex workers in Myanmar. 91VCT and clinical servicesTOP offers a wide range of clinical services in fifteendics and the remaining dics offer VCT and referrals toprivate clinics for HIV/STI diagnostic and treatment,in particular those run by PSI supported Sun QualityHealth Clinics networks.Page 38

Total female sex workers reached by outreach activitythrough TOP, 2004–April 2011200 000196 500130 306100 00089 46897 29647 57867 09764 25722 1762004 2005 2006 2007 2008 2009 2010 2011–AprilSource: TOP, PSI Myanmar, USAID, UNFPA 2011Enabling a safe space for female sex workers:Total members at TOP DiCs, 2004–201150 00041 59745 19430 00030 72920 84710 0008 16014 0985223 2462004 2005 2006 2007 2008 2009 2010 2011Source: TOP, PSI Myanmar, USAID, UNFPA, 2011.Page 39

TOP STI consultation and treatment service uptake byfemale sex workers, 2004–February 201112 00011 7709 2276 0006 2044 7464 9482 6343551 2712004 2005 2006 2007 2008 2009 2010 2011–FebSource: TOP, PSI Myanmar, USAID 2004–2011.Voluntary counselling and testingFree VCT services are provided in a friendly,confidential and non-judgemental environment bytwo trained community counsellors. Peer outreachworkers encourage female sex workers and men whohave sex with men to test periodically. In Yangon,Mandalay, Pathein, Bago and Pyay rapid testing isavailable at the dic but confirmatory tests are doneexternally. Blood screening in all other sites is carriedout in collaboration with local hospitals and clinics.Every day, TOP transports blood samples for screeningto the nearest clinic. dics are intentionally locatedclose to hospitals to minimise transportation time.Accompanied referral is provided for those takingconfirmatory tests. In 2010, 12 107 sex workers andmen who have sex with men reportedly accessed VCTservices in Myanmar. Of these people, 40% had doneso via TOP programme. 92STI diagnosis and treatmentIn 16 sites TOP offers free diagnosis and treatmentservices for STI. 93 Diagnostic tests include diagnosisRPR (Rapid Plasma Reagin), treponema pallidumhaemagglutination test, smear test, wet mount testand speculum examination. STI treatment is providedfor syphilis, ulcers, urethral discharge, anal discharge,genital warts, genital herpes and chlamydia. Treatmentof more complex STI is referred to partnering clinicsand hospitals. TOP is the largest STI clinical serviceprovider in Myanmar. 94 In 2009, it provided STIdiagnostic and treatment services to 84 500 peopleout of a total number of 135 000 cases attended by allimplementing organizations.Management of OI and diagnosis andtreatment of TBAt the dic, doctors from partnering health care facilitiesoffer free diagnosis and treatment for OI. Diagnosisfor most OI, including TB, is carried out in the on-sitelaboratory facility. DOTS treatment is provided free ofcost.Referral for HIV treatmentTOP refers individuals to partnering hospitals for CD4count, viral load testing and antiretroviral therapyaccess services. For those not yet on antiretroviraltreatment, co-trimoxazole prophylaxis is providedat dics. Every effort is made to ensure femalePage 40

“ Advocacy is critical to our work [for scaling up]…when weopen a centre, we invite local community members to see ourservices. This creates a supportive environment…”TOP’s Senior Programme Manager,Kaythi Winaccessibility of services and programmes. In July 2004,TOP began with one intervention site in Yangon; a dicwith an STI facility for female sex workers. A dic formen who have sex with men was launched in August2004. By the end of the year, a group of peer outreachworkers were trained to start building a network thattoday reaches thousands of sex workers and men whohave sex with men.Scaling up services required mapping and RapidSituational Assessments (RSA), carried out by trainedvolunteer community members. The RSA identifyrisk factors for female sex workers and men who havesex with men around each intervention site and thefindings of the RSA and mapping exercises inform decisionsabout the appropriateness of location for a dic,service needs and a context-specific advocacy strategyinvolving key stakeholders such as communityleaders, government officials and health care providers.Approximately, three to six months of fieldwork isrequired for effective planning and set up of a new dic.Clinical services are established once outreach and dicservices have been in place in for one year.TOP staff regularly meet with local authoritiesand INGOs, furnishing updates of their work. This ispart of a concerted effort made to maintain good relationswith people living in the neighbourhood wheredics are situated. Meticulous planning, communityledadvocacy and collaboration with local partners andlocal community have been a recipe for successful dicsin each location.“Advocacy is critical to our work. When weassess an area for opening a dic, we repeatedly visitthe relevant government officials (i.e. the NAP TeamLeader, health care providers, and local communityleaders) in that particular township, and advocate withthem on issues facing community people, share ourplan and seek needed support to open an interventionsite,” explains TOP’s Programme Manager, Kaythi Win.“Once we open a centre, we invite local communitymembers in that locality to come and see our services.This creates a supportive environment for us to implementour programmes and seek help to solve problemswe might face,” she adds.The rapid scale up of TOP services has been madepossible by a strong staff capacity development programme.A mobile team comprising communitymembers from Yangon, regularly visits each siteto monitor local advocacy, financial and programmemanagement. They provide regular support andsupervision.TOP has received on-going technical assistancefrom PSI Myanmar. An advisor provides technical assistanceto the local team establishing the dic from inceptionto implementation. The team’s role is to buildcommunity capacity to enable effective managementby the community. In addition, there has been invaluabletechnical support and advice from various regionalpartners, such as APNSW and sex worker organizationsin other countries. Kaythi Win, has used guidance andsupport of APNSW to ensure service delivery is groundedin a human rights approach.Page 43

Sun Quality Health Clinics Networks 98The private sector is the major provider for peopleseeking basic health products and services inMyanmar, with about 80% of health care visitsmade in the private sector. In a country where theaverage income is less than US$ 2 per day, peoplepay for health care. According to a study by PSI, 99there were 5 578 general practitioners in Myanmarin 2009, with 2 400 new doctors joining the privatesector every year. The Myanmar Medical Councilissues licenses to all doctors, however, there is noregulatory system to assess or monitor the qualityof care provided.In 2001, PSI Myanmar launched Sun Quality Health(SQH), a network of private clinics run by highlyqualified doctors specialising in reproductive health,TB, pneumonia, diarrhoeal diseases, Malaria andsexually transmitted infections, including HIV. PSIMyanmar provides training, patient educationmaterials, access to high-quality products, andsupervision and monitoring. The providers committo specified service standards and a price structurethat makes their services affordable to people onlimited income. PSI Myanmar collaborates with theMyanmar Medical Association offering continuingmedical education to these doctors.Building on the success of SQH, in 2008, PSIMyanmar launched a second franchise, SunPrimary Health, to increase access to health carein rural areas, where about 70% of the country’spopulation lives. This network includes midwives,lower-level medical staff and farmers. They aretrained and supported to provide education,services and products for reproductive health,diarrhoeal diseases, Pneumonia and Malaria, andthey refer clients to SQH clinics for TB and otheracute illnesses. By February 2011, PSI had 1 229SQH providers in 169 of Myanmar’s 325 townshipsand 1 029 Sun Primary Health providers in 45townships. In 2010 alone, PSI provided more than1.2 million reproductive health consultations, tested205 439 people for Malaria and provided treatmentto 44 739 people, and contributed to registeringand treating about 11% of the country’s TB cases. InMyanmar, this model has emerged as an importantway to strengthen health systems; by buildinglocal capacity in the private sector and scaling upaccess to health care for marginalized and poorcommunities, such as female sex workers and menwho have sex with men. 100Page 44

Lessons• HIV prevention programmes can be effectivelyscaled up by being community led. TOP hasemerged as the largest HIV programme for menwho have sex with men, covering 70% of thispopulation in Myanmar, and one of the largestfor female sex workers with 55% benefiting fromits services. 101 Mobilizing and empowering thesecommunities to be in control of programmedesign, delivery and monitoring have been criticalto achieving impressive scale up.• Peer-progression outreach model can pave theway for sustainable community leadership.Female sex workers and men who have sex withmen regard peer outreach workers as leaders.The incentive of this model promotes communityleadership development.• Investing in capacity training is crucial toscaling up and programme effectiveness.Capacity building of peer outreach workers isnot limited to effective communication aboutHIV prevention and learning how to conductcondom demonstrations. It is about learningways to mobilize, motivate and bring togethercommunities to assert their human rights. Peerworkers are trained to be catalysts; bridging thegap between isolated community members andavailable services. Hence, formal, classroombasedtrainings are inadequate to develop thenecessary skills. Informal sessions that includediscussions, sharing and learning among peerworkers have been more effective, generatingdemand for and fostering stronger relationshipsbetween the community and service providers.• Providing VCT through trained communitycounsellors increases uptake of HIV testing. Earlyexperiences revealed that female sex workers werereluctant to access VCT when counsellors were notfrom the community.• Peer outreach work can improve health-seekingbehaviours. The number of female sex workersseeking a wide range of sexual and reproductivehealth services at the dic and/or in the partneringclinics has steadily increased partly due outreachwhich has built awareness of and demand for HIVand SRH services.• Public-private partnership for health caredelivery can improve use of health care services.The network of Sun Health Clinics providessubsidized SRH, STI and HIV-related health services.This has improved access to and use of healthcare services by rural, poor and marginalizedcommunities. The involvement of governmentbodies such as the Myanmar Medical Council hasfurther improved health care services.Page 45

Gaps, challenges and opportunitiesSex work is illegal in Myanmar under the Suppressionof Prostitution Act 1949, including soliciting andowning and managing a brothel. The Act providesheavy penalties for soliciting including imprisonmentfor between one year and three years, and femalesex workers may be detained in a ‘prescribed centre’. 102Violence against sex workers is a major concernand sex workers in Myanmar are generally silent onthe abuses they face. 103 Though some headway hasbeen made with the police to address such violence, ithas not significantly reduced harassment. Accordingto Kaythi Win, “We even have an in-house lawyer atTOP, who is also a member of our community, but wehave found it difficult to provide legal aid and takelegal action.” The Myanmar Government has recentlystarted collaborating with TOP and UNFPA and UNDP toundertake research on violence against sex workers toinform policy and programmes to prevent and respondeffectively to violence against sex workers. 104Enforcement practices under the Suppression ofProstitution Act 1949 and lower socioeconomic statusof women in Myanmar contribute to high levels ofstigma and discrimination against female sex workers.This in turn hinders their access to HIV prevention,treatment and social protection services. Through itscommunity approach TOP has, to an extent, addressedinternalised stigma. However, more needs to be donewith and for sex workers, men who have sex with menand people living with HIV in the wider society.Sustainability is a constant concern, especially inthe context of declining funding for HIV. Resourcesmobilized by PSI Myanmar currently fund TOP’s servicedelivery. Without sustained funding, the efficacy andscale of TOP will be compromised. The need to planfor different revenue models is a priority and communitiesneed to be at the forefront of this planning.Moving forward, staff members envision TOPas an independent Community-based Organization(CBO). The changing political climate in Myanmar,increased demand for democracy, and more civilparticipation in development of the country presentconcrete opportunity for this vision to becomea reality. While the organization could continue asa HIV programme of PSI Myanmar, the challenge isto develop and sustain it independently. Essentialto this process is consensus building at all levels totransfer the responsibility to the community, andcontinued financial and resource support frompartners.Page 46

Case Study2HIV preventionand treatmentservices for maleand transgendersex workers inTianjin, China:Dark BluePage 48

In 2004, a small group of volunteers in Tianjin,a city east of Beijing, People’s Democratic of China,formed the Tianjin Dark Blue Voluntary WorkingGroup (Dark Blue), with the common vision that allsexual minorities — lesbians, gay men, bisexuals, andtransgender (LGBT), 105 have the right to lead healthylives with equality, respect and dignity.Although Dark Blue is a LGBT organization, theirsupport services are mainly for gay men, men who havesex with men and transgender people. It started providingservices for male sex workers locally referred to as‘money boys’, and transgender sex workers in 2008. 106Now with nine full-time staff and 31 outreach workers,Dark Blue has emerged as the only support system andprimary HIV service provider for male and transgendersex workers in Tianjin. Services and programmesinclude a drop-in-centre with HIV and STI testing andtreatment facility, outreach services, internet-basedradio and chat-room programmes, training and educationas well as health service referrals.Dark Blue’s constant engagement with the LGBTcommunity and rigorous monitoring of programmesensures that emergent needs of this community areaddressed. Dark Blue has mobilized many male andtransgender sex workers who now regularly participatein programmes and benefit from its services.In addition to imparting skills and fostering confidenceamong sex workers and sexual minorities to livehealthier lives, sexual minorities living in Tianjin cannow access health services that do not discriminateagainst them.This case study documents Dark Blue’s evolving experiencein providing HIV and STI prevention and treatmentservices for male and transgender sex workers inTianjin.HIV among male and trans gendersex workers in TianjinDark Blue estimates that there are currently between300 and 500 transgender people and 3 000 to 5 000males selling sex in Tianjin, in a diverse range of venuesand locations. 107 In Tianjin, there are approximately20-30 brothels, 108 one public bathhouse, two saunasand more than 20 areas where business is conductedin specific streets and along the Haihe River.In 2008, initial efforts to reach men who have sexwith men and transgender people in Tianjin revealedthat large numbers had male and female commercialsexual partners. In 2009 Dark Blue undertooka baseline survey among 89 male sex workers thatalso included mapping the male and transgender sexworker population in Tianjin. 109 Key findings were that:• the average age of male sex workers was 21 years,with 29% self-identifying as gay, 18% as heterosexualand 52% as bisexual;• the male sex workers moved in and out of sex workregularly, depending on financial circumstances;• they had low awareness of HIV and limited skills tonegotiate safer sex;• the large majority of the sample had alcohol anddrug-related problems, exacerbated by poverty;• prevalence of HIV among the sample was almost7%. 110The high levels of HIV in the sample are consistentwith findings in other studies. These have suggestedthat prevalence of HIV and syphilis among malesex workers is much higher than among the generalpopulation of men who have sex with men in Tianjin. 111While in 2009 the prevalence of syphilis among menwho have sex with men in Tianjin was 19%, it was 29%among male sex workers. 112The baseline study findings and communityengagement, laid the foundations for developingDark Blue’s HIV services. These services are informed bythe issues faced by male and transgender sex workers,which often radically differ from those of the generalpopulations of men who have sex with men.Page 49

Dark Blue’s model forHIV prevention, care andtreatment servicesDuring 2009 alliances were formed with bathhouseand pub owners, hospitals and the local Centre forDisease Control (CDC) in Tianjin. Simultaneously,Blue Dark sought funding to work with male andtransgender sex workers.With a grant from UNFPA in 2010, Dark Blue developedan integrated scheme of HIV and STI prevention,care and treatment services for sex workers within theexisting programme for men who have sex with men.Although UNFPA funding ceased in 2011, funding fromother organizations and individual donors enabled thework to continue. 113A safe space for community networking,education, services and supportDark Blue offers a safe space at its drop-in-centre(dic) for community members to interact with eachother. At the centre, people can access HIV testing andtreatment facilities, condoms, lubricants and sexualhealth information.Noting that many young men who have sex withmen, transgender people and male and transgendersex workers used social networking media to interactwith each other and search for partners and clients, in2004 Dark Blue initiated a web-based programme withthe aim of reaching younger people.Building partnerships for effectiveprogrammesEstablishing partnerships have been crucial to thesuccess of Dark Blue’s programmes. Long-standingpartnerships with the Tianjin Centre for DiseaseControl and Preventtion (CDC), health service providersand owners of sex clubs 114 has been instrumentalin ensuring the provision of high-quality, nondiscriminatoryHIV/STI prevention, treatment and careservices for sex workers.“ At the centre, everyone is treated equallyand with respect. I don’t have to be afraid ofbeing gay or being a sex worker and worryabout how others will judge me. The healthservices they offer are of great quality, betterthan at some hospitals where I am afraidto go. Because of the friendly and relaxedenvironment, I feel comfortable here anddon’t feel ashamed talking about my issues,discussing my problems, as I am around somany others with similar issues. We are allfriends here.”A male sex worker who regularly attends the DiC“The cooperation from the CDC helps us get medicineson time, get our community members tested andtreated quickly; the cooperation from sex club ownersgets us access to the most vulnerable sex workers whoneed HIV services; the cooperation from the healthservice providers gets our community get treated forSTI, opportunistic infections (OI) and HIV in a nonthreateningand non-discriminatory environment,”a Dark Blue outreach worker explained. “Withoutworking with them, we would have never been ableto maintain the reach and the quality of services weprovide for our community,” the worker added.Across the country, CDCs are increasingly recognizingthe benefits of community engagement in HIV prevention.115 The Tianjin CDC is committed to HIV preventionamong sex workers. “It is a mutually beneficial relationshipbetween CDC and us; we need their supportand resources to run our Programmes that benefitthe community and in return, we support them ontheir public health efforts by encouraging communitymembers to test and treat early,” said Dark Blue’sfounder, Gaga.The cooperation of owners and managers of sexclubs is also critical to reach the most vulnerablePage 50

Use of interactive communications technologies:Gay Radio‘Gay Radio’ is a web-based, virtual interactive safespace or platform for sexual minorities and maleand transgender sex worker communities run byDark Blue. It provides:• interactive one-on-one audio-visual chat roomfor counselling and access to information on HIV/STI and other health issues, health services andentertainment;• group interaction on various relevant topics.The principles underlying the platform aim to fosterfriendship provide support and create a non-threateningenvironment to reinforce messages on safersex and discuss issues relevant to the community.Trained counsellors moderate Gay Radio with up-todateinformation. In 2012, Dark Blue estimated thatmore than 20 000 community members log in eachmonth. It runs round the clock and can be accessedby subscription from anywhere in the world.While Gay Radio began as a platform to empowerLGBT people, it has evolved into a discussion forumon topics such as sex and sexuality, lifestyle matters,marriage and family relations. Gay Radio hostsan interactive ‘Guest House’ programme, invitingdomestic and foreign scholars and activists to speakon subjects concerning LGBT communities.“Through the Gay Radio platform, we talk aboutdiscovering our sexual identities, overcoming selfstigmatizationand fear in addressing societaldiscrimination, our need for healthy lifestyle andways to develop one; we talk about our sex lives,our relationships and focus on safe sex practices.We talk about HIV treatment, care and support foreach other,” said Dark Blue founder, Gaga, outliningcentral elements of the interactive platform thatDark Blue report have led to a broad community ofsupport built within the chat rooms. “This has ledto the creation of a ‘safety net’ for people using theplatform, especially for those who frequently traveland find themselves without any support system andwithout access to critical information that a circle offriends helps bring about so as to facilitate disclosinginner feelings, asking questions, seeking advice, andso on,” Gaga added.The accessibility of the Gay Radio chat room andservices has been effective in raising HIV awarenessamong male and transgender sex workers, eventhough they are a highly mobile population. GayRadio provides anonymity. The privacy of the chatroom encourages people to seek advice on sexualhealth and related problems.“Providing an opportunity to hearand interact with role models andmotivational speakers from the LGBTcommunity can be a life changingexperience, especially for overcomingself-stigma and reinforcing safesexual practices and healthy living.”A member of the Gay Radio programmePage 51

populations. Partnerships with owners and managersare built through repeated contact, advocacy meetings,training, and awareness raising. Dark Blue organizestraining that brings owners and managers togetherwith sex workers to discuss issues like safer sex, STI/HIV prevention, the importance of early testing andtreatment of HIV/STI, and to strategize ways to ensurethe health and safety of workers.Consequently, sex clubs in Tianjin have becomea major outreach site for HIV and STI prevention, andfor on-site treatment of some STIs such as syphilis. Thepartnership has fostered understanding that preventingHIV and STI among sex workers and their clientsnot only benefits individuals, but also makes goodbusiness sense. “If one of the clients discovers thata sex worker at this bathhouse has a STI, news rapidlyspreads among the clients and then we become unpopular.The business suffers. It is good to have theseservices for sex workers here. Because of Dark Blue,more use condoms consistently; they are protectedand healthy,” a public bathhouse owner in Tianjinexplained.The partnership has made both sex workers andowners better equipped to handle crisis situations andpresent a united front. 116“Without working with [the CDC], we wouldhave never been able to maintain the reachand the quality of services we provide forour community,”Outreach worker, Dark BlueCollaboration with health care providers has alsobeen important to Dark Blue’s efforts. Recognizingsex workers had low uptake of STI/HIV treatmentand follow-up services, CDC and Dark Blue identifiedthree key health service delivery centres to collaboratewith. Doctors in sexual health, HIV treatment and carecentres that were sensitive on issues of sexuality wereidentified. CDC and Dark Blue trained them to deliver“It is good to have services forsex workers here [in the bathhouse].Because of Dark Blue, more [clientsand sex workers] use condomsconsistently; they are protected andhealthy,”A public bathhouse owner, Tianjinservices in a non-discriminatory manner. Communitymembers are then referred to these professionals,when needed.The partnership has had resulted in increasednumbers of community members receiving treatmentfor STIs, getting timely CD4 and viral load count andearly treatment of HIV. In the past, community clinicswere closed on Saturdays but are now open for certainhours every Saturday, making it easier for sex workersto visit. “The doctors kindly run a special clinic forsex workers every Tuesday afternoon between 1.30and 5pm which is perfect time for sex workers to visit.Syphilis treatment only costs 75 yuan at these clinicsfor sex workers as opposed to the 4 000 yuan at otherhospitals,” Dark Blue’s founder Gaga explained. “Thisis made possible because of the lasting cooperationbetween us.”OutreachAll thirty-one staff members conduct outreach and peereducationactivities across 15 selected sites in Tianjin.Most of these sites are sex clubs. Outreach volunteersreceive 50 Chinese yuan to cover transport costs. Priorto outreach, micro-planning and mapping exercisesare undertaken to identify sites and determine thenumber of sex workers that would benefit. Outreachworkers are expected to maintain contact with 50–60male sex workers, reinforcing safer sex messagesand motivating them for early testing and treatment.Page 52

“ Repeat contact helps us to provide individual support to each of themembers of our community in a holistic way and throughout theperiod they wish to maintain contact with us.”Outreach worker, Dark Blue“Repeat contact helps us to provide individual supportto each of the members of our community in a holisticway and throughout the period they wish to maintaincontact with us. Because the same outreach workeris responsible for maintaining contact with the samemember throughout the period of their interaction,right from when they meet to when they seek helpto be tested or treated, a standard quality of serviceprovision and personalised care is made possible,which are not usually found in hospitals otherwise,”explained a Dark Blue outreach worker.Gay Radio, the dic, Voluntary Testing and Counselling(VCT) at sex clubs and other health service providersare discussed during outreach.Outreach workers receive periodic training toupdate their knowledge and skills. The trainingincludes interpersonal communication skills, use ofIEC materials and technical knowledge on HIV and STI.Short orientations are organized every week to shareproblems and build knowledge and skills.According to Dark Blue’s estimates, the numberof community members contacted through outreachhas increased from 9 000 in 2010 to 20 000 in 2011.Outreach to sex work locations where previously“ Partnership has had resulted inincreased numbers of communitymembers receiving treatment for STIs,getting timely CD4 and viral load countand early treatment of HIV”Gaga, Dark Blue founderthere had been little or no HIV interventions, such asin the public bathhouses, has significantly contributedto increasing HIV awareness and condom use.Training and orientation on skills in sexwork and occupational safetyTraining and orientation programmes for communitymembers are organized and designed for fun andeducation. Topics of training programmes aredecided collectively by outreach workers, based onconcerns raised by sex workers in the community.Staff members facilitate the Programmes along withexternal experts, if needed. Occupational safety ispart of the training. Sex workers have gained practicalknowledge and skills in negotiating safer sex and fairprices, pleasure enhancing for improving business,methods and techniques in sexual positions and sexacts and dealing with abusive clients.Personalized on-site andreferral services for HIV and STIcounselling, testing and treatmentDark Blue provides the following comprehensivesexual health services:On-site VCT using rapid HIV testingDark Blue receives free HIV rapid test kits from CDC andother donor organizations. Rapid HIV tests, voluntaryand confidential pre and post-test counsellingare provided in brothels, bathhouses and at dics.Availability of these in community locations hasmade HIV testing more accessible and convenientfor sex workers. As a result, there has been a markedincrease in uptake of VCT. In 2009, 2 163 people testedat on-site VCT, rising to 4 501 in 2011. 117 Approximately,80% of male sex workers and their clients had theirinitial HIV test in bathhouses. 118Dark Blue counsellors are certified by the CDC. Theyreceive periodic refresher courses on counsellingskills and updates on new testing technologies. Thebenefits of testing and early treatment are reinforcedon Gay Radio and its chat room programmes, throughPage 53

“When other community members see that their fellow positive friends are beingtreated with kindness, care and compassion, it encourages them to seek help, becausethey know that they are also going to be treated well. “Outreach worker, Dark Blueoutreach, in training and orientation programmes,and by disseminating IEC materials.Continuity of support for people livingwith HIVConfirmatory tests are conducted at CDC. If the resultis positive, counselling includes discussing treatmentand care options, available health care services andhealthy living. When requested, the counsellorcoordinates with the designated outreach worker foraccompanied referral for an initial health check-up,including CD4 and viral load and commencement oftreatment.“When other community members see thattheir fellow positive friends are being treated withkindness, care and compassion, it encourages them toseek help, because they know that they are also goingto be treated well. Since we started providing personalisedcare to the positive sex workers, treatment adherencehas also improved,” a Dark Blue Outreach workerexplained.Dark Blue outreach workers provide continuity ofcare and support for people living with HIV for as longas they wish to remain in contact.Dark Blue has demonstrated that an integratedapproach to community-based rapid HIV testing,combined with support to sex workers who test HIVpositive, improves access to HIV treatment and care.In 2011, over 80% of those who tested HIV positive atDark Blue sites required HIV treatment. In 2010 and2011 a total of 172 people tested HIV positive and weresuccessfully referred for an initial health check-up. 119services increased from 33 in 2008, 219 in 2009 to 421in 2010. 120Emergency shelter for sex workersDark Blue observed that sex workers, particularlythose living with HIV, are frequently homeless, dueto critical ill health, family estrangement, violenceand social ostracism. To ameliorate this, Dark Blueopened a temporary emergency shelter. Ideally, theshelter should be able to accommodate people untilalternatives can be found. In reality, it is constantlyfull with some residents requiring long-term stay.This puts enormous constraints upon the availabilityof place at the shelter, indicating the urgent need tocreate a wider social protection system for sex workers,positive people and sexual and gender minorities.Mobilizing clients of male sex andtransgender sex workersSeven clients have been trained as volunteers toreach out to other clients. They regularly distributeIEC materials, condoms and lubricants and shareinformation on HIV, STIs and Dark Blue’s services.Clients are invited to participate in twice-a-monthtraining and orientation programmes on topicschosen by clients such as safer sex, healthy living,and enhancing sexual pleasure. The involvement ofclients in implementing the programme has promotedconsistent use of condoms in brothels and amongclients’ regular sex partners. A total of 170 clientsregularly visit the various centres.STI diagnostics and referrals fortreatmentApart from HIV tests, diagnostic tests for seven STIsare available at on-site locations. Blood samplesare collected and sent to the local CDC for testing.Symptomatic treatment for minor STIs are providedat the centre free of charge and complex STI casesare referred to partner hospitals and clinics. Followupsupport is offered. The number of men who havesex with men and male sex workers referred for STIPage 54

Lessons• Long-term partnership provides sex workers’sustained access to high-quality health services.Synergies between partners have contributedto the sustainability of HIV and STI services formale and transgender sex workers. Buildingeffective partnerships requires persistence andan investment of time and resources. To sustainthe partnership, it is important that both partnersbenefit and that there are overlapping areas ofinterest and concern. For example, bathhouseowners needed condoms and lubricants thatDark Blue was able to supply. In the case of CDC,they recognized that partnering organizationssuch as Dark Blue enabled them to reach maleand transgender sex workers. By linking with CDC,Dark Blue has ensured that communities haveaccess to government health services.• Providing integrated health services forsex workers requires a supportive policyenvironment, committed leadership and CBOgovernmentpartnership. China’s national andlocal policies prioritize HIV prevention amongmale and transgender sex workers. “There hasto be a will and commitment from the leadersof the local CDC to work with small CBOs like us,”Dark Blue’s founder Gaga said. Almost all aspectsof Dark Blue’s service delivery have requiredsupport and cooperation from the CDC; includingverification for social insurance applications forpeople living with HIV. Moreover the Chinesegovernment ensures that good quality healthfacilities, an abundant supply of condoms andlubricants and free HIV treatment are providedin rural and urban areas. This has providedan excellent basis for developing linked andintegrated services.• On-site availability of HIV rapid tests increaseuptake of VCT services. The ease of rapid HIVtesting has encouraged a culture of HIV testingamong men who have sex with men and male andtransgender sex workers. Availability of rapid testkits has reduced logistical problems of inadequatelaboratory facilities and blood transportation.• Friendly, non-judgmental staff and privacy forHIV counselling improves uptake. Ensuring thatcounselling follows the established protocolshas been a key to improving the communities’confidence to test.• Ensuring quality of care and a comprehensiverange of health services for sex workers livingwith HIV requires investment in time andresources. Sex workers often require immediateand sustained support from the time they testpositive. Considerable investment of financialand human resources and capacity is required toprovide individuals with continuity of care.• Facilitating networks is critical to communitymobilization and health promotion. Dark Blue’swork provides a strong model of integrating peeroutreach with innovative community educationand networking.Page 55

Gaps, challenges and opportunitiesDark Blue has been unable to register the organizationand this has prevented its growth and ability to actautonomously. It has not been able to receive fundsdirectly from the government or other donors, andhas to rely on registered organizations to route funds.Dark Blue currently receives funding support from 11organizations and has six organizations routing theirfunds. A service fee of 5% is levied and has been borneby Dark Blue’s programmes.It is difficult to reach male and transgendersex workers doing business over the Internet and tomaintain regular contact with this highly mobile population.Getting health services to hidden populationssuch as male sex workers who are HIV positive posesa great challenge. Despite difficulties, Dark Blue hasmade considerable progress.Countering social stigma and discriminationagainst sex workers and sexual minorities, and organizationsthat work with them, remains a struggle.In the last five years, the Dark Blue office has relocatedseven times due to this problem. Male sex workersliving with HIV are particularly vulnerable to socialand familial ostracism and they often withdraw fromsocial interactions and services on learning that theyare HIV positive. When associated treatment costsare too high, sex workers may terminate contact withhealth and support services.Nevertheless, Dark Blue has an excellent relationshipwith the local CDC in Tianjin and is increasinglybecoming an example across China of improvingmale and transgender sex workers’ access to HIVtesting, treatment and care. In July 2012, the nationalCDC consultation was hosted in Tianjin and Dark Bluewas invited as the main resource organization toprovide training and share experiences of theirmodel. This is a great achievement and a newbeginning.Dark Blue is looking forward to evolving intoa national resource centre for men who have sex withmen and male and transgender sex workers. Theyare planning to register as a CBO renaming it “TianjinDark Blue Health and Development Service Centre.”All indications point towards a journey that willcontinue to make a significant improvement in thelives of sex workers and sexual minorities in China.105 The acronym ‘LGBT’ is used as an umbrella term for groups and/orindividuals whose sexual orientation or gender identity differ fromheterosexuality and who may be subject to discrimination, violenceand other human rights violations on that basis. Information anddata presented in this article may not apply equally to all the groupsrepresented by this acronym.106 Male sex workers or ‘money boys’ includes all males who are involved inselling sex to male clients. Reference to transgender sex workers refer toboth pre-op and post-op male to female transgender persons who sell sex.107 Dark Blue, 2009. Mapping of MTSW populations in Tianjin.108 Brothels, bathhouse and saunas are often temporary in nature. Theytend to shut down as new clubs open. Recently, some brothels have beentemporarily moved from Beijing to Tianjin, due to police crackdown on sexwork in Beijing.109 Dark Blue, 2009. Mapping of MTSW populations in Tianjin.110 Ibid.111 Zhongquan, LIU et al., 2009. The prevalence of HIV and syphilis infectionamong money boys in Tianjin. Chin J AIDS STD Vol. 15 No 3 Jun. 2009.112 UNAIDS. MSM Country Snapshot China. August 2010: Version 2.113 Individual donors include major contributions from financially secureChina-based men who have sex with men living with HIV.114 Otherwise known as ‘entertainment venues’, Dark Blue refers to theseas ‘sex clubs’, since no activity other than sexual activity takes place inthem. There are five types of ‘sex clubs’ in Tianjin where male and TGsex workers either solicit male clients and/or have engage in paid sex withthem. These are brothels, public bathhouses and massage parlours, pubsand streets. Soliciting also takes place over the Internet. While the street isnot usually a venue for having sex, sex workers who solicit clients on thestreet tend to move to other venues to provide them with sexual services.In China, sex clubs are legally registered as small businesses.115 Hui Li et al. 2010. From spectators to implementers: civil societyorganizations involved in AIDS programmes in China. International Journalof Epidemiology 2010; 39: ii 65–ii71 doi:10.1093/ije/dyq223. Accessed on 3June, 2012 from http://ije.oxfordjournals.org/content/39/suppl_2/ii65.full.pdf+html in Bangkok Thailand.116 At the time of this documentation, Dark Blue reported that policecrackdowns were not as frequent as in some of the other cities such asKunming. In the last two years, there has only been one police crackdownin Tianjin according to staff.117 These figures include testing of men who have sex with men.Approximately 10-20% of the total number is male and transgendersex workers.118 Dark Blue, 2009. Mapping of MTSW populations in Tianjin. For moreinformation about this study, contact: tjgaga@gmail.com.119 As reported by Dark Blue during documentation interviews.120 Ibid.Page 56

Case Study3“ Small ants like us will keep workingtogether to build a ‘wall’ as a shield forsex workers to have their own standing insociety with safety and good quality of life.”Ms. Surang Janyam, founder, Service Workers in GroupBuilding communityand working withpolice: SWING’sorganizationaldevelopment journeyPage 57

Service Workers in Group (SWING) was establishedin September 2004 with the core vision to protectand promote the human rights of sex workers. InNovember 2009, it was registered as a foundation inthe Kingdom of Thailand (Thailand).Transforming lives:Nim’s storyAt first, Nim did not trust SWING’s peereducators, but warily accepted to go ona retreat with the organization. It wasthere that she saw that SWING truly cared.“Within only a couple of days I got mysense of human being back after lookingdown on myself for a long time.” Inspired,Nim joined the organization and soonwas selected to become a Peer Educator.By 2006, Nim had become a full-timestaff member, and her outlook on lifehad changed dramatically. “I am moreconfident, in talking and communicatingwith people, in expressing my thoughts.I can lead Peer Education — before I couldnot make decisions, but now whenmembers come to me with problems I amready to help.” 121The HIV epidemic in ThailandSex workers and their clients were a critical part ofThailand’s early success in reversing the HIV epidemicin the 1990s. New HIV infections and AIDS-relateddeaths are declining and there is a stable trend in HIVprevalence. 122 HIV prevalence remains concentratedamong people who inject drugs (21.9% in 2010),female sex workers (1.8% in 2011) and men who havesex with men (20% in 2010). 123 The Asian EpidemicModel (AEM) has estimated that 43 040 new infectionswill occur during 2012–2016. Among the estimatednumber of new infections, 62% will be throughtransmission among men who have sex with men,female sex workers and their clients and people whoinject drugs. 124A rapid escalation of HIV among men who havesex with men has been observed in 3 cities. In a2010 survey, HIV infection among men who havesex with men was high in Bangkok (31.3%). Lowerprevalence was observed in Chiang Mai and Phuket.HIV prevalence among men who have sex with menbelow 25 years was 12.1%. In 2010, HIV prevalenceamong the transgender population was estimated at10% and 16% among male sex workers in the sentinelsites. HIV prevalence among male and transgender sexworkers has not declined in subsequent years. 125The journey of SWING 126In the course of her work with female sex workers inBangkok in the 1990s, Ms. Surang Janyam, the currentdirector of SWING, noticed an increasing numberof male and transgender sex workers needing HIVservices. Surang, Chamrong Phaengnongyang, thedeputy director of SWING and a team of like-mindedpeople (mainly former sex workers) started informalnetworking with this community. With technicalassistance from Family Health International 360(FHI360), they began mapping male sex work hot-spotsand interviewing male and transgender sex workersto assess their needs. The needs that emerged werefor services to diagnose and treat STIs, including HIV,non-formal education and English classes. Based onthis, they approached FHI360 for funds to commencea project: this became known as Service Workers inGroup (SWING). SWING is the first organization inThailand to focus on meeting the needs of HIV servicesfor male and transgender sex workers.With limited funds to cover operational costs atthe outset, the core group approached communitymembers and former clients for donations. RaisingPage 58

evaluates organizational efficiency and modifiesaccordingly. For example, in 2008, each of SWING’soffices had their own administrative and financialunits. This was not cost effective and it proveddifficult to ensure standardised procedures. Thisled to centralizing the administrative and financialmanagement system.• Human resource management and staff capacitydevelopment policy and plan: From inception,SWING has developed staff capacity in a variety ofways. Experienced staff members of SWING playan active role in mentoring new staff. Staff areperiodically assessed on technical knowledge,organizational principles and commitment to thecommunity and work. Regular staff performanceappraisal, that involves partners and stakeholders,is conducted. Outstanding staff members arerewarded. This system has helped retain efficientstaff and volunteers. In addition, SWING arrangesstaff training every three months, based on assessedneeds.• Transparent financial management: SWING developeda financial regulation manual in 2004, revising thisin 2007 for the organization’s registration. Financialand programmatic audits are carried out regularly.• Public relations and marketing: Using variousmarketing strategies and IEC materials such asbrochures, information leaflets, posters, T-shirts,SWING publicises the organization, its services andprogrammes nationally and internationally. Staffmembers receive training in public relations andmarketing skills.Growing with SWING: Preecha’sstory:“I have grown [at SWING] so much that I couldn’tbelieve I would come this far. I told my friends inmy hometown that I gave lecture to nurses andpolice officers. They did not believe me. I onlywent to junior high school. Before I joined SWING,I couldn’t use a computer… I can use Excel andWord now…I have developed so much in manyways. My analytical thinking has improved. Ihave more responsibilities… Now I take care ofother staff making them think.”Preecha, SWING Manager, Pattaya 128• Inclusive governance structure: SWING has a governingboard that meets once a year. It comprisesmembers who are from different backgrounds inThai society, including sex workers. Board membersare also available when SWING needs their adviceand support. The board does not have decision-makingpower over financial or programmatic matters.• Monitoring and evaluation: Supported by PACTThailand, an organizational evaluation was conductedin 2009. This identified the need to strengthenthe monitoring and evaluation (M&E) system forprogrammes. This was instituted with a subsequentgrant from PACT Thailand.Page 61

Lessons• Creating solidarity among community andstaff is critical for organizational development.This solidarity arises from developing commongoals, ownership of these goals and jointcommitment to achieve them.Because our staff work with utmost sincerity anddedication, we have gained more recognitionin Thailand beyond what a community-basedorganization generally receives in this region.For example, we were recently invited by theMalaysian AIDS Council (MAC) to provide technicalsupport for the formulation of its strategic planfor 2008-2010; of which two key strategies wereto reduce HIV vulnerability among men who havesex with men and among sex workers as well astranssexuals. In Pattaya, everyone knows SWINGand when the community members say thatthey belong to SWING, the treatment they receivechanges.”Male sex worker and staff member, SWING• Nurturing staff can lead to scale up ofprogrammes and organizational growth.Effective team work and unity are a result ofstaff being empowered and nurtured by theorganization. This motivates people to workbeyond their job description and contributes tothe growth of the organization.• Donor investment in staff capacity buildingsupports organizational growth. SWING hasbeen fortunate to receive donor supportfor capacity building. This has enabled thedevelopment of its organizational policy andprocedures and contributed to strengtheningprogramming quality.• Forging partnerships with key stakeholderscontributes to organizational growth. Win-winpartnerships have been established with policeand health service providers and entertainmentvenue partners 129 that have led to expandingservices for sex workers. With the latter, thecooperation was founded upon:• Understanding that healthy workers meansbetter business.• Earning trust with venue owners thatfostered trust across the sector.• Permitting access to venues to reach sexworkers with services.• Cultivating friendship with venue owners.This was achieved by meeting them oftento jointly discuss solutions to problemsthat concerned them, such as business,HIV prevention and raids.Page 62

“SWING taught us how to be open-mindedand to make friends. [SWING is] a home fullof friendly and supportive brothers andsisters.”Police cadet ‘Dome’ who took part in the SWINGinternship programmeand it became so successful,” SWING’s director, Surangrecounted.Tee, Deputy Director of SWING adds: “We did allof this because we really believe that working withthem, will help change their attitudes about us. Notonly has that happened we have also made goodfriends.” A total of 36 cadets completed the SWINGinternship programme during the four years that itran. As a result, SWING gained credibility in many ofthe police stations across Bangkok.The cadets’ perspective 134Police cadets, Paeh, Sorn, and Dome, internedwith SWING in September 2007. Prior to joining theprogramme, all three reported having negativeattitudes towards male sex workers and men whohave sex with men. “On my first day with SWING,I felt uncomfortable working with the MSM staffand was quite shocked to go into male sex workhot-spot areas. It was a community that I didn’teven think existed,” Paeh recalls. Sorn, who usedto “walk away from men who have sex with menand male sex workers”, also noted a significantshift in his feelings: “Now I feel male sex workersare ordinary people living in the same societyas we do,” he remarked. Paeh remembers thesatisfaction of helping to organize a camping tripfor a group of sex workers. “I was simply happywhen I saw them happy. For some, it was the firstcamping trip in their life.” Explaining the valuablelessons he learned through interning with SWING,Dome says: “SWING taught us how to be openmindedand to make friends. I felt like I coulddiscuss my problems and issues with the staff. Tome SWING is not an organization, but a home fullof friendly and supportive brothers and sisters.”Page 64

Impact on preventing violenceSensitizing 36 cadets was a step forward but it has notstopped the violence against sex workers in Bangkokor elsewhere in Thailand. However, addressingviolence has become easier, as one staff membershares: “We have not been able to prevent violenceevery time before it occurs but we can certainly use thehelp of cadets and their friends and networks to get usthe help we need to report on any violent incident, torelease sex workers who are randomly arrested and tobe freed from paying fines.”Positive changes have been noted in the behaviourof police officers in Bangkok and at other constabularieswhere interns are stationed. 135 One staff memberreported fewer arrests and incidents of harassmentand a more helpful approach towards sex workers.Another SWING member noted that sex workers havebenefited from the programme by developing practicalskills to deal with police officers.Although the SWING internship initiative endedin 2008, SWING still depends on support from itsnetwork of cadets:“Just few days ago [in 2012], a sex worker wasfined in one of the cities where SWING works;the police officer dealing with her used abusivelanguage and demanded a lot of money torelease her. She knew that she had the right toask for help and call anyone if she wishes. So,she rang up one of the cadets in another stationand asked him to talk to the police officer. Uponbriefly chatting on the phone with the cadet,he released her without any fine. She did noteven call the SWING office for help; she called thecadet.”Surang Janyam, Director of SWINGContinued efforts to address violenceWorking in partnership with police continues toinform SWING’s efforts to address violence against sexworkers, one of the greatest challenges for sex workorganizations in Thailand.In 2011, SWING initiated The Rights ProtectionVolunteers for Sex Workers in Pattaya. 136 Thiscollaboration between SWING, the Pattaya TourismPolice Division and the Pattaya MunicipalityAdministration aimed to decrease stigma anddiscrimination by improving community liaisonsbetween sex workers and tourist police. A baselinesurvey on types and severity of violence was conductedbetween June 2011 and February 2012 with 443transgender, male and female sex workers. 137 Findingsincluded that 87.1% of sex workers surveyed reportedbeing humiliated by officials, 86.4% reported beingforced to have unpaid sex, 86.7% reported that clientsrefused to use condoms and 92.2% were forced toperform sexual acts against their will.Sixty two sex workers were trained as ‘RightsProtection Volunteers’ and conducted outreachreaching 2 769 sex workers on the streets and inentertainment venues. Volunteers worked with touristpolice, police informers (such as motor-cycle taxidrivers) and responded to crisis situations involvingsex workers. One of the biggest challenges duringthis project was ensuring access to legal aid. A lawyerwas hired and some local organizations providinglegal services offered their support. However, lack ofknowledge surrounding the legal and social issuesof sex workers made it difficult for sex workers toaccess the appropriate legal assistance. Despite thesechallenges, in seven months the programme gainedsupport in Pattaya among sex workers, the police, andthe municipality and bar owners.Page 65

Lessons• Improving police liaisons with the sexwork community through cadet internshipincreases mutual understanding andenhances sex workers’ confidence indealing with the police.• Developing partnerships with police, healthcare providers and entertainment venueowners requires trust and understandingdivergent perspectives.• Developing allies within the police forceis as important as working to alter theoppressive aspects of law enforcementstructures.• Cooperating with the police can lowerincidence of police violence. Sex workersinvolved in the cadet internship programmereported a reduction in verbal abuse, fewerarrests and shorter time periods in policecustody. Sex workers anecdotally reportedthat bail was easier to access, as was officialreporting of violent incidents.Gaps, challenges and opportunitiesLack of rigorous data collection and analysis ofinterventions are a limitation of the programme. Thisis not unique to SWING, as discussed in section 1,there is a need for greater investment of financial andtechnical resources to ensure high-quality monitoringand evaluation. There is much to be gain frominvesting in strong sex worker organizations such asSWING that have demonstrated their capacity to builda strong organization, engage in effective mobilizationof sex workers and design innovative programmesthat address the existing and emerging needs of theircommunities. Technical support to build capacityfor within sex worker led programmes for effectivemonitor and evaluation, particularly for interventionswhere there is limited evidence, builds the evidencebase about what works, critical to ensuring the mosteffective use of resources.In their work addressing violence against sexworkers, SWING has faced challenges in securingaccess to legal assistance and ensuring sex workers areaware of their legal rights and are working to developpartnerships to address this.Over eight years, SWING has transformed froma project into a legally registered foundation thatis recognized for serving the sex work communityacross multiple locations in Thailand. Increasingly,organizational sustainability is a concern due to thediminishing funds available for HIV programming.With regards to the cadet internship programme,limited funds prevented enrolling more interns.SWING is working to diversify its sources of fundingand increase its organizational capacity to raise funds,so that resources are well aligned with its commitmentto innovative strategies that mobilize and engagecommunities themselves to address the issues ofconcern they experience.Page 66

121 Pact Thailand/USAID, 2011. SWING — A CBO Success Story. Unpublished.122 UNAIDS, 2011. HIV in Asia and the Pacific: Getting to Zero. UNAIDS.123 Thailand UNGASS Report, (reporting period 2010–2011) published 2012.124 Ibid.125 Ibid.126 This section has largely drawn upon PACT Thailand’s 2011 documentation of SWING — A CBO Success Story. Unpublished.127 SWING, 2011. SWING’s Organizational Profile, 2011. SWING. Unpublished.128 PACT Thailand’s 2011 documentation of SWING-A CBO Success Story. Unpublished.129 For example, proprietors of massage parlours and bars.130 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA, October 2012, Section 4.9 Thailand.131 Ibid.132 National Police Cadet Academy is the training institution of Ministry of Interior responsible for planning and implementation of pre-serviceand in-service training programmes for the newly enrolled police cadets. In 1990s when Thailand’s HIV epidemic rapidly spread among theuniform services, the Ministry of Interior in collaboration with the Ministry of Health introduced an HIV in the Workplace programme. Sincethen, the national police cadet academy provides training on HIV prevention, treatment, care and support to all the newly recruited cadets.133 This is an internship programme that the Police Cadet Academy provides to third-year police cadets. It gives them the opportunity to workwith a community-based organization of their choice. The objective is to expose the cadets to a range of social issues and broaden theirunderstanding of social inequality. Since 2009, the programme has been suspended for reasons unknown to SWING. All cadet internships nowtake place in government-run social facilities.134 PACT Thailand’s 2008 summary documentation of the Police Cadet Internship Programme at SWING. Unpublished.134 PACT Thailand’s 2008 summary documentation of the Police Cadet Internship Programme at SWING. Unpublished.135 Turning an enemy into an ally: SWING’s police cadet internships on HIV prevention among sex workers, PACT 2007, http://www.pactworld.org/cs/reach_news_and_media_swing_story.136 SWING, 2011. Survey of Violence against Sex workers in Pattaya. The survey was conducted with technical support from the Institute ofPopulation and Social Research (IPSR), Mahidol University. Its key findings include that 92.9% of surveyed sex workers were wrongly arrested,86.9% were arrested for allegedly having condoms, 87.1% reported being humiliated by officials, 40.7% were fired from their jobs when foundHIV positive, 43.2% forced to reveal HIV status, 52.9% forced to test for HIV, 86.4% forced to have unpaid sex, 86.7% reported that clientsrefused to use condoms and 92.2% were forced to perform sexual acts against their will. This reporting was based on sex workers’ experiencesof violence in the last three months.137 SWING, 2011. Project report on Rights Protection Volunteers for Sex workers in Pattaya. Unpublished.Page 67

Case Study4Reaching low-feesex workers withHIV and STI servicesin Kunming, China:experiences ofthe Lily Women’sWellness CentrePage 68

The Lily Women’s Wellness Centre started asa drop-in-centre (dic) for female sex workers in2005. It is now a community-based organization(CBO), though not yet registered. It provides HIV andSTI prevention and treatment services for femalesex workers at 64 sites in Kunming, including at theKunming Municipal Women’s Compulsory Shelter andEducation Centre. 138In September 2005, the Kunming Red CrossSociety 139 (KMRC) began implementing HIV preventioninterventions among female sex workers in the XishanDistrict of Kunming City, with support from the China/UK Project and Futures Group, Europe. One outcomeof this was the establishment of the Lily Women’sWellness Centre.In 2007, KMRC, Kunming Centre for Disease Controland Prevention (CDC) 140 and FHI360 141 decided to focuson reaching the most vulnerable groups of sex workerswith HIV and STI prevention programmes and tostrengthen community-led approaches in outreachand service provisions. Female sex workers with lowfees were identified as one such group. This led LilyWomen’s Wellness Centre transforming from a dic toa CBO. Kunming CDC has played an important role inthe growth of the organization. Due to being unable tolegally register and receive and manage funds, KMRC iscurrently responsible for the financial management ofLily Women’s Wellness Centre, and provides supportfor monitoring. Otherwise, the organization designsand implements its programme independently. TheWellness Centre currently has nine full-time staffmembers, seven of whom are sex workers.HIV and sex work in KunmingThe capital city of Yunnan province, Kunming, hasa flourishing tourism industry and a population of 5.7million, of which 1.7 million are migrants. Yunnan isamong the six provinces with the highest number ofreported HIV cases in China. 142Kunming has more than 14 000 female sex workersworking in 14 districts. 143 In 2007, the CDC undertooka large-scale mapping exercise that highlighted that:• most female sex workers in Kunming (and othercities) came from rural areas, and were highlymobile;• a majority are illiterate and have negligible awarenessof HIV;• many had lower levels of condom use and expressedan urgent need for sexual and reproductive healthservices;• most worked on the streets and in ‘touch-touch’dancing halls, 144 hair salons, saunas and massageparlours, rented rooms, night clubs and cheaphotels. 145This study found that HIV prevalence among femalesex workers was 2% but the STI prevalence wasalarmingly high, at 30%. Low-fee sex workers werefound to have a higher turnover of clients than othersex workers, were more vulnerable to contracting HIV,had the lowest literacy levels and awareness on HIVand had limited access to condoms and HIV preventionservices. The CDC study was ground-breaking in thatit identified the places where low-fee sex workersworked, therefore enabling an outreach strategy forproviding them with HIV and STI prevention andtreatment services.In response to these findings Kunming CDC, FHI360and KMRC decided to concentrate on addressing HIVand STI prevention and treatment needs of low-feesex workers through the Lily Women’s WellnessCentre. This work was undertaken between October2007 and September 2011. As a result of changes inUSAID financial support, funding provided throughFHI360 was phased out in late 2011. At the time ofdocumentation (May 2012), Lily Women’s WellnessCentre was operating in Kunming with support fromanother funding agency. It continues to provide femalePage 69

sex workers with a range of services and referrals togovernment health services.The Lily modelDiC: safe space for communitynetworking, education and outreachBetween 2007 and 2011, a total of 4 459 femalesex workers visited the dic. This is strategicallylocated close to numerous dancing halls, massageparlours, hair salons, night clubs and cheap hotels,thus providing easy access for low-fee sex workers andtheir clients. 146While the dic is a place for sex workers to networkwith each other, it also serves as a base for outreachstaff to plan activities, solve problems, stock up oncondoms and lubricants, and share updates from thefield.Every Wednesday, the centre hosts a variety oftraining programmes for sex workers based on theirinterest and needs. These are free of cost and opento all sex workers. A schedule of regular activities isposted at the centre. “Our dic and these trainings arereally popular among our community members. Thisis our only space for sharing and learning from eachother, making friends and resolving our problems.Otherwise, we would have had nowhere to go. Eventhough Kunming is rapidly changing and many ofour community members go in and out of the city,they keep visiting us here [the dic] and participatein different event,” said an outreach worker from theCentre.Peer-based outreachAll outreach workers are trained in peer-educationtechniques. They participate in other periodictraining opportunities organized by KMRC and“This is our only space for sharing andlearning from each other, making friendsand resolving our problems. Otherwise,we would have had nowhere to go.”Peer-based outreachAll outreach workers are trained in peer-educationtechniques. They participate in other periodictraining opportunities organized by KMRC andKunming CDC. Outreach is a central part of thecentre’s work. During the period of 2007–2011, theprogramme reached over 21 654 female sex workers inKunming.Seven outreach workers conduct regular outreachactivities across 63 sites in and around Kunming cityand at one re-education centre where sex workersare detained during police crackdowns. 147, 148 Mappingexercises are conducted every six months, andoutreach plans are altered accordingly. Outreachworkers work in pairs, building trust with sex workersthrough several methods, such as sharing personalstories and ensuring information is conveyed inaccessible language.Outreach workers keep a log of dates, venues andcontacts established and maintained. At each site,particularly where low-fee sex workers operate ingroups, the outreach workers identify a team leaderamongst the sex workers.Lily peer teams in action“During police crackdowns, all of our outreachactivities stopped for a short period of time.We could not visit the field and they could notcome to us. So, we started using mobile phonesto communicate with our community membersabout their situation, and find ways to providecondoms to them in a discreet manner. Beforewe did not have a team leader and it was difficultto keep track of what happened to sex workersduring crackdown, but now that we have a teamleader for each small group of sex workers,the team leader keeps us informed about theirsituation and we find ways to provide condomsto them.”Outreach worker,Lily Women’s Wellness CentreOutreach worker, Lily Women’s Wellness CentrePage 70

Kunming CDC. Outreach is a central part of thecentre’s work. During the period of 2007–2011, theprogramme reached over 21 654 female sex workers inKunming.Seven outreach workers conduct regular outreachactivities across 63 sites in and around Kunming cityand at one re-education centre where sex workersare detained during police crackdowns. 147, 148 Mappingexercises are conducted every six months, andoutreach plans are altered accordingly. Outreachworkers work in pairs, building trust with sex workersthrough several methods, such as sharing personalstories and ensuring information is conveyed inaccessible language.Outreach workers keep a log of dates, venues andcontacts established and maintained. At each site,particularly where low-fee sex workers operate ingroups, the outreach workers identify a team leaderamongst the sex workers. Lily Women’s WellnessCentre has developed a wide array of sex workerfriendlyadvocacy and information materials andinteractive training tools. Outreach activities includeboth one-on-one and group interactive sessions.These sessions focus on discussing a wide rangeof issues including HIV and STI prevention andtreatment, sexual and reproductive health andfinancial literacy to help sex workers manage theirpersonal finances. Participation in outreach activitiesis voluntary. During the project period supported byFHI360, 12 outreach workers conducted 16 outreachsessions every month. Since then, both the numberof outreach workers and outreach sessions per monthhas decreased.Provision of regular STI andreproductive health check-upand referral for diagnosis andtreatmentLily Women’s Wellness Centre collaborates with CDC toprovide health services on-site in the dic and throughCDC clinics. Free STI and reproductive clinical servicesare provided at the dic with the assistance of the localdoctors from CDC Kunming. Up until September 2011,these were provided twice a week and subsequently,once a week.STI and reproductive clinical services at the dicinclude physical and gynaecological examinations;pregnancy testing; periodic presumptive treatment(PPT) for sex workers at their first visit and subsequentcheck-up and treatment at three month intervals; 149referral for STI treatment to the Kunming CDC SexuallyTransmitted Diseases (STD) clinic; referral to MaternalChild Health clinics for reproductive health servicesincluding contraception counselling and full range ofPage 71

Number of female sex workers referredto the Kunming CDC for STI services1 2168386898982008 2009 2010 2011Source: KMRC, 2012, First Narrative Project Report.contraceptive methods; and, accompanied referral onrequest.In cases where sex workers are unable to receiveclinical services at the dic, they can visit the STD clinicat Kunming CDC or seek accompanied referral from theLily Women’s Wellness Centre. The Kunming CDC STDclinic is open five days a week, providing simple STIcheck-up, diagnostic and treatment services.As part of a collaboration between FHI360 andKunming CDC, FHI360 conducted training on STI managementfor clinical staff of the CDC STD clinics toensure that the China National STI Guidelines 2007 andFHI360’s STI standards were strictly adhered to. Qualityof service was assessed annually. This collaborationbetween FHI360 and CDC Kunming included providingSTI diagnostics and some treatment services 150 at a subsidizedrate of one-time fee of 70 Chinese yuan per sexworker. 151Testing and treatment for other STIs are at extracost and usually referred to government general hospitalsor private clinics. There were plans to forge linksbetween Kunming CDC, the Lily Women’s WellnessCentre and government-run facilities. However, thiscould not be initiated due to lack of funding.Providing STI diagnostic and treatment serviceshas been one of the key components of the programme.An average of 800 female sex workers werereached annually. 152 Although the numbers referredto STI services was below the numbers of sex workersreached during outreach activities, the programmewas able to achieve more than its set targets for 2008and 2009. In 2010, the service uptake declined by 57%compared with 2009. In 2011, although it increasedslightly, uptake has not returned to 2009 level. Policecrackdowns, which began in 2010, are noted as a majorfactor for the substantial drop in service uptake. 153The end of USAID funding through FHI360 hascreated uncertainty regarding the continuation of thiscollaboration. Although an interim funding solutionhad been found in 2012 for other aspects of the LilyCentre’s work, it is unclear how the STI and SRHservices will be provided and who will be responsiblefor maintaining and monitoring the effectiveness ofservice delivery in the future. This illustrates some ofthe challenges in building the long term sustainabilityof programme efforts, especially if they are reliant onone external funding source.Page 72

“We have seen an increase in uptake of VCT services at the centre since the introductionof rapid test kits… More sex workers are coming to use this service because it’s quick,requires less blood, doctors from the CDC are not involved and tests are completelyanonymous”VCT counsellor, Lily Women’s Wellness CentreOn-site Voluntary Counselling andTesting (VCT) services for HIV andsyphilisBefore the availability of HIV rapid test kits at thecentre, the Lily Women’s Wellness Centre providedon-site VCT services including pre-test and post-testcounselling. However, reaching female sex workerswith VCT services presented a major challenge.Although the numbers of those who tested for HIVincreased from 127 in 2008 to 229 in 2009, the numbersremained constant at 247 in 2010 and 2011. 154, 155 Whilethe project was able to reach over 21 000 sex workersthrough outreach services, only 850 female sex workersreceived VCT services during the project cycle. 156Towards the end of 2011, Lily Women’s WellnessCentre was able to provide rapid testing for HIV andsyphilis. This had the immediate effect of increasingservice uptake. As previously, trained counsellorsprovide pre- and post-test counselling. The centrestrongly emphasizes the importance of privacyand confidentiality during the process of testingand a non-threatening and friendly environment.For sex workers who receive a positive test result,referrals for confirmatory tests at Kunming CDC areprovided on request.“We have seen an increase in uptake of VCTservices at the centre since the introduction of rapidtest kits. For example, between the periods of Januaryto April 2012, more than 130 sex workers have alreadyreceived VCT services at the centre. This is already halfof the total HIV tests done in the entire year of 2011,”explained a VCT counsellor from the Centre. “Moresex workers are coming to use this service because it’squick, requires less blood, doctors from the CDC arenot involved and tests are completely anonymous,”the counsellor added.Referral to HIV treatment,care and support servicesThe aim of the Lily Centre referral system is to ensurethat sex workers living with HIV have immediateaccess to a health assessment and subsequenthealth monitoring, care and support. The initialassessment involves testing for CD4 and viral load andcommencement of HIV treatment where required.Information about these services is disseminatedto sex workers through outreach and trainingprogrammes. One outreach worker is appointed toprovide on-going support to a group of sex workersliving with HIV.Outreach workers at the centre noted the challengesexist in ensuring effective referral for HIV treatment,care and support services available in Kunming.“Female sex workers, especially thepositive sex workers, face high levels ofstigma and discrimination and so, theydon’t want to go to public health carefacilities although services providedthere are of good quality,” said oneoutreach worker at the dicAlthough these concerns have been reported to publichealth officials in Kunming, the problem remainsunresolved. There is a need for commitment from allpartners to address all barriers to accessing health caresettings. This includes overcoming the human andfinancial resource constraints to ensure communitybasedsupport and referrals, and a collaborativeapproach to addressing stigma and discrimination inhealth care settings.Page 73

Anecdotal evidence suggests that economic empowermentprogrammes are highly beneficial for sex workers, as increasedcontrol over finances offers greater security and hope.Economic empowermentinitiativesCapacity development in financial literacyand money managementIn 2010, Lily Women’s Wellness Centre began offeringservices that help female sex workers realize theirfinancial goals. The Director of the centre, Lhang Yusaid that during interactions with female sex workers,they found that a majority “have dreams of makingmoney, getting rich and accumulate savings but theydon’t have the knowledge and skills or the means todo so.” A financial literacy programme was developedin response, which focussed on enhancing knowledgeand skills in personal finance, particularly in trackingincome and expenses, savings and investmentstrategies. Interestingly, financial logic was usedto promote safer sex and condom use during thesetrainings, making the link between financial securitiesand maintaining health as an important aspect of a sexworker’s work.Referral to banks for savings andinvestment in mutual fundsSex workers rarely have access to banks. The LilyWomen’s Wellness Centre initiated a referralprogramme with cooperating banks where sex workerscould open savings accounts or invest in a mutualfundscheme. 157 Professionals from cooperating banksprovided advice to female sex worker about investingmoney in mutual funds. “It is very successful. Manyfemale sex workers have already bought mutual funds.Due to popular demand, the same orientation wasrepeated twice in 2011,” the Manager said.producing beautiful handicrafts. But the cost formaking such products is expensive. For example,it could cost about 200 yuan to buy the materialsneeded to make a cross-stitch. Although the sexworker could then sell the same for up to 500 yuan,earning a profit of 300 yuan, getting the actual saleconcluded is always difficult. Sometimes it takes up totwo months to sell one cross-stitch.”Lily Women’s Wellness Centre currently lacksadequate resources to strengthen these additionalsupport services. However they recognize the needto forge partnerships with business entrepreneurs,recruitment agencies, financial backers and retailsellers and ensure sex workers can access existingsocial protection, education and poverty reductionprogrammes. Anecdotal evidence suggests thateconomic empowerment programmes are highlybeneficial for sex workers to increase control overtheir financial resources and improve their financialsecurity.“[Referral to banks] is very successful.Many female sex workers have alreadybought mutual funds.”Manager of the Lily Women’s Wellness CentreVocational trainingVocational training is provided by external expertsand focuses on enhancing other marketable skillsof sex workers. This is not without challenge, asoften initial outlay costs required for the makingof products (for example handicrafts) is expensiveand on-sale of products is never guaranteed. As thedeputy manager of the Lily Centre explains, “Someof the sex workers become skilled quickly and beginPage 74

Lessons• An enabling environment is critical to sustainoutreach activities and maintain serviceprovision for sex workers. This has been achievedby collaborating with the police department, andthe buy-in of sex work venue owners, managersand the local community. Nonetheless, policecrackdowns have been shown to impact on theeffectiveness of programmes and attention mustbe paid to addressing the structural factors thatshape risk and vulnerability to HIV infection.• In a challenging socio-political environmentservice delivery through a community-ledapproach is a necessity. The combination ofhigh levels of stigmatization of sex workersand police crackdowns create a complex andchallenging environment for addressing HIVamong sex workers. Lily Women’s WellnessCentre has responded to new and emergingneeds of sex workers in this complex context,underscoring that the most effective way to reachlow-fee sex workers in this environment is throughcommunity-led peer outreach.• Programmes aimed at strengtheningpartnerships between CBO and key stakeholdersneed adequate resources. Partnership-buildingactivities require human and financial resourcesfor both planning and implementation.• CBO-led female sex worker intervention modelscan be scaled up through replicating in similarsocio-political contexts. More than 170 peoplefrom national, provincial and local level CDCs, theWomen’s Federation of China and from severalNGOs in Hong Kong and Lao People’s DemocraticRepublic have visited the centre to learn from itsexperience. 158 Staff members have been invitedto provide technical assistance in designing andimplementing similar programmes in other parts ofChina.• Availability of HIV rapid tests on-site helpsincrease demand for VCT services. Communitymembers prefer rapid tests; they are quicker,easier to provide in community settings anddo not involve multiple points of contacts orrequire paying a visit to a health clinic. Combinedwith friendly, non-judgmental and confidentialcounselling, this leads to greater uptake of VCT.Page 75

Gaps, challenges and opportunitiesThe registering and mobilization of CBOs in China iscomplex and the Lily Women’s Wellness Centre is notregistered as an organization. 159 This has contributedto the hampering of its growth, ability to functionautonomously, and operate with protection affordedby a legal status. Due to this, the centre is not able toreceive funds directly from the government or otherdonors.According to the Centre, frequent crackdownsby police have often driven female sex workers inKunming into hidden locales, increasing their vulnerabilityto violence and limiting their access to HIV preventionand treatment services. The fear of arrest anddetention increases the likelihood of sex workers relocatingfrequently. A reported strong presence ofmafia, illegal gangs and criminals in new locations canpresent additional risks. These factors have severelyhindered Lily Women’s Wellness Centre’s efforts toprovide HIV prevention and treatment services forsex workers. 160Compulsory detention and rehabilitation centresraise serious human rights concerns for sex workers,threatening the health of detainees, including throughincreased vulnerability to HIV and tuberculosis (TB)infection. 161 There is no evidence to suggest that thesecentres provide an effective environment for the ‘rehabilitation’of sex workers. Lily Women’s WellnessCentre reports that most sex workers return to sexwork upon release from compulsory detention as theyhave no other means by which to generate income.“In the re-education centre, it’s not like sex workershave the opportunity to participate in trainings thatenhance their vocational skills or there are any effortsin placing them in other jobs. So, one cannot expectthe sex workers to come out of the centre charged andready to take up new jobs and earn a living. Inevitably,they end up going back to sex work,” reported a sexworker at the Lily Women’s Wellness Centre.“We have built an effective servicedelivery model for sex workers. Now weneed technical assistance and financialresources to expand our services in greateramount and in more places.”Gaizi, staff member, Lily Women’s Wellness Centre“One cannot expect the sex workers tocome out of [rehabilitation] centrescharged and ready to take up new jobs andearn a living. Inevitably, they end up goingback to sex work.”A sex worker, Lily Women’s Wellness Centre.Page 76

138 Kunming Municipal Women’s Compulsory Shelter and Education Centre,also known as the Women Re-education Centre in Chang Po, is a detentioncentre for female sex workers to live in and work when they are arrestedduring police crackdowns. It is the only such centre in Kunming, housingon average 1 000 sex workers per year. A large majority are low-feesex workers, who are particularly targeted in police crackdowns. Sex workersare required to stay at the centre for a period ranging between six monthsto two years, where they study and do menial jobs like peeling beans. Theyget paid for this work and receive free accommodation and food along withroutine health check-ups, which includes screening for HIV and STI. AlthoughSTI treatment is paid for, sex workers in the Re-education Centre have to payfor their personal care items, such as toothbrushes, sanitary napkins andmake-up etc. According to the Lily Women’s Wellness Centre, the prevalenceof HIV and STI among female sex workers living at the Re-education Centrecould be significantly higher than that of sex workers in the city, thus theneed to provide continued HIV/STI prevention and treatment services. Fora critique of such institutions see the United Nations Joint Statement onCompulsory Drug Detention and Rehabilitation Centres, March 2012, whichcalls on States to close compulsory drug detention and rehabilitation centresand implement voluntary, evidence-informed and rights-based health andsocial services in the community. It notes that the deprivation of libertywithout due process is a violation of internationally recognized human rightsstandards. It further notes that where a State is unable to close such centresrapidly, it is urged to undertake a range of action including immediatelyestablishing health care, social and education services.139 The Kunming Red Cross, established in April 1922, is a government-affiliatedorganization operating independently, but in cooperation with the localDepartment of Health. KMRC has been active in HIV prevention in Yunnanprovince since 1997.140 The Centre for Disease Control and Prevention (CDC) is an arm of theMinistry of Health in China, operating at the central and provincial levelswith branches in the cities and towns across the country. Kunming CDC hasan HIV/AIDS department, which implements HIV policy and programmesacross Yunnan province.141 Previously known as Family Health International.142 2012 China AIDS Response Progress Report, Ministry of Health People’sRepublic of China, 2012.143 CDC Kunming. 2007. Surveillance and mapping of female sex workers inKunming, Yunnan, China.144 Touch-touch dancing halls are entertainment venues where a dancer is paidto dance with clients for 15 minutes or longer in complete darkness. Duringthis period, the client can fondle, kiss, touch and engage in other sexualactivities with the chosen dancer. According to sex workers at Lily Women’sWellness Centre, when the lights are turned on used condoms can be foundon the dancing floor.145 CDC Kunming. 2007. Surveillance and mapping of female sex workers inKunming, Yunnan, China.146 Lily Women’s Wellness Centre does not implement any programmes for themale clients of female sex workers. However, it has witnessed increasingnumbers of regular clients of female sex workers visiting the drop-in-centreto receive HIV and STI information.147 As noted, USAID funding through FHI360 ended in November 2011. Sincethen the number of outreach workers has reduced from twelve to seven.148 Research on the Impact of 2010 Crackdown on Sex Work and HIVInterventions in China, China Sex Worker Organization Network Forum,2010. See also Protecting Sex workers Key to Preventing Spread of HIV,which discusses the impact crackdowns by law enforcement authoritiestargeting sex work as a threat regularly faced by sex workers, particularly,low-level street-based sex workers. UNAIDS, http://www.unaids.org.cn/en/index/topic.asp?id=783&classname=Photo%20Stories&class=2. Accessed 27August 2012.149 Inclusion of this case study in this collection is not an endorsement of theuse of PPT, as normative guidance on this issue is currently unclear. WHO,UNFPA and UNAIDS are working together with the Global Network of SexWorker Projects to finalize global guidance on prevention and treatment ofHIV and other sexually transmitted infections for sex workers, including onthe issue of PPT. It is hoped this guidance will be released in the last quarterof 2012.150 Treatment services include syphilis, gonorrhoea, genital warts PV, genitalherpes and chlamydia.151 Kunming Red Cross Society. 2011. Final Narrative Report, HIV/STI Preventionand Care for FSWs in Kunming. Submitted to FHI360, 2012.153 Ibid. See also Research on the Impact of 2010 Crackdown on Sex Work andHIV Interventions in China, China Sex Worker Organization Network Forum,2010.154 Ibid.155 It is noted that HIV testing among sex workers in China is improving butremain low. The percentage of sex workers who received at least one testduring the last 12 months and received their results increased for 36.9%to 38.2% during period 2010 – 2011, 2012 China AIDS Response ProgressReport, Ministry of Health People’s Republic of China, 2012.156 Ibid.157 In mutual-fund scheme, a sex worker is required to invest between 300 to600 Yuan every month. The deposit earns a higher interest rate than anyother saving and investment schemes. Funds can be withdrawn anytime.158 Ibid.159 See for example: NGO Law Monitor China for an analysis of legal issues forNGOs and COS in China. www.icnl.org/research/monitor/china.pdf160 Worker Organization Network Forum, 2010. See also ProtectingSex workers Key to Preventing Spread of HIV which discusses the impact‘crackdowns’ by law enforcement authorities targeting sex work asa threat regularly faced by sex workers, particularly, low-level streetbasedsex workers. UNAIDS, http://www.unaids.org.cn/en/index/topic.asp?id=783&classname=Photo%20Stories&class=2. Accessed 27 August2012.161 The United Nations Joint Statement on Compulsory drug detention andrehabilitation centres, March 2012, calls on States to close compulsory drugdetention and rehabilitation centres and implement voluntary, evidenceinformedand rights-based health and social services in the community. Itnotes that the deprivation of liberty without due process is a violation ofinternationally recognized human rights standards.Page 77

Case Study5Sex worker-led HIVtreatment, care andsupport programme:VAMP Plus, IndiaPage 78

VAMP — Veshya Anyay Mukti Parishad 162 — isa registered collective of about 5 000 femalesex workers from seven districts in WesternMaharashtra and North Karnataka, the Republic ofIndia (India). VAMP uses rights-based approachesto empower and collectivise sex workers to claim,promote and protect their rights to live and work insafety, prevent exposure to HIV and other STIs, addressviolence, and increase access to public services.In 1996 VAMP started as an outreach programme ofSampada Gramin Mahila Sanstha (SANGRAM), a NGObased in Sangli. It originally focused on HIV preventionthrough peer-based interventions and condomuse promotion among sex workers in two high densitysex work areas in Sangli. In 2000, it began advocatingfor community-led support systems to increasesex workers’ access to health and other social services.That same year, VAMP began addressing violenceagainst sex workers and the broader issues of socialexclusion, marginalization and discrimination as wellas the urgent treatment, care and support needs ofsex workers living with HIV.In 2007, a group of sex workers living with HIVcame together to form VAMP Plus, a wing of VAMP thataims to address socioeconomic, health and psychologicalneeds of sex workers living with HIV. VAMP Plusfocuses on three key areas:• facilitating access to HIV testing and treatmentservices through awareness, education, outreach andaccompanied referral;• creating a community care and safety net that helpssex workers living with HIV advocate, seek andreceive treatment, care and support and addressproblems related to health and well-being includingnutrition, shelter and safety;• creating a safe space for sex workers living with HIVto discuss their rights, the legal and social issues affectingthem and their families, and develop collectiveaction to assert and claim their rights.VAMP Plus conducts individualised outreach,counselling and accompanied referral services.Through these services they have ensured that almostall sex workers from their collective who have testedHIV positive and need treatment, are supported toaccess health services, and receive ART and/or othertreatment for opportunistic infections (OI) from civilhospitals 163 and private clinics across seven districtsin the two states. A total of 629 sex workers livingwith HIV currently receive continuing care andsupport, including supplementary food supply. VAMPPlus supports treatment adherence by providingpsychosocial support and counselling, monitoring ofside effects and facilitating access to required healthservices. Foster care and hospice facilities are providedfor those who are ill and need support during therecovery period.HIV and sex work context and thebeginnings of VAMP PlusWhen HIV first became apparent in India, itsprevalence was high in the States of Maharashtra andKarnataka. These were among the priority states forHIV prevention and treatment programmes. Wheninitially rolled out, many of the treatment programmesdid not adequately reach women, sex workers and menwho have sex with men. By mid-2000s, a large numberof sex workers (and other key affected populations) inthese states were testing HIV positive and at varyingstages of illness. In the absence of treatment, care andsupport services, and given the high levels of stigmaand discrimination against sex workers, access to thelimited services that existed was seriously delayed andas a result, many sex workers died unnecessarily ofAIDS-related illnesses.Illnesses related to HIV had become the subject ofroutine discussions among the sex worker communityin Sangli. Regular clients, who constituted a majorsource of income for sex workers, stopped visiting dueto ill health. Sex workers struggled with their friendsand colleagues dying; attending and organizingweekly funerals and managing their orphanedPage 79

children became a part of life. The dire situation facingsex workers was the impetus for starting VAMP Plus,a support group for sex workers living with HIV.The shifting environment of treatment,care and supportSince VAMP Plus began its work, the situation inIndia has improved considerably with regards toHIV treatment, care and support. The availability ofand access to affordable HIV drugs has significantlyimproved throughout India due to policiesimplemented by the government, with support frominternational partners, to provide HIV testing andantiretroviral treatment free of charge and to make itwidely available.Although stigma and discrimination continue tobe a challenge, dissuading HIV positive sex workersfrom accessing health services, determined and relentlessadvocacy by SANGRAM and VAMP with thelocal government hospitals in the areas where theywork have resulted in a changed environment. Withsupport from SANGRAM, VAMP Plus has, over theyears, had many individual meetings and consultationswith senior health officials, health workers andother relevant partners to discuss strategies to addressstigma and discrimination in health care settings.An important part of the work of VAMP and VAMPPlus is the conduct of sensitization workshops andtraining programmes for health care providers. Thesefocus on building an understanding of the impact ofstigma and discrimination on sex workers’ access toHIV prevention and treatment, and on sex workers’rights to health and other public services.Female sex worker and VAMP Plus outreach workerAnita Terdale, describes the change she has witnessedfirst-hand: “Before, we [sex workers] were treatedlike animals. We were not even allowed in the [civil]hospital to receive any kind of medical check-up.When we had to be admitted, we were given roomsnear the toilets or in isolated corners, separated fromothers. But now we are treated like anyone else. We areaccommodated in the same rooms as other patients.Hospitals and doctors are more respectful and sensitiveto our needs. And we feel comfortable going tothese hospitals.”Sex workers have made themselves part of thesolution. When the civil hospital did not have adequateresources to develop the required infrastructurefor ART programmes in Sangli, SANGRAM providedfinancial support to build an ART centre within thehospital premises. 164 This was a strategic move toimprove sex workers’ access to broader health services,including HIV treatment services. As noted by MeenaSeshu, General Secretary of SANGRAM, “this signifiedour continued fight for the protection of sex workers’rights and commitment to addressing HIV.” Apart fromdeveloping the centre’s infrastructure, the financesupported the purchase of laboratory and otherhospital equipment required for running the centre.As a result, sex workers are more empowered andorganized in their responses to HIV. The efforts madeby VAMP Plus to facilitate sex workers’ collective actionin claiming, promoting and protecting their rights, hasled to an increased recognition of sex worker rights andwider social acceptance. The sex worker community’sperceptions about health and well-being have changed.They are more know ledgeable about the importance ofearly testing and treatment, and more willing to test.“Before, we [sex workers] were treated likeanimals. We were not even allowed in thehospital to receive any kind of medicalcheck-up … Now we are treated likeanyone else. We are accommodated in thesame rooms as other patients. Hospitalsand doctors are more respectful andsensitive to our needs.”Female sex worker and VAMP Plus outreach workerAnita TerdalePage 80

This has resulted in a significant improvement intheir health-seeking behaviour. An awareness of rightscoupled with this has, in turn, created the demand forfriendly and affordable health services.Over the years, VAMP Plus has adapted its approachesand introduced new programmes to ensure thatthe services provided are responsive to the emergingneeds of sex workers living with HIV and their families.For example, in response to the growing numbers ofchildren orphaned due to HIV, and single mothers whoare too ill to care for their children, in 2009 VAMP Plusestablished Mitra, a hostel for children of sex workersliving with and/or affected by HIV.Key programme strategies forVAMP PlusOutreach, counselling andaccompanied referralVAMP Plus implements a peer-based outreachprogramme for education and awareness on HIV testingand treatment, pre- and post-test counselling on HIVand accompanied referral for HIV testing. Outreachsessions are individualised, prioritizing one-to-onepersonal interaction, discussion and counselling.Counselling focuses on the benefits of testing, testingprocedure and consequences of results.Outreach workers accompany sex workers whowish to test for HIV to the civil hospitals. They receivepre-test counselling and a free HIV test. The test resultsare available on the same day. If a test result is negative,individuals are counselled on strategies to remain soand advised to come back for routine testing everythree months. If the result is positive, initial counsellingis provided and individuals are referred for an immediatehealth check-up, including CD4 count to determinetreatment eligibility. Once this assessment iscompleted, and when a sex worker who receives a HIVpositive result is ready, peer-outreach workers provideanother round of post-test counselling, specificallydesigned for sex workers living with HIV.Follow-up support, determination oftreatment eligibility and treatmentadherenceProviding post-test counselling as part of followupsupport encourages sex workers living withHIV to access other care and support servicesand improves adherence to treatment. In VAMP’sexperience, two levels of counselling — by peeroutreach workers and health care providers — isa more effective way to increase uptake of HIVtreatment services. Combined with accompaniedreferral, it helps in addressing the commonchallenge of people who test HIV positive being‘lost to follow-up’ and assists sex workers to accesshealth care services for OI and commencing andmonitoring HIV treatment when required.Peer-outreach workers provide on-going psychologicaland practical support to sex workersliving with HIV. Outreach workers are assigned tosupport individuals from the point they are consideringtaking an HIV test, to commencing andmanaging treatment if they test HIV positive.This allows mutual trust to build between thesex worker and outreach worker, which has thebenefit of helping outreach workers manage caseseffectively.Page 81

Follow-up health checks include testing for CD4count, sonography, sputum test for TB, chest X-rayand haemoglobin test. This health check-up packageis provided free of cost by the various departments atthe civil hospital. Not only is it more convenient tohave all these tests performed under the same roof,it accelerates the process for determining treatmenteligibility. Furthermore, locating the treatment centrein the civil hospital makes coordinating, monitoringand following up any emerging treatment-relatedissues, including managing OI and illnesses related toHIV, far more efficient.At the commencement of treatment, sex workersliving with HIV are advised to visit the ART centreevery fifteen days for regular check-ups, includingmonitoring side effects. The check-up intervalsdecrease as the sex workers adjust to the drugregimen and their health conditions improve.Throughout this period, the assigned outreach workergoes with the sex worker for these health visits.Community-based care and supportA large majority of sex workers living with HIV, andtheir family members, receive care and supportservices through VAMP Plus home-based and fostercare programmes, which are located within thecommunity. VAMP Plus has also established a referralsystem with two other AIDS care centres.Most sex workers living with HIV are cared forat their homes. Peer outreach workers have becomede facto ‘families’ and caregivers of sex workers whobecome unwell. Trained in home-based care techniques,these designated peer-outreach workers constantlyferry sex workers living with HIV back andforth from the hospital, organizing food and childcareand even supporting ailing lovers. Their counsellingskills are put to use in supporting sex workersand their families through anxiety and grief. They areresponsible for mobilizing support to address any immediatemedical or social needs of sex workers livingwith HIV or their family members.“Because of fear of discrimination, manysex workers do not want to take HIV test.My CD4 count was 71 when I got HIV testedfor the first time; with the right treatmentand the support I have received from myfriends and community members, it isnow 930. Improvement in my healthstatus is a testimony of the positive impactof HIV testing and treatment. Usingpersonal stories to encourage and motivesex workers to get tested is very effective inmy experience.”Shantamma Gollars, outreach worker, VAMP PlusIn India, hospitalized patients are expected toorganize their own helpers to bring food and water.Many sex workers do not have family members whocan do this. Therefore, VAMP Plus has a roster ofsex workers who provide 24-hour support as careworkers. They carry food, clean clothes and cleandrinking water for the patient. If a mother is admittedin hospital, in the interim her children are cared forby the community — from sending them to school, tosupporting them physically and emotionally.In 2008, VAMP Plus started a hospice care servicefor critically ill sex workers who cannot care forthemselves, due to AIDS-related illness or otherreasons such as disability. When Renukaambi,a female sex worker based in Sangli died, she left hersavings to VAMP. With this money, VAMP constructeda multi-purpose hall and a room. The multi-purposehall is used for holding health clinics every morningand evening, and supplementary education forchildren of sex workers, while the room has beenturned into a hospice care centre. VAMP Plus memberssimilarly provides 24-hour care for those living in thehospice centre.Page 82

Lessons• Individualized peer-outreach supportis effective in facilitating access to HIVtesting and treatment services and inreducing ‘lost to follow-up’ sex workers.In VAMP’s experience, an individualisedsupport facilitates conversation and trustmore effectively than a group outreachsession. It fosters privacy and confidentialitywhereby sex workers can share their innerfears about HIV testing and facilitates accessto HIV treatment and care.• Continued counselling and psychosocialsupport for sex workers living with HIV canreduce psychological distress. This supporthas had an extremely positive effect onthe members of VAMP Plus, helping dealingthem with stigma and develop copingstrategies. Anita Terdale, VAMP Plus outreachworker living with HIV explained that suchsupport has given sex workers courageand confidence to face difficulties and livehealthier and happier lives: “Sex workerswilling to receive support and help to dealwith stress, anxiety and fear are able toaccess health and social services on time.They are the ones living healthy and happy.Those who feared and ran away from theseservices have all died. Sex workers can seethis around us. This bitter truth helps us tomotive our community and develop copingmechanisms for emotional and healthproblems.”“Thanks to the ART, very few sex workersare actually falling sick these days. Butat times, we do face situations whereinsex workers do not have any familysupport, get critically ill and cannot carefor themselves. In such situations, theyneed our help 24/7 and they need medicalcare every day. That’s why we neededa hospice care centre. Here [in the hospicecare centre], we organize doctor’s visitevery day and also help around the clock.’Anita Terdale, outreach worker living with HIV, VAMP Plus• Locating key HIV treatment-relatedservices under one roof can improveservice uptake. Locating services togethersaves time, money and is easier thanvisiting multiple hospitals for different testsand treatment. According to VAMP, thisarrangement appeals to sex workers andmay contribute to improving service uptake.Page 83

Case Study6USHA MultipurposeCooperative SocietyPage 85

“It’s our own bank, not for non-sex workers or outsiders... We are proud in theonly sex worker cooperative…I am proud of myself that through USHA, I metso many people and am well known. I got trained, learned to talk to others,and learned how bank is run.”Julie, daughter of a sex worker, daily collectorUSHA 165 Multipurpose Cooperative Society is thelargest sex worker-led financial institution inAsia, steered by Durbar Mahila SamanwayaCommittee (DMSC), a sex worker collective in WestBengal, India. DMSC, a collective of 65 000 sex workers,is a forum for all sex workers. In 1995, a group ofsex workers from DMSC created USHA as their own financialinstitution.The cooperative’s goals are to enable sex workersto become financially secure; establish worker’s recognitionand rights of sex workers; and to ensure educationand career development opportunities forsex workers’ children.USHA has a current membership of 16 228 femaleand transgender sex workers. Four to five thousandmembers receive loans annually. Female and transgendersex workers or their daughters over 18 years canopen accounts and are eligible for loans. USHA hasone of the best loan recovery rates in the state ofWest Bengal (over 90%) with an annual turnover ofUS$ 2.7 million and capital assets of more than US$1 million. 166USHA’s core services are:• savings accounts, daily collection accounts and fixeddeposits, and a tie-in product with the Life InsuranceCorporation of India;• providing loans to members;• supporting self-employment schemes forsex workers;• social marketing strategies generate resources forDMSC to better meet the community’s needs.History behind the cooperativeSex workers in West Bengal were denied accessto financial institutions and could not open bankaccounts, as they were unable to produce thenecessary documents. As a result, the majority ofsex workers deposited their money in unauthorisedfinancial institutions (such as chit funds) 167 or left it inthe care of their madams, risking mismanagement oftheir money and sometimes outright loss of savings.Common experiences among sex workers in DMSCwere being cheated by these agencies and having theirsavings taken away by their lovers (babus), local goonsand the police. Many did not know how to save moneyfrom their daily incomes and usually spent all theirearnings. Moreover, there was the prospect of financialinsecurity for aged sex workers. They had a decliningincome, increased health-related expenses alongwith often financially supporting the family. Duringa financial emergency, sex workers were generallyat the mercy of loan sharks who charged exorbitantinterest rates, sometimes as high as 300% per annum.Sex workers were often caught in an inescapablespiral of debt, compounding often fragile financialsituations.At the same time DMSC was consolidating itslearning from the HIV prevention programmes theyhad been implementing since 1992. One of the lessonswas that structural barriers limited sex workers’access to health, social and financial support services.They learned that financial insecurity promptedsex workers to compromise their safety, such asbeing unable to insist that a client use a condom forfear of losing business. Increasing the likelihood ofan STI/HIV infection, this ultimately spiralled intogreater expense on health care. USHA cooperative wasformed to address these socioeconomic and healthvulnerabilities of sex workers.Page 86

Why a cooperative?DMSC had the option of opening a bank account,engaging with a life insurance company or initiatinga microcredit or cooperative scheme. Based ondiscussions with community members, it becameapparent that there was a need to create a financialinstitution, exclusively of, and for, sex workers.The community wanted an institution to addressthe underlying factors which prevented them fromaccessing financial support elsewhere. Communityinvolvement throughout the process of forminga cooperative ensured their needs were met andpriorities respected. An additional, extremely helpful,factor was that the Indian government providesassistance to cooperatives by giving working capitalloans and infrastructure development support.Early strugglesWhen the sex workers from DMSC approachedthe Government Cooperative Department seekingsupport to start a cooperative, they realized that theycould not register the cooperative under the WestBengal Cooperative Law. Firstly, they did not havethe required start-up funds. Secondly, sex workerswere considered immoral under the Cooperative Lawand only people with ‘good’ moral character couldregister a cooperative. DMSC decided to advocate fora change in clause in the law regarding ‘immorality’.What followed was an intense lobbying and advocacycampaign. Finally, in August 1995, DMSC succeeded inpersuading the Government of West Bengal to removethe notion of ‘morality’ from the Cooperative Law.USHA could be legally registered as a cooperative of,and for, sex workers.The registration of USHA marked a victory on twoaccounts. First, the changes to the Cooperative Law hadthe effect of recognizing sex work as an occupation.This was used to bolster wider advocacy campaigns forsex workers’ rights. Second, it challenged the powerrelations between money lenders and sex workers bydisempowering the system that upheld exploitativeeconomic conditions.The local money-lending loan sharks were aggravatedby the formation of USHA. They lodged complaintsto local city councillors accusing them of misappropriatingfunds. DMSC advocated at the state andlocal levels to counter these false allegations. 168Initially there was also resistance from within thecommunity. Bitter experiences had taught sex workersto be wary of any ‘new deals’ involving money. Timewas spent in building trust. As members realized thattheir money in USHA earned a good interest and theycould access loans against their deposits at very lowinterest rates, their trust grew, as did the membership.Seed funding, of approximately US$ 1 800, securedfrom the State Department of Cooperatives, contributedto boosting USHA’s credibility.Elements of success:Key components of thecooperative programmeGovernance and managementA board of nine directors, all of whom are sex workers,governs USHA’s management and operations. They areelected by a two-tier system. In the first phase, all thegeneral members vote for forty-five representatives.The elected representatives then elect the boardmembers who hold office for three years and no morethan two consecutive terms. The president, secretaryand treasurer are elected from the board members. Asthe executive committee, they make all key and finaldecisions. This democratic approach has encouragedcommunity members to participate in the decisionmakingprocess. “The most important thing is thatall our services are directed towards members’ wellbeingand they can aspire to be on the board to makedecisions one day,” says USHA’s President at the time ofdocumentation, Abida Begum.As a member of the steering committee of DMSC,USHA participates in the joint policy making forum ofPage 87

The cycle of economic insecurityand vulnerability to HIVLess negotiatingpowerUnprotected sexLack of savingsIncreasedvulnerability toSTI/HIVFurther reduction ofeconomic stabilityTaking loans frommoney lendersIncreased burden topay interestBuying healthcare services fromprivate sectorPage 88

“The most important thing is that all our services are directed towards members’ wellbeingand they can aspire to be on the board to make decisions one day,”Abida Begum, USHA Presidentsex workers of DMSC. This addresses potential conflictof interest between financial management issues andinterests of the community.USHA has developed three operational policyguidelines focussing on:• staff recruitment: priority is given to sex workersand the daughters of sex workers for all positions;• loan disbursement: priority is given to the poorest ofthe community;• flexible working hours: the working hours are determinedby the needs of the community.There are 47 employees of USHA and the ratio for maleto female staff is 1:2.Services offeredPrimarily USHA gives loans to its members, someof whom have taken loans of up to 2 500 000 Indianrupees (US$ 40 000) to start their own businesses.“I took loans three times: once to buy land, then tobuild a house and finally for my daughter’s marriage,”explained an elderly sex worker. USHA providesvocational training to members who want to startsmall business ventures. This ensures that businessesset up by sex workers run effectively and are able togenerate income.Furthermore, financial empowerment has enabledsex workers to independently approach external financialinstitutions for borrowing, as citizens with rightsand as workers.Making services responsive to communityneedsIn USHA’s experience, a financial institute witha human face is critical. “Other banks are concernedabout money, we are concerned about our members,”stated a member of USHA. This is achieved by raisingawareness about services offered and by providingreliable and friendly saving schemes to encouragesex workers to create a culture of saving. “I can depositmy daily earnings which can be later used. In thepast, babu used to take away my money” commentedJyotsna, another member of USHA.Page 89

“Other banks are concerned about money, we are concerned about our members.”A member of USHAUSHA constantly updates their services to cater to theneeds of their members. They make their servicesuser-friendly by:• Ensuring that transactions are quick and easy,• Offering attractive interest on savings that motivatesex workers to save more;• Maintaining a caring approach through personalisedcontact with members. As one member explained,“It’s the love and care from USHA, the daily collectorsand board members, who make me feel that USHAis mine. When I was ill, the president delivered theloan at the hospital, which other banks can never dofor me;”• Introducing a daily collection system. This offerssex workers a more efficient financial transactionand creates jobs. USHA was granted permission bythe Cooperative Department to undertake dailycollection. This boosted membership and theamount of money deposited increased five-fold inone year.168 USHA trains and employs daughtersof sex workers as daily collectors, broadeningtheir engagement in the DMSC movement. As Julie,daughter of a sex worker recounted, becominga daily collector has boosted her feeling ofownership and empowerment: “It’s our own bank,not for non-sex workers or outsiders... We are proudin the only sex worker cooperative…I am proud ofmyself that through USHA; I met so many people andam well known. I got trained, learned talk to others,and learned how bank is run.”An unforeseen but significant positive impact of USHAis that member’s registration cards are now used toobtain voter ID cards and rations cards, enablingsex workers to access other civil entitlements.Moving beyond microcredit programmingSince its inception, USHA has emphasized incomegeneration through various social marketing strategies.Marketing of businesses helps generate income forsex workers. The condom social marketing programmeis the most profitable venture of USHA, selling around3.5 million condoms per annum. 170 In 2010–2011 alone,USHA sold 9 432 458 condoms, generating a profit of1 086 298 Indian Rupees (approximately US$ 19 636). 171 USHA currently acts as DMSC’s primary financialagent, building up an assets base to safeguard itssustainability. 172 The financial success of USHA hasenabled it to take bank loans, investing the surplusesto build DMSC’s capital assets. Greater financialindependence has allowed DMSC to be more proactivein meeting the needs of the community. For example,they have been able to establish new health clinics andeducation centres for sex workers and their children.The income generating capacity of USHA demonstratesthe programmes’ effectiveness and in turn assists inmobilizing additional resources from donor agencies.Through experience USHA has developed technicalexpertise and a robust infrastructure equipping it toact as the financial institution for other sex workers’organizations affiliated to DMSC. At present, USHA hasmore than 5 000 registered members and its increasingturnover is hailed as a success story of the Cooperativemovement in West Bengal by the Department ofCooperatives. 173Condom social marketingThe Condom Social Marketing Programme, referredto as Basanti Sena, started in 1998, in response tothe phase out of DMSC’s HIV programme. With this,distribution of free condoms stopped and sex workers“It’s the love and care from USHA, the dailycollectors and board members, who makeme feel that USHA is mine. When I wasill, the president delivered the loan at thehospital, which other banks can never dofor me.”A member of USHAPage 90

Loan purposes8%Buy land4%Business-related expenses12% To repay high-interest loans17%Medical expenses4%Help a friend or relative15%Marriage of children or relative21%House repair orconstruction16%3%Education of childrenHousehold or personal expensesGrowth in USHA Cooperative Membership 1995–201117 500 Members12 5007 5002 500Year 1995200020052010Page 91

Lessonshad to buy them. This was a strategy for sustainabilityof condom distribution and safer sexual practices.The main objectives of the programme are to createa demand for condoms through awareness raisingand counselling, and ensure availability of goodquality and affordable condoms.Initially, social marketing was conducted in highdensitysex work areas of Kolkata. Later, a three-levelmarketing strategy was adopted:• one-on-one and group counselling to highlight theimportance of condom use and developing condomuse negotiation;• advertising condoms and promoting its use by distributingleaflets, through cultural programmes likestreet plays and large-scale community awarenesscampaigns;• establishing outlets for selling and storing condomsin each sex work area.Two teams of Basanti Sena, each comprising offive members and a team leader, coordinate theprogramme. Limited social marketing of lubricantsis conducted, as this is provided free for male andtransgender sex workers by the State AIDS ControlSociety.• Economic empowerment increases sex workers’morale and self-confidence, improves standardof living and is empowering for the communityas a whole.• A sex worker-led financial institution has widersocial and political implications. It legitimizessex work as an occupation and sex workers’right to control their own economic resources.Moreover, this has influenced other collectivesof marginalized communities to replicate themodel, taking technical help from USHA. Anothereffect is the reduction of interest rates bymoneylenders. 174• Economic security improves sex workers’control over their work environment, includingthe ability to negotiate safer sex. Sex workersexperience less financial exploitation whenthey manage their own finances. Since socialmarketing of condoms is tied to the visits madeby daily collector, the message of consistencyin condom use is constantly reinforced. Forsex workers living with HIV, access to USHAmeans being able to better take of their health.• Financial services must be responsive to theeveryday needs and realities of sex workers.USHA’s responsiveness to the need for dailycollection improved savings and increasedmembership.• Investing in capacity building of sex workers infinancial management and public relations iscritical to efficacy of a sex worker-led financialinstitution. Various local banks, experts andadvisors of DMSC have given technical inputs toplan, run and monitor USHA cooperative.Page 92

Gaps, challenges and opportunitiesIt was not an easy journey to introduce regular savingsschemes for sex workers or new concepts of socialmarketing. Moneylenders and chit funds poseda constant challenge. Many moneylenders are friendsof sex workers and many sex workers are still unawareof USHA’s services. In financial emergencies, they tendto go to moneylenders. To raise awareness about theinherent dangers of this, USHA distributes informationthrough pamphlets, daily collectors and disseminateswarnings issued by the Reserve Bank of India.Another challenge can be the madams and loversappropriating sex workers’ income. Dealing with thisrequires more tact because they are the sex worker’s‘family’. USHA depends on the strong field presence ofDMSC for this.Low-levels of literacy and lack of expertise infinance and accounting among the USHA staff, includingthe collectors, continues to make USHA dependenton technical advisors and DMSC for support. They areaware of the need to consider sustainable approachesto building capacity of the sex worker community inthese areas. Continued efforts are required to expandUSHA’s business initiatives.The keystone of USHA’s future plans are strengtheningand expanding its business ventures and continuingto provide financial and social support to more sexworker communities across a wider geographicalarea.There is concern about the safety and security ofelderly, retired sex workers and those living with HIV.USHA plans to set up an old age home and a largescaleproduction unit for generating employment forworkers who opt out of sex work, or retire. They willcontinue to bolster campaigns for the recognitionof sex work as work and assert sex workers’ humanrights.USHA has emerged as an inspirational financialinstitution. Currently, staff members providetechnical support and guidance to initiate a similarfinancial institution model in Tangail, a brothel inBangladesh, for TOP in Myanmar and Ashodaya inMysore, India. With technical and financial supportfrom USHA, a cooperative for male sex workers inWest Bengal will start in August 2012. The successof these will demonstrate USHA’s impact and itspotential for replication.164 In Hindi, the word means dawn, as it is the dawn of financial support initiated for sex workers, by sex workers.165 Jana, Samarjit, 2011. The Political economy of Sex workers Cooperative. Presentation made at University of Pennsylvania, USA on 14 April, 2011. DMSC: WestBengal, India.166 Chit funds are private and often unregulated financial institutions that give loans at exorbitant interest rates.167 See http://www.durbar.org/html/micro_credit.asp. Accessed on 28 May, 2012 in Bangkok, Thailand.168 DMSC and TAAH Research Team. Meeting community needs for HIV prevention and more, Intersectoral action for health in the Sonagachi red-light area ofKolkata. Date, Unknown. Accessed from http://www.who.int/social_determinants/resources/isa_sonagachi_ind.pdf on 28 May, 2012 in Bangkok Thailand.169 Jana, Samarjit, 2011. The Political economy of Sex workers Cooperative. Presentation made at University of Pennsylvania, USA on 14 April, 2011. DMSC: WestBengal, India.170 DMSC, 2012. Social Marketing of Condoms by USHA Cooperative Society, Ltd. Internal Document, unpublished.171 http://www.durbar.org/html/micro_credit.asp172 From http://www.eugad.eu/wiki/index.php?title=India_-_Living_with_Dignity_-_Kolkata accessed on 28 May, 2012 in Bangkok Thailand.173 http://www.durbar.org/html/micro_credit.asp accessed on 29 May, 2012 from Bangkok Thailand.Page 93

Case Study7Durjoy Nari Sangha:addressing violenceagainst sex workersin BangladeshPage 94

Durjoy Nari Sangha 175 is a CBO governed byfemale sex workers in Bangladesh. Its visionis to empower freelance female sex workers 176to secure rights of equality, dignity, health and safety.Currently 3 500 sex workers from Dhaka and othertowns are registered members.In 1997, CARE Bangladesh (CARE) pioneered an interventionamongst street-based sex workers — ‘StoppingHIV/AIDS through Knowledge and Training Initiative’(SHAKTI). Key activities were outreach, drop-incentres,STI referrals, condom promotion and rightsawareness among sex workers. Community empowermentand sex worker participation were cornerstonesof SHAKTI’s approach.A few months into the project, 20 sex workersvisited Durbar Mahila Samanwaya Committee (DMSC)in Kolkata, India to study sex worker collectivisation.This was their first exposure to a large-scale programmeled by sex workers who viewed themselvesand their work positively. It was an eye opener to realizethe commonality of their experiences and inspired thesex workers of Bangladesh to move forwards towardsbuilding a strong community and sex worker-ledorganization.In 1998, the sex workers decided to form DurjoyNari Sangha (Durjoy) and an eleven-member committee177 was democratically elected. In 2005, Durjoy registeredwith the NGO Affairs Bureau enabling it to receiveforeign funds. In 2009, it expanded services to includehome and hotel-based sex workers.As of 2012, Durjoy is the largest sex worker organizationin Bangladesh and a strong advocate forsex workers’ rights. It reports implementing HIV preventionprogrammes in four divisions and 26 districtsof Bangladesh, providing services to more than 14 000sex workers. 178 Services include legal rights educationfor sex workers rights and legal advice and referrals.This case study focuses on Durjoy’s programme toprevent and respond to violence against sex workers.HIV prevalence and violenceagainst sex workers in BangladeshHIV prevalence in Bangladesh is less than 0.1% in thegeneral population. 179 HIV prevalence among femalesex workers, men who have sex with men, transgenderpeople and people who use drugs is 0.7%. 180 However,national HIV prevalence figures often mask higherprevalence in specific districts. For example, in Hili,a small border town in the northwest, HIV prevalenceis estimated at 1.6% among female sex workers. 181Syphilis rates are estimated at 13% among street-basedsex workers in Hili, 10% in Chittagong and 9% amonghotel-based sex workers in Sylhet. 182During the first half of 2011, violence againstwomen and girls topped all crimes reported to thepolice. A total of 7 285 cases of violence against womenwere registered of which 1 586 were rape. 183 The levelsof violence against female sex workers 184 are higherthan in the general female population. 185 In 2007, CARE,Durjoy and Nari Mukti Sangha carried out a base-linesurvey among 381 female sex workers in Dhaka, Khulnaand Tangail. 186 The key findings were:• 94% experienced violence. The types of violenceincluded verbal, physical and mental abuseand sexual assault. Among those who experiencedviolence, 65% faced sexual violence duringpregnancy.• In Dhaka, 81% of street-based sex workers and 62%in Khulna reported local gang members (mastan)and police as the main perpetrators. In brothels, theperpetrators were madams (sardanis) (69%), clients(48%) and lovers (babus) (38%).• Street-based sex workers face slightly higherviolence than brothel-based sex workers. On averagea street-based sex worker in Dhaka faced eleven incidentsof mental violence, six of sexual violence, fiveof economic and five of social violence from theirclients, per month.Page 95

The extent and severity of violence against sex workers does not result inpublic outcry; rather, it is normalized. Often, prevailing stigma againstsex workers means they are not considered worthy of support and protection.• Among 351 sex workers who faced violence,a majority attempted to report it; 15% to the policeand 71% sought NGO assistance.• About 50% experienced barriers in reporting. Thisincluded social stigma, reluctance by the police toregister a complaint, demands for money, lack ofprivacy, poor quality of services, verbal abuse andmisbehaviour.• Sex workers often experience psychologicalproblems due to limited support to deal withviolence, and inability to access legal recourse. 187The extent and severity of violence against sex workersdoes not result in public outcry; rather, it is normalised.Often, prevailing stigma against sex workers meansthey are not considered worthy of support andprotection. Internalised stigma among sex workersthemselves was also evident, with many sex workersin Bangladesh considering violence normal or ‘part oftheir job’. 188 This has an adverse impact on the health ofsex workers and their families, particularly children.Stigma, the threat of violence and low self-esteem wasfound to contribute to mental ill health and impedeaccess to health care services. The study indicatesa connection between violence and low condom use,and hence increased vulnerability to HIV and STIs.PROTIRODH project: a modelfor addressing violence againstsex workersIn response to the baseline findings from the SHAKTIproject, CARE in partnership with Durjoy designedand implemented a project to address violenceagainst women, highlighting female sex workersas a particularly vulnerable group. The project,‘Promoting Rights of the Disadvantaged by PreventingViolence Against Women’ (PROTIRODH), 189 aimed atpreventing and responding to violence and improvingwomen’s access to legal and health services. The projectcomponent focussing on street-based sex workerscommenced in 2007 and was implemented for threeyears in Dhaka and Khulna.The programme objectives were to:• prevent violence by mobilizing and buildingcapacities of sex workers and community partners,including clients, police, local businessmen, goonsand religious leaders;• ensure that sex workers who experience violence canaccess legal, health and protection services;• address violence by addressing barriers to reportingviolence, enhancing access to legal support andimproving responsiveness of law enforcement andjudicial systems.The baseline findings informed the design ofPROTIRODH. CARE facilitated capacity building forDurjoy, provided technical guidance and support todevelop partnerships between the community, districtlevel government bodies, NGOs and communityleaders. It helped advocate with police and judiciaryto improve their understanding the nature of violenceagainst sex workers and to ensure police werefollowing correct procedures for prosecuting cases ofviolence against sex workers.Activities during the first phase of project implementationwere:• Thirteen sex workers were recruited as project staffin Dhaka, and nine in Khulna.• Mapping the availability of legal, health and socialservices to street-based sex workers who experienceviolence. During this, partnerships were forged withpotential service providers.• A tool kit was developed for individual case managementof violence.• CARE trained PROTIRODH staff in team building;community mobilization and networking;Page 96

Referral linkages to free servicesA unique and cost-effective feature of the programmewas that it built partnerships with existing serviceproviders to provide free services to sex workers. Thesepartners included designated health care providers ingovernment hospitals, two lawyers, shelter homes andNGOs offering psychosocial services. The followingfacilities were made available free of charge tosex workers:• Emergency medical treatment and health check-upat government hospitals. CARE provided financialassistance to cover medication costs for up to sevendays. Thereafter in the case of insolvent patients, theVASW and watchdog committee mobilized resourcesfrom within the community.• Legal aid for complainants of violence, includingcounselling on rights and legal options and assistancein reporting at the local police station. Withthe help of the committees, a large number of caseswere resolved out of court. Four cases went to court.• Counselling, psychosocial care and support for complainantsof violence by trained VASW committeemembers. Twenty-two community counsellors werecertified in psychosocial counselling.• Referrals to emergency shelter run by NGOs.• Access to a hotline telephone service. The numberwas widely distributed to sex workers encouragingthem to call for help and committee members respondedto distress calls.Creating a supportive legal andpolicy environment for sex workersCreating a supportive legal and policy environment forsex workers was a key objective of PROTIRODH.Advocacy campaigns to address widerstigma and discriminationCommittees periodically organized awareness raisingcampaigns on issues of stigma and violence faced bysex workers, at the community, sub-district and districtlevels. Key messages focussed on raising awareness ofthe nature and extent of violence against sex workers,the rights of sex workers to safety, protection, dignityand freedom from violence. Campaigns were organizedto coincide with events such as International Women’sDay and World AIDS Day. Forum Theatre was alsoused to promote messages. 191 Campaigns targetedlocal government bodies, civil society organizations,human rights groups and community and religiousleaders.Police officers were trained to understand violenceagainst sex workers as a human rights violation and therole of law enforcers in curbing it and prosecuting offenders.Quarterly meetings were organized to ensurethat police were performing their duties humanely,documenting cases and supporting the case in court.National advocacy workshops were organizedannually for PROTIRODH stakeholders and championsto disseminate information and lessons learnt fromthe project.Impact and reactions:life improvementsIndependent qualitative and quantitative evaluationscarried out at the end of the project revealed significantimprovements in sex workers’ quality of life. 192 Thiscould be seen as a direct result of improving thequality and immediacy of response by institutions andservices for survivors of violence. Key achievements ofthe project were:Page 98

Cases attended between July-October 2009 andservice referrals made 189AreaType of violencePhysical Psychological Sexual Economic SocialDhaka 106 106 49 45Khulna 65 65 86 62 46Area Types of service referral madeHealth Counselling Legal Economic Shelter SalishDhaka 63 106 0 2 0 0Khulna 29 65 0 16 22Incidence reductionA significant reduction in all forms of violenceexperienced by both brothel and street-basedsex workers was reported at the end of the project,when compared with the baseline. 193 Violence byclients had declined sharply. Economic violence byclients had reduced by 57%, sexual violence by 55%,mental violence by 47% and physical violence by 39%.Social and political violence remained unchanged at14%.Increased reporting of violence andaccess to servicesSex workers reported a deeper understanding of theirrights. They indicated more willingness to report casesof violence at police stations and seek legal assistanceand health care. Street-based sex workers in Khulnareported that their ability to protest against violenceincreased by 75% and 41% in Dhaka. Sex workersreported significant improvement in the availabilityand quality of health care services. In Khulna,79% of sex workers accessed health care servicesat government facilities. In Dhaka, 34% reportedaccessing government hospitals and 47% privateclinics. Others reported accessing health care facilitiesrun by NGOs. A significant change in the attitudes ofhealth care service providers was noted. This is likelyto account for the improved health-seeking behavioursof sex workers. 195Reduction in stigma and discrimination,particularly among male communitymembersThrough its approach in mass mobilization ofrelevant community members, service providers,government institutions and most importantly thesex worker community themselves, PROTIRODH hashad a meaningful impact on reducing the overallstigma and discrimination towards sex workers. Thishas led to an improved social environment morePage 99

Opinions of sex workers on reduction in violence by area 19419%Sufficiently reducedSame as beforeDhaka7%74%Moderate reduction45%Sufficiently reduced3%Same as beforeKhulna52%Moderate reduction56%Sufficiently reduced4%Same as beforeTangail40%Moderate reductionNote: The figures in the graphs above have been averaged from responses over ten categories.Rounding has been applied to the averaged figures. For the full dataset see page 107, footnote 196.Page 100

Opinions of sex workers on improvement inenvironment in and around work area 197IndicatorsWhether any change in the status by areaSufficiently improved (%) Moderately improved (%)Dhaka Khulna Tangail Dhaka Khulna TangailPolice raid 13.0 39.0 73.0 77.5 61.0 25.0Violence by mastan 12.5 40.0 81.0 66.5 59.0 18.0Overall security 15.0 47.0 86.0 77.5 53.0 13.0Brothel environment - - 83.0 17.0 - 15.0Others 1.5 1.0 1.0 2.0 - 1.0empathetic and supportive to sex workers and theirfamilies. Given the patriarchal society in Bangladesh,the involvement of key male figures at the local levelwas an astute strategy. Sex workers and watchdogcommittee members reported improvement in thefollowing areas: 196• mechanisms for reporting violence at local policestations;• access to birth registration and school enrolment forchildren of sex workers;• increased participation by sex workers in socialevents and community gatherings (i.e. weddings,festival, birthday parties);• better social perception of sex workers and theirfamilies.Improvements in the material conditionsof sex workers 197Sex workers reported higher self-esteem and greaterconfidence as a result of gaining knowledge of theirrights and developing skills to protest against violence.The project resulted in building solidarity amongthose who had taken a lead role in its implementation.A marked increase in sex workers’ control overfinances and an improvement in health and socialconditions were noted. Specifically, sex workersreported experiencing:Greater independence and control over situationswhen dealing with clients, local goons and intimatepartners. Sex workers reported greater ability to circumventsexual exploitation. For example, 72% ofsex workers in Khulna, and 66% in Dhaka said theywere better able to collect payment for sexual servicesin cases of defaulting clients. They were more able toresist forced sex. The ability to make decisions of when,where and with whom they did business improved byover 50%. At all intervention sites, the demand for freesex reduced by more than 50%. Their ability to save increasedmarginally from 54% in the baseline to 67%in the end-line survey. Sex workers reported havingPage 101

Lessonsmore control over earnings and better financial managementskills. Significantly, 85% said they enjoyedgreater control over how they spent their earnings.Increased use of condoms with clients indicatesthat creating safety mechanisms to respond to violencehas a direct effect on HIV prevention. On average, 89%of clients used condoms at every sexual encounterwith sex workers, 96% in Dhaka and 84% in Khulna.Reduction in drug use: Baseline findings suggestedalmost one-fifth of the respondents used drugs. Bythe end of the project, 70% reported ‘reasonable reduction’,10% ‘significant reduction’, while 20% reportedcontinued usage.• Building social capital and alliances withinthe community, particularly among men,reduces incidence of violence. Widespreadviolence against sex workers in Bangladeshis a reflection of the broader societal andcommunity norm that has made violence anacceptable feature of its culture. Addressingsuch norms requires active participationof those who contribute to violenceperpetuation. Involving critical communityactors — particularly men — to prevent andalleviate violence contributed to the success ofPROTIRODH. Engaging with police, lawyers andhealth care service providers on committeesto monitor and respond to violence ensuredsustainability.• Linking sex workers to health and legalservices improves case reporting and results.Ensuring that sex workers had immediateaccess to health and legal services afterexperiencing incidents of violence was criticalto the success of the project. The combinationof support from the community members, andbeing able to seek health services encouragedsex workers to report violence, seek legal aidand demand justice.• Creating support systems to respond toviolence enhances decision-making poweramong sex workers. The project showed thata supportive social environment for sex workersmakes a significant difference in sex workers’ability to negotiate with clients, refuse sex,handle financial transactions more assertivelyand insist on condoms.Page 102

Lessons• Providing legal education builds understandingof rights and gives greater voice for sex workers.PROTIRODH used legal education to augmentthe sex workers’ knowledge of rights and tocreate an understanding in the wider communityabout inequalities faced by sex workers andtheir families. This had the effect of fosteringempathy towards sex workers. A strong indicatorof this was sex workers’ ability to register birthsand enrol their children in schools. Buildingsex workers’ understanding of legal rights andstrategies address violence also led to increasedlikelihood of case reporting and improved policeresponsiveness.• Sex worker-led projects are more effective andpromote sustainability. Almost all sex workerswho participated in PROTIRODH reported increasedself-confidence. 199 Building sex workers’ capacityto become agents of change, claim rights andsolve problems improves their ability to protestagainst violence and develop partnership withother stakeholders to prevent and respond toviolence. Most critically, sex worker involvementcreated sustained capacity to continue addressingviolence after completion of the project. Durjoyreport that the VASW and watchdog committeesare still functional, even after the project ended,and sex workers continue to have access toservices as a result of services linkages developedduring the project.• Building a partnership network strengthensadvocacy and action. Building capacity ofsex workers to solve problems in partnershipwith key community actors including police,health service providers and community leaders,improves sex worker agency to take charge oftheir lives, find solutions to their problems, accesslegal, health and social support services and playa central role in advocacy to bring about changewithin communities to reduce stigma and violence.Capacity building of all partners not only enabledthe effective management of the project; itfacilitated partners to become powerful advocatesfor the protection and promotion of rights ofsex workers. Capacity building was both a meansand an outcome of the project. Partnershipnetwork building strengthened advocacy efforts.It enabled negotiation with institutions that aregenerally unsympathetic to sex workers, sothat they gain access to social, economic andpsychological resources. CARE played an essentialrole in leveraging these partnerships.Page 103

There is a continuing need to address this through scaling up the approaches thathave been successful in improving police-sex worker relations.Gaps, challenges and opportunitiesThe greatest challenge faced by Durjoy was reducingpolice violence. While a reduction of violence by otherperpetrators was evident, sex workers continued toface police violence, especially in Dhaka. One possibleexplanation is the legal environment. If conductedprivately and voluntarily by an adult sex worker,sex work is not illegal in Bangladesh. However,there are laws that criminalise aspects of sex work,including prohibiting soliciting in public and keepinga brothel. 200 Lack of awareness among police is anotherreason for continued violence. Sensitized policemenare a small number who had undergone training. Thereis a continuing need to address this through scaling upthe approaches that have been successful in improvingpolice-sex worker relations. Another challenge wasseeking legal recourse in cases of severe violence. Mostreported cases were managed out of court. However,all four cases that did go to court were fraught withproblems. The court considers the evidence of thecomplainant but often requires presenting a witnessto the violence. Due to stigma surrounding sex work itwas difficult to secure a witness. Secondly, due to thehigh mobility of street-based sex workers, attendanceat court hearings was low. Further, sex workers areoften reluctant to appear in court due to fear of morestigma and high financial costs.A major gap in the programme was its inabilityto respond to the range and severity of mental healthissues among sex workers. Although counsellingwas always available, it was clear that mental healthservices for sex workers must extend to diagnosis andcomprehensive treatment facilities. The project wasunable to adequately help those with substance addiction.Harm reduction programmes for sex workersurgently need to be developed.Looking to the future, sustainability of impact iscritical. A major outcome of PROTIRODH is thatconcrete and sustained mechanisms to addressviolence against sex workers in Bangladesh, thoughlimited, are now in place. The Durjoy sex workers areall trained counsellors and VASW committee membersand continue to network with watchdog committeemembers and health, legal service providers onviolence against sex worker issues. Based on learningfrom PROTIRODH, Durjoy is currently implementinganother project funded by CARE Bangladesh calledSolidarity and Empowerment through Education,Motivation and Awareness (SEEMA). This projectstrengthens existing service linkages deaveloped toaddress violence against sex workers and aims toimprove service delivery. The focus of this project is onreducing poverty among sex workers and improvingtheir working conditions.Page 104

175 English translation: ‘From distance, we win’.176 Beneficiaries include street, home and hotel-based sex workers.177 All members are sex workers. Their term is for two years.178 Durjoy is a sub-recipient of a Global Fund Grant, Round 6.179 UNGASS Country Progress Report, Bangladesh, 2012.180 Ibid; National HIV Serological Surveillance, 2011 Bangladesh — 9th Round Technical Report. IEDCR and ICDDR, B, 2011. Accessed online at: http://www.aidsdatahub.org/dmdocuments/HSS_9th_round_2011.pdf. Accessed on 24 September, 2012.181 UNGASS Country Progress Report, Bangladesh, 2012.182 National HIV Serological Surveillance, 2011 Bangladesh — 9th Round Technical Report. IEDCR and ICDDR, B, 2011. Accessed online September 2012 at: http://www.aidsdatahub.org/dmdocuments/HSS_9th_round_2011.pdf.183 According to Amnesty International Annual Report for Bangladesh, 2011. See: http://www.amnesty.org/en/region/bangladesh/report-2011#section-12-3.184 Violence against sex workers is defined as any act of violence that results in, or is likely to result in verbal, physical, economical, sexual or psychological harmor suffering to sex workers.185 Bangladesh Institute for Development Studies (BIDS), 2007.Final Report, the final evaluation of CARE Bangladesh’s PROTIRODH Project.186 CARE Bangladesh, 2007. Final Report on Baseline Survey for Assessing the Knowledge, Attitude and Practices with Regard to Violence against Women andSex workers. Bangladesh Institute of Development (BIDS).187 Ibid.188 Ibid.189 PROTIRODH project had two components. One component focussed on reducing violence against women in rural settings of Bangladesh and the otherfocussed on addressing violence against street-based and brothel-based sex workers. Both of the programme components used the same frameworkand strategies but partners were different. The implementing partners for the sex worker component were Durjoy and CARE Bangladesh for street-basedsex workers and Nari Mukti Sangha for brothel-based sex workers. The focus of this documentation is on the Durjoy/CARE collaboration for street-basedsex workers.190 DNS, 2009.Project PROTIRODH Periodic Project Update. Internal document, not published.191 A theatre technique that involves audiences in the narrative.192 Bangladesh Institute for Development Studies (BIDS), 2007. Final Report, the final evaluation of CARE Bangladesh’s PROTIRODH Project.193 PROTIRODH evaluation data for reduction in incidences of violence has not been disaggregated by street-based and brothel- based sex workers.194 Bangladesh Institute for Development Studies (BIDS), 2007. Final Report, the final evaluation of CARE Bangladesh’s PROTIRODH Project.195 Ibid.196 Ibid.By whom /perpetratorsDhaka Khulna TangailSufficientlyreducedModeratereductionSame asbeforeSufficientlyreduced197 Ibid.198 Ibid.199 Ibid.200 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA, October 2012.ModeratereductionSame asbeforeSufficientlyreducedModeratereductionClient 19.00 71.30 9.70 38.40 60.60 1.00 64.10 34.80 1.10Police 13.90 74.20 11.30 38.40 61.60 - 57.00 43.00 -Mastan 10.90 67.90 20.70 32.30 63.50 4.20 60.20 39.80 -Sardarni / madam 8.10 86.30 5.60 33.30 63.90 2.80 37.40 56.00 6.60Husband 13.10 74.90 11.00 28.10 66.70 5.30 56.90 41.40 1.70Babu / lovers 15.70 77.30 5.90 32.60 67.40 - 49.40 47.20 3.40Dalal / pimps 20.00 76.40 2.90 38.60 61.40 - 31.90 47.30 6.60Journalist 30.20 66.50 2.80 70.40 29.60 - 58.00 42.00 -Shop owners 20.40 77.00 2.00 54.10 45.90 - 58.20 35.80 4.50Other sex workers 36.80 60.00 3.20 85.50 14.50 - 83.70 16.30 -Same asbeforePage 105

Case Study8Protecting andpromoting the humanrights of LGBTIcommunities inNepal: experiences ofBlue Diamond SocietyPage 106

Blue Diamond Society (BDS) was founded andregistered in 2001. It is the leading communitybasedorganization (CBO) of the Federation ofSexual and Gender Minorities (FSGMN), a network oflesbian, gay bisexual and transgender and intersex 201(LGBTI) people in the Federal Democratic Republicof Nepal (Nepal). This network comprises of 37 CBOsin 25 districts. The mission of BDS is to improvethe immediate and long-term social and economicconditions of sexual and gender minorities inNepal, ensuring that these communities have equalrights, access to health services, social protectionand economic opportunities. The key strategies forachievement of this mission are:• advocacy at the national level to create a supportivelegal and policy environment;• delivery of HIV prevention, treatment and care andsupport services;• human rights programming for the legalempowerment of LGBTI;• building leadership among individual LGBTI andCBOs.Responding to what they saw as appalling social,economic and health conditions for LGBTI in Nepal,Director and founder member of BDS Sunil Babu Pantand six men who have sex with men, and transgendercolleagues decided to form an organization to addressthese issues. 202 Largely hidden, the community ofmen who have sex with men and transgender washighly stigmatized and experienced discriminationin many aspects of their lives. It was observed by BDSthat in this environment of social exclusion, healthseekingbehaviour was poor, and many, particularlytransgender people, had few income generatingoptions, causing many to engage in sex work.Violence and lack of social support was common.As a result, low self-esteem and depression was rifeamong LGBTI people. Like other LGBTI and sex workerorganizations in the Asia-Pacific region, BDS initiallyexperienced difficulties in registering an LGBTIorganization. They therefore decided to register as anorganization for promoting reproductive and healthrights of a marginalized community.Early discussions among the founding teamfocussed on the need for a comprehensive approachto the problems faced by LGBTI and ways of helpingthem assert their legal rights. Given the socio-politicalcontext at that time, there was indifference to LGBTIrights as a political issue and the idea of communitymobilization was premature. Strategically, the teamdecided to focus on advocating for the right to healthwithin an HIV prevention framework. BDS begannetworking and building partnerships with variousstakeholders — government and non-governmentorganizations, donors, other members of civil societyand, most importantly, within their own community.Very soon, BDS was involved in drafting the NationalHIV and AIDS Strategy. They used this opportunityto advocate for the rights of men who have sex withmen and transgender people to have access to HIVprevention, treatment and care services.BDS embarked on a journey of providing HIVprevention, treatment and care services for men whohave sex with men and the transgender community,including male and transgender sex workers. Indoing so, BDS strategically leveraged the HIV agendato build the capacity of these communities toform CBOs in various parts of the country. Whiledelivering HIV-related information and services wasthe stated agenda, there was a strong commitmentto empowering the community, through selfacceptance,to achieve better health and movetowards building their capacity to claim theirrights. Early experiences in HIV prevention haddemonstrated to BDS that a supportive legal andsocial environment was vital in order to make HIVprevention for men who have sex with men andtransgender people effective. For example, BDS notedthat violence was extreme and extensive and actedas a barrier to people accessing essential services.This information was used to advocate with police,Page 107

lawyers, donors and other partners, that strategiesfor HIV prevention must include creating anenabling environment. This holistic approach to HIVguaranteed that the human rights concerns of LGBTIcommunities in Nepal were heard at national andinternational forums.BDS HIV programmes, funded by various donors,reach more than 300 000 men who have sex withmen and transgender people annually, includingthose who are sex workers. 203 This is achieved throughoutreach, drop-in-centres and professionally staffedclinics in 38 districts in Nepal. In addition, BDSimplements a legal empowerment programme andhas a strong advocacy component for improving thelegal, policy and social environment for LGBTI.BDS is not a sex worker organization and does notimplement programmes exclusively for sex workers.However, a significant proportion of men who havesex with men and transgender people, sell and buysex in Nepal. 204 BDS takes an integrated approach tomeeting the community’s needs and advocating forthe rights of male and transgender sex workers andensuring access to services. 205This case study documents the efforts of BDS tosecure legal and policy change and implementation oftheir legal empowerment programme and leadershipdevelopment among sexual and gender minorities,and male and transgender sex workers in Nepal.HIV among men who have sex withmen and transgender sex workersin NepalNepal’s HIV epidemic is concentrated among keyaffected populations (KAPs) including men who havesex with men, 206 people who inject drugs, femalesex workers and their clients, and migrant labourersand their spouses. In 2009, the Nepal IBBS Surveyreported national HIV prevalence among men whohave sex with men in Kathmandu at 3.8%. 207These surveys indicated that 25% of men whohave sex with men were married and that a considerableproportion had sexual relationships with menand women other than their spouses. 208 A 2011 nationallevel mapping and size estimation study found that54% of male and transgender sex workers in Nepalhad engaged in paid sex during six months prior to thesurvey, and had an average of five commercial sexualpartners during this time period. 209The environment of stigmatization and discrimination,including extreme forms of violence that undermineaccess to HIV information and services,further compounds the risk of HIV among male andtransgender sex workers. 210 BDS has primarily addressedthese risks and vulnerabilities by advocatingfor supportive legal, policy and social environmentsfor sexual and gender minorities.Central programme components ofBDSAdvocating for human rights of LGBTIThe impact of sustained advocacy efforts by BDS hasled to increased socio-political recognition of LGBTIrights and securing of a range of civic entitlements fortransgender people. These include: 211• A landmark decision by the Supreme Court of Nepalin 2007 ordering the Government of Nepal to grantcitizenship rights to sexual and gender minorities. 212• Two constitutional sub-committees referred to thelegal recognition of and protective provisions forsexual and gender minorities in their preliminarydrafts of the Constitution.Page 108

• The recognition of sexual and gender minoritiesas a ‘marginalized community’ in the allocation ofnational resources from the 11th Development Planof Nepal for improving socioeconomic conditions ofmarginalized communities. 213• Recognition of the third gender category by theHuman Rights Commission and banks. For example,on registration and complaint forms, a boxmentioning ‘others’ rather than only ‘male’ and‘female’ has been added.• Central Bureau of Statistics (CBS) of Nepal hasincluded a third gender category in its census form.This provides an opportunity for transgender peopleto access government schemes.• The third gender category has been included in thevoter’s list since elections held in 2010.• Prioritization of support in the social developmentof sexual and gender minorities in a Memorandumof Understanding held between the Nepal andNorwegian government in March 2009.• An eminent publishing house, Nai Prakashan, hasestablished an award to recognize the social contributionsof LGBTI people in Nepal.• In the Bachelors and Master’s Degree Social Sciencetextbook, produced as part of the governmenteducation curriculum, a definition of LGBTI wasintroduced.• Allocation of resources to men who have sex withmen and transgender populations in the NationalAIDS Policy and Plan.Several factors have contributed to the efficacy of BDSadvocacy work, as outlined in the below sections.Community capacity buildingBDS has a methodical approach to advocacy ensuringthat it is needs-based, effective and sustainable.Advocacy, for BDS, is both a means to multipleoutcomes and a valuable process. As a process, it buildscommunity leaders, and engages the communityin advocating for their rights. Community capacitybuilding has been integral to achieve this. “Unless anduntil we can have a collective voice to speak out againstthe marginalization and social discrimination we face,we cannot advocate for our rights or count on someoneelse to do so,” explained Manisha, a transgenderwoman and Deputy Director, BDS.BDS provides regular capacity-building training forcommunity members in several areas including HIVawareness, life-skills and counselling skills, legal andhuman rights education and advocacy. Those showingparticular interest and commitment are trained towork in HIV programme management. Through thisexperience, some activists have taken up importantpositions in decision-making bodies. For example,Bhumika Shrestha is now the General ConventionMember of the Nepali Congress Party. Manisha Dhakalis a Member of the Asia-Pacific Transgender Networkand Pinky Gurung is a member of the Global FundCountry Coordinating Mechanism.CBO and leadership developmentAdvocacy is more effective when organizationsrather than individuals carry it out. Over the years,the governance and management of BDS has becomeparticipatory, more inclusive and transparent. Asthe community grew in numbers and capacity, BDSdecentralized branch offices and networks andtransformed into locally governed CBOs. This is anillustration of successful community and leadershipbuilding, allowing communities’ autonomy andflexibility to adapt activities and responses tothe local context. “In the beginning, we were notempowered and we did not have full understandingand knowledge of issues. So Sunil [BDS’ founder]took the lead in making the decisions. But over theyears, we have become empowered and have a goodunderstanding of the issues, so now we are involved inPage 109

“Unless we have a collective voice tospeak out against the marginalizationand social discrimination we face, wecannot advocate for our rights or count onsomeone else to do so.”Manisha, a transgender woman and Deputy Director, BDSthe decision-making. Important decisions at BDS aretaken in coordination of the staff and board members,”explained Pinky Gurung, a transgender woman andBDS board member.As of 2012, 37 CBOs with their own governing bodyand constitution have formed through leadership developmentefforts. Legal recognition of these CBOshas given them credibility with district level governmentbodies, enabling better local resource mobilizationand less dependence on BDS head office in Kathmandu.In 2011, seven new CBOs were formed andregistered.BDS invests in CBO capacity development, offeringtraining in leadership development, literacy, managerialskills, proposal writing and fund raising. It providesopportunities for potential community leaders to participatein formal leadership training, public speakingcourses and higher education. BDS provides CBOsadvice and support on governance, management andprogrammes. As a result, seven CBOs are currently representedin the District AIDS Coordination Committee.This participation provides opportunities to influencelocal governments to include men who have sex withmen and transgender communities when planningfor HIV prevention and treatment service delivery. Toimprove the social and economic conditions of theirLGBTI communities, 16 CBOs have mobilized resourcesfrom the district level Local Development Committees.“ Important decisions at BDS are takenin coordination of the staff and boardmembers.”Pinky Gurung, a transgender woman and BDS boardmember.Advocacy campaignsBDS conducts nationwide campaigns to sensitize thebroader society to issues affecting the LGBTI community.These have taken shape as rallies, mass meetings,seminars, workshops, publications, media campaigns,and TV and radio broadcasts. They are generally organizedaround important festivals. Gay Pride, for example,is organized on the festival of Gaijatra, 214 a local carnival.Use of mediaMedia has contributed significantly to counteringnegative representation of LGBTI people and raisinggeneral awareness on their socioeconomic conditions.LGBTI issues have featured in print and electronicmedia every week. In collaboration with the nationaltelevision channel, BDS broadcasted ‘Third Sex’ —a weekly programme that explored issues of thetransgender community in the current political, socialand cultural context of Nepal, and in relation to othercommunities. 215“With responsibilities comes confidence asleaders and increased commitments.”Manisha, Deputy Director, BDSSpecialized policy and law reformstrategiesBDS’s advocacy strategies involves review of lawsand policies which discriminate against the LGBTIcommunity, documenting human rights abuses,developing advocacy messages and forming allianceswith human rights bodies, such as the NationalHuman Rights Commission (NHRC), to support lobbyand advocacy for change.Page 110

Advocacy to action: impactof law and policy reformsstrategies“Having legal rights sends a strong messageto the authorities that they can no longerdiscriminate.”Sunil Pant, Director, BDSConstitutional rights of transgender peopleBDS hired three lawyers to review the existingConstitution, laws and policies of Nepal regardingthe third gender. It partnered with key allies tosensitize and lobby members of the ConstitutionalAssembly (CA). It organized sit-ins, mass ralliesand media campaigns, and held meetings with thejudiciary to ensure that the constitution recognizesand includes transgender people as citizens ofNepal. At present, drafting of the new constitutionhas come to a temporary halt due to politicalproblems. However, there has been a de factoagreement on recognition of transgender personsand fulfilment of their rights in the new constitutionthat will be formed in the future. “When theconstitution drafting process will start again, wewill ensure that earlier commitments to grantconstitutional rights for TG persons are fulfilled, ourefforts for advocacy will continue until such rightsare guaranteed by the new constitution,” said SunilPant, Director, BDS.Ending discrimination against LGBTIstudents in the higher education systemLGBTI students, particularly those who aretransgender, are subjected to stigma and discriminationin higher education. This leads toearly drop-outs from school. BDS has documentedthese as violations of the right to education.LGBTI Student Forum, a CBO under FSGMN, recentlyinitiated dialogue with the Ministry of Education.This has led to the establishment of a committeeof relevant stakeholders including governmentofficials, human rights bodies, politicians, NGOsand INGOs to jointly lead an investigation.Forming alliances with legal institutionsSignificant legal challenges for the LGBTI communityin Nepal have meant forming alliances with recognizedlegal institutions and senior lawyers. The Nepal Bar Associationand NHRC have been providing support to BDSin their legal interventions. BDS has full-time staff inKathmandu responsible for collaborating with NHRC.This ensures that rights violations are regularly reportedto a recognized human rights body. In 2011, a transgendermember took up an internship at NHRC. This helpedBDS generate a better understanding of the Commissionand its working, thereby improving communities’ accessto it and ability to influence the Commission’s work.Provision of legal servicesIn addition to building alliances with legal institutions,BDS has a legal department in each of its officebranches housing two lawyers. 216 The legal departmentis responsible for implementing human rightsprogrammes and running legal services. Their workincludes:• Legal advice and counselling for individuals who haveexperienced human rights violations. Complainantsare assisted to consider legal and non-legal optionsand the consequences of taking legal action.• Legal referral service. Around 50 cases are beingpursued under both criminal and civil laws in differentcourts around Nepal. 217 People seeking legalredress for violent attacks make up the majority ofcases. Such cases have to be registered in the humanrights cell within local police stations. When perpetratorsare police officers, reports of assault made byindividual sex workers are often not taken forward.However, police officials are more responsive to registeringcases when approached by BDS; hence BDSis involved in assisting people in reporting violenceto police. BDS provide follow-up advice and supportuntil the case is resolved. Where complaints areagainst police, these are filed with the NHRC for investigation.Based on its findings NHRC makes recommendationsto the relevant ministries. These recom-Page 111

“[Legal] training has transformed our communities’ perspective on their rights and theircapacities to claim it. From feeling like they are nobody to being able to stand up fortheir rights as a transgender person or a man who has sex with men is an indication ofempowered community and real a measure of success.”Manisha, Deputy Director, BDS.mendations need to be implemented within threemonths and compensation must be paid by the governmentor perpetrator/s. Civil cases usually concernproperty rights. If such cases cannot be resolved outof court by the community, BDS files the case withthe relevant court.claim our rights. From feeling like they are nobody tobeing able to stand up for their rights as a transgenderperson or a man who has sex with men is an indicationof empowered community and real a measure of thesuccess of the trainings,” explained Manisha, DeputyDirector, BDS.• Documentation of human rights violations. Documentinghuman rights violations including casessuch as discrimination in health care settings,violence and denial of housing, help to build an understandingabout the nature and extent of such incidents.This informs legal and non-legal options ofredress, and is an advocacy tool to address systemicdiscrimination in specific settings, and for advancinglaw and policy reform and social change. 218• Filing public interest litigation (PIL). The SupremeCourt Decision in 2007 to grant citizenship rightsto sexual and gender minorities has provideda powerful tool for pursuing cases regarding civicentitlements such as including third gender asa category for gender identity in identification documents.At the international level, BDS used the InternationalConvention on Civil and Political Rights(ICCRP), to which Nepal is signatory, to lobby for theprovision of a separate box for identifying people ofthird gender in the election ballot. Many hearingshave been in favour of the transgender communityand some have influenced changes in law and policy.Legal empowerment trainingBetween 2010 and 2011, over 10 000 communitymembers participated in human rights and legaltrainings provided across five regions. The trainingswere designed to increase community knowledgeof human rights and build skills about how to claimthese rights. A concrete outcome of these trainingprogrammes is the increased capacity of CBOs tosolve a large majority of cases at the district levels.“These trainings have transformed our communities’perspective on their rights and their capacities toPage 112

Lessons• Cooperation with media can positively alterrepresentations of the LGBTI community.Typically, the media has represented the LGBTIcommunity as being sexually promiscuous anddisease carriers. This has fuelled stigma anddiscrimination against this community. However,a steady transformation has occurred in theattitudes of media by engaging with mediagroups, confronting their prejudice and holdingsensitization campaigns. This has resulted inmore accurate portrayals of the LGBTI communityand promotion of their rights.• Addressing violence, stigma and discriminationrequires safe space for speaking out. Fear ofviolence, marginalization and social exclusionkeeps the LGBTI community underground andsilent. Without verbalising their experiencesof violence and discrimination, it is impossibleto build alliances and document human rightsabuses — both of which are critical for advancingthe rights of the LGBTI community. Creatinga safe space for speaking out is thereforefundamental.• Documenting human rights violationis essential to fighting social injustice.The process of documenting human rightsviolations includes a thorough description ofthe incident, where and when it occurred, thenames of those involved, including witnesses,and photographs, if available. Documentationillustrates the nature and magnitude of social,familial and state violence against the LGBTIcommunity. This is a powerful advocacy tool forlegal, policy and social change.• Developing group leadership is important inlarge-scale advocacy campaigns. Group leadersshare responsibilities for guiding advocacyactions. Consistency in leadership is critical toensuring continuity throughout a campaign.Gaps, challenges and opportunitiesUnfortunately conflicting legislative frameworks inNepal, coupled with an unstable political situation,continues to maintain a hostile legal and socialenvironment for LGBTI people. Although sex workitself is not specifically criminalised, in practice,sex workers are often arrested for public orderoffences under the Public Offences and Penalties Act,1970. It is paradoxical that while the Trafficking andTransportation (Control) Act 2007 states that it is anoffence to purchase sex, the courts have recognizedthe constitutional rights of sex workers. At the timeof documentation, the draft Criminal Code stillcontained provisions that criminalise ‘unnatural’sexual acts, including same-sex relationships,prescribing jail terms up to sixteen years and fines. 219Criminalisation of same-sex relation shipsexacerbates stigma, discrimination and violenceagainst LGBTI, seriously threatening their access tocritical health services, including HIV prevention,treatment, care and support.Providing follow-up legal support can bechallenging, particularly after a case is filed. Somesections of the LGBTI community tend to be highlymobile; this is particularly true of sex workers.They fear that lodging a complaint will lead to morestigma and/or violence by perpetrators, or his or hersupporters. These fears persist even with the offer ofpolice protection. Aside from community members,BDS staff members have been known to receivethreats of more violence if they report crimes toauthorities. 220Transgender people experience the worst formsof violence, discrimination and social exclusion.They are frequently denied access to educational andemployment opportunities, disowned by families,evicted by landlords, and denied property rights. 221Many transgender people work as sex workers andend up living on the streets. As Sofi, dic Manager fromCruiseAid Nepal, 222 recounted, even as sex workers,they do not have a place for providing sexual servicesbecause most entertainment venues do not allowtransgender entry into their territory. “So, they operatePage 113

“We have joined hands with Dalits, women’s groups and other socially marginalizedgroups to fight the injustice. This sense of equal opportunity and openness will continueto support our movement.”Sunil Pant, Director, BDSon the streets, move from place to place, which makesthem more susceptible to police violence and timelyaccess to condoms becomes difficult,” Sofi said.These factors contribute to making it exceedinglydifficult to reach and maintain contact with transgenderpeople and ensure their access to health services.Despite continued outreach by BDS, the number oftransgender persons accessing VCT and STI clinicsremains relatively low. “The health and social needsof transgender sex workers are colossal but there isa limitation to how much BDS can do. Greater effortis required to bring together other organizationswho work on sex workers’ issues, including the thirdgender sex workers.” CruiseNepal dic Manager Sofiadded.In surveillance and behavioural surveys, itis common for data on male sex workers to besubsumed under the ‘men who have sex with men’category. 223 This reduces understanding of the specificneeds of male and transgender sex workers. Althoughcondom use at last anal sex and STI treatment have reportedlyincreased slightly among men who have sexwith men, 224 the lack of disaggregated data makes itdifficult to know the degree to which safer sex is practicedamong male and transgender sex workers. In2011, a mapping and size estimation study and behaviouraldata was collected as part of the mapping andsize estimation exercise in Nepal among men whohave sex with men, transgender persons and male andtransgender sex workers. This indicated that 67% ofmale and transgender sex workers and their clientshad been tested for HIV. Among those who had undergoneHIV testing, 25% reported that they hadtaken the test one or more years before the survey. 225Building on the experience of BDS and other CBOs, andthe recognition of the specific risks and vulnerabilitiesof male and transgender sex workers by the government,United Nations and donors, an opportunityis emerging to prioritize HIV prevention programmesfor this population.In 10 years, BDS has transformed the landscape ofLGBTI issues in Nepal. Being part of a national LGBTInetwork, male and transgender sex workers nowhave access to legal aid, HIV prevention and treatmentservices. They are actively involved in runningCBOs under the Federation of Sexual and Gender Minorities,and participate in its governing body. Thereis no doubt that this has contributed immensely toempowering the lives of many male and transgendersex workers. BDS will continue to nurture leaders andstrengthen alliances already formed with other marginalizedcommunities in Nepal to fight discriminationand injustice.Although BDS has been successful in raising substantialfunds for HIV programmes, and expanding itsdonor base to include funders of human rights work,programme sustainability is still a major concernfor the future. A decrease in HIV funding threatensthe organization’s progress, particularly with a resource-heavyinfrastructure of multiple offices, dicsand clinics that have been the backbone of communitymobilization, advocacy and programmeimplementation.Addressing funding challenges, BDS has beguncollaborating with the National Centre for AIDS andSTD Control, under GFATM Round 10, to pilot a projectthat links BDS-led community outreach to HIV and STIclinics at government health facilities.Page 114

201 BDS defines intersex individuals as those who are born with an atypical combination of physical features that usually distinguish female from male, hencewhose biological sex cannot be classified as clearly male or female.202 Sunil subsequently became the first openly gay member of the now dissolved Constitutional Assembly of Nepal.203 See BDS, 2010. Annual Report on HIV Program, January-December 2010. Internal document, unpublished and BDS, 2011. Semi-Annual report on HIV Program,January-July 2011. Internal document, unpublished.204 See 2008 UNAIDS Report on Review of Existing and Emerging Patterns of Sex Work in Nepal in Context of HIV/AIDS from HIV and AIDS Data Hub for Asia-Pacific at http://www.aidsdatahub.org/en/bhutan-reference-library/item/19750-review-of-existing-and-emerging-patterns-of-sex-work-in-nepal-in-context-ofhiv/aids-iyengar-s-and-rout-s-2008.Accessed on 10 May 2012.205 It may be of importance to note that BDS explicitly emphasizes protection of its constituents’ rights as sexual and gender minorities. The emphasiz on theirrights as sex workers is implicit in its mission statement and advocacy efforts.206 As stated earlier, in the National Strategy for HIV and AIDS, the phrase ‘men who have sex with men’ include male and transgender sex workers.207 IBBS survey results, 2011.208 Ibid.209 HIV/AIDS and STI Control Board (HSCB) & National Center for AIDS and STD Control (NCASC), 2011. Mapping & Size Estimation of Most-At-Risk-Population inNepal -2011. Vol. 1 Male Sex workers, Transgender and their clients. The Nielsen Company Nepal/UNAIDS/World Bank.210 BDS, 2011. Annual report on Human Rights Programs. BDS, Internal Report. Unpublished.211 See http://www.bds.org.np/human_rights.html accessed on 17 June 2012.212 Two transgender men, Bishnu Adhikary and Badri Pun, were able to get their citizenship ID using their own gender identity as transgender men, as ruled bythe Supreme Court.213 BDS has been receiving these allocated funds from the government since 2009. Since 2011, the funding allocation has increased to NRS 30 lakh (around US$38 500) annually.214 Gaijatra, is the festival of cows, celebrated mainly in Kathmandu Valley by the Newari community, in the month of Bhadra (August-September).215 The programme has been now phased out and similar new programme ‘Pahichan’ has been launched through another government TV channel.216 BDS lawyers are also members of the LGBTI community.217 Criminal charges are prosecuted by the state against the offender. BDS provides support, legal advice and assistance to people who have reported violence topolice and where charges have been laid.218 All documentation of cases is undertaken with consent of the person concerned. Where experiences are used in advocacy, identifying information isremoved.219 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA, October 2012.220 BDS, 2011. Human Rights Program Report 2011. Internal document, unpublished.221 Ibid.222 CruiseAid Nepal is one of the CBOs under the Federation of Sexual and Gender Minorities.223 MSM is the acronym used to denote men who have sex with men.224 National Center for AIDS and STD Control/MoH and UNAIDS, 2010. Nepal National UNGASS Report, 2010.225 HIV/AIDS and STI Control Board (HSCB) & National Center for AIDS and STD Control (NCASC), 2011. Mapping & Size Estimation of Most-At-Risk-Population inNepal -2011. Vol. 1 Male Sex workers, Transgender and their clients. The Nielsen Company Nepal/UNAIDS/World Bank.Page 115

Case Study9Community-tocommunitylearning:Experiences of theAshodaya Academy“I am no less than an officer in a governmentoffice. I have excellent facilitation skills,research skills; I can teach well andcommunicate with impact; I can analyseproblems and articulate my concerns. Becauseof the opportunity to teach and learn, I have anidentity.”Jaya Lakshmi, sex worker and Ashodaya faculty memberPage 116

Ashodaya Academy is the capacity developmentwing of Ashodaya Samithi, 226 a CBO ofsex workers in Mysore, the Republic of India(India). It functions as a ‘learning site’ for community-ledHIV interventions and implements communityto-community227capacity development programmesin India and in the Asia-Pacific region. The approach isto use the ‘inherent ability of sex workers to learn fromeach other’. 228 The objective is to empower communitiesto address their needs, take positional power, andassume greater responsibility in the design and implementationof HIV programming and advocacy.Ashodaya Academy’s pedagogical approaches are:• Conducting a combined classroom and field basedtraining programmes. Lessons from the field areused to inform training content, and apply classroom based concepts to the on ground realties.• Using first-hand experiences. This successfullybridges the gap between theory and practice andmakes community-led action for HIV prevention andother community issues more responsive to specificcommunity needs.• Using sex workers as trainers. Personal testimonyand sex workers’ experiences in community-led HIVintervention are particularly useful tools that canmitigate the power imbalances that exist betweenteacher and student. This contributes to an ethos ofshared ownership of the learning process.Ashodaya Academy has trained over 5 000 peopleover five years, including community members, NGOstaff and government officials in India. It collaborateswith National AIDS Control Organization (NACO), StateAIDS Control Societies and Avahan. 229 The Ashodayamodel has led to mobilization and empowermentof sex workers in Gujarat, Maharashtra, Rajasthanand Andhra Pradesh. Additionally, the Academy hassuccessfully trained people from the community, NGOsand government officials in eight countries in Asiaand the Pacific.BeginningsIn 2004, supported by Avahan, the Bill and MelindaGates Foundation’s India programme, the Universityof Manitoba initiated a research project in Mysoreas a ‘research and innovation’ site. 230 The aim was toidentify the processes for developing a communityledstructural intervention among sex workers inMysore. The available information on sex workerpopulations in Mysore had been collected by externalresearchers and epidemiologists. This projectbrought about a significant shift in control over thegeneration of knowledge. Sex workers were trainedto use methodologically sound, community-friendlyapproaches for mapping, population estimationand HIV programme planning for the sex workcommunity. The project supported sex workers toacquire new skills in collectivising, managing crisesand learn ways to assert control over various aspectsof life, including addressing violence, control overfinances and retaining custody of children. Thoseinvolved started consolidating what they had learntto articulate the elements of effective community ledstructural interventions for responding to HIV amongsex workers.In 2005, the sex workers who had been part of thisresearch project decided to form Ashodaya Samithi,which became highly successful in implementingcommunity-led HIV programmes, achieving improvedcondom use and reducing risky sexual behaviours. 231Within a year, several NGOs began sending staff to visitthe organization to obtain knowledge about peer educationtechniques. While members of Ashodaya werestill in a learning mode, they simultaneously begansharing their newly acquired knowledge with otherNGOs and CBOs. This laid the foundation for a systematicand institutionalized community-to-communitycapacity development programme. In 2007, Ashodaya Samithi formally becameAvahan’s first learning site for a community-led structuralintervention. In 2008, it was officially recognizedas the national learning site by NACO and implementeda comprehensive capacity development programmeunder NACP-III. 232 A year later, Ashodaya Samithi wasPage 117

Progress in development of the Ashodaya AcademyResearch & innovation site2004Cross-learning to Avahan partners2005–2007Internal learning2004–ongoingAvahan Learning Site2007NACO Learning Site2008Regional Learning Site2009Source: Ashodaya Academy, 2010selected as the regional learning site on HIV and sexwork-related interventions in the Asia-Pacific andreceived a one-year grant from the UNAIDS-Asian DevelopmentBank (ADB) Cooperation Project. Underthis grant, Ashodaya Academy designed and conductedregional training for sex worker groups from eightcountries in the region.uptake. 236 In Asia and the Pacific, there is recognitionthat community-to-community programmes canproduce considerable results. 237 In India, using communityled interventions have led to rapid mobilization,enabling significant scaling up of effective HIVprevention interventions among populations most atrisk, including sex workers. 238Context: communitycapacity development within HIVpreventionThe vital role of building community capacity inachieving effectiveness in health and developmentprogrammes has been well documented. 233 It iscommon for capacity-building tools and interventionsto be developed and implemented by non-communityactors. They are not always based on the needs of localorganizations or communities. 234 As a result, too oftencommunities become passive recipients of capacitybuilding programmes, raising concerns about theresponsiveness, ownership, and sustainability of HIVinterventions. 235In the context of HIV programming, evidenceshows that building capacity of the beneficiary communityensures appropriateness and sustainabilityof HIV prevention programmes and improve serviceCore components of Ashodaya’scapacity developmentprogrammesSelection and capacity development offaculty membersCurrently, there are 35 trainers, all sex workers,who form the faculty of Ashodaya Academy, andimplement the Academy’s training and mentoringprogramme. Occasionally, the Academy draws onnon-community resource people and members of sexwork communities in other parts of India to providetraining. For example, members and advisors fromDurbar Mahila Samanwaya Committee (DMSC) inWest Bengal have been invited on several occasionsto facilitate sessions on designing and implementingeconomic empowerment programmes, such as theUSHA Cooperative model (see page 85).Page 118

The faculty’s development training focuses onstrengthening knowledge and skills regarding HIVprogramming and advocacy and developing trainingskills including:• exploration of attitudes, expectations, beliefs of thetrainers in order to assess and develop their abilityand commitment to the work and community;• technical knowledge of HIV prevention andtreatment;• knowledge of programmes including economic empowermentand social protection schemes; humanrights and legal issues;• methodology for HIV programming development;• training skills and translating these into action;• self and group reflection to solve problems theyencounter and as a part of an on-going learningprocess;• periodic training programmes aimed at increasingtechnical knowledge and developing new skills basedon emerging needs. For example, when trainers feltthe need to enhance their technical knowledge of lawsand legal environment affecting sex workers rights,Lawyers Collective, India were called as a resource.Specific criteria were used to identify faculty membersincluding that they were empowered enough to openlyidentify as a sex worker, experienced in communityledinterventions and had demonstrated communityleadership skills reflected in having support withinthe community, demonstrated commitment to workin the community and exceptional communicationand interpersonal skills.Formative assessmentAshodaya Academy conducts a formative assessment toidentify programme gaps and gauge the socioeconomicand legal environment where the intervention willtake place. This includes assessing the attitudes andexpectations of partners, resources available to thecommunity, and factors that might inhibit start upthat need to be addressed. Formative assessmentalso identifies the community trainees’ learningexpectations this helps in adapting the trainingcurricula to meet each particular communities’ needs.The process of the formative assessment is entirelyparticipatory. As a result, it provides trainees withtheir first exposure to understanding the importanceof formative assessment and how to conduct it.Page 119

Training curriculumThe curriculum is designed to address theenvironmental context and needs of trainees.Sometimes, during an assessment the trainers discoverthat the specified interest of the trainees is not whatis actually needed (see box ‘Adapting to changingenvironments’).Nevertheless, the training curriculum comprisesof some non-negotiable elements. These are:• Perspective building of sex work and sex workers.This helps build self-awareness and is an integralpart of the training. It helps trainees gain anunderstanding of the socioeconomic contextsaffecting sex workers and the implications of thesefor HIV intervention strategies. Moreover, it fosterssensitivity and understanding towards sex workers,which is essential to bridge the gap between thecommunity and service providers.• Putting core values into practices. Recognizing thevalue of sex workers’ inputs in HIV interventionis vital. Learning to imbibe core values of mutualrespect, supporting each other to resolve problems,developing trust and friendship are a key aspect oftraining.• Role of non-community members in communityledinterventions. Non-community members oftenfacilitate sessions on specific technical areas such aslegal issues, social protection programmes amongothers.An essential part of the Ashodaya Academy’s workhas been developing tools that provide a soundmethodology for use by communities in assessing,planning, implementing and monitoring HIVprogrammes. Ashodaya Academy has developedthe following tools with technical support from theUniversity of Manitoba:The ‘capture-recapture’ tool used to map sex work‘hot-spots’ and estimate the size of the population forplanning;Adapting to changingenvironments: an example ofhow training curriculum wasreadjusted based on externalenvironment issues“We were asked to provide capacity buildingsupport to conduct outreach among sex workersin Mandya. The trainees wanted to learnoutreach techniques for HIV prevention butwhen we went there for a formative assessment,we realized that there was a huge backlashagainst sex workers from the police, the localgoons and the broader community members.In this situation, using outreach techniquesalone would not be effective in reachingsex workers with HIV prevention services. Theexternal environment needed to be improved.So, we trained communities to understandingthe interconnectedness between outreach andthe external environment and to apply skillsand techniques build alliance and partnershipswith key stakeholders such as police and localleaders. The focus of the training curriculumwas on building relationships with the key noncommunitypartners in order to gain the supportneeded for implementing a robust outreachprogramme and at the same time, on buildingtrust and relationships with the communitymembers in order to mobilize them and conductoutreach. In this case, learning the techniqueof outreach was not the first step in capacitybuilding.”A male sex worker, Ashodaya AcademyCommunity FacultyPage 120

• outreach planning;• conducting stakeholder analysis;• community mobilization;• community monitoring systems and programmecompetency building.Training methodologyAshodaya Academy bridges the gap between theoryand practice in their approach to community-tocommunitylearning. Training programmes combineboth classroom and field-oriented. For example, if thetopic is building rapport with the police, trainees aretaken on a field visit to the police station learn aboutengaging with the police.The classroom-based training conducted in theAshodaya Academy is designed to enhance technicalknowledge and skills of trainees. Community-friendlyvisual aids, personal stories, role-play and groupexercises are some of the methods used.In the field-based training, the focus is to apply theideas from the classroom in the ‘real world’. Traineesare assisted to think through and discuss translatingclassroom learning in to action in their owncommunities. Where training takes place at AshodayaAcademy, field visits are conducted in and aroundMysore. Where training takes place in other places,locations for field-based learning are identified as partof the formative assessment. Fieldwork can take theform of visits to government hospitals, communityclinics, HIV prevention interventions sites such asoutreach or drop in centres and police stations.The length and content of training programmesvary considerably, ranging from three days to onemonth in duration. The standard package of a three-daytraining course focuses on providing comprehensiveknowledge and developing the skills set to design,implement and monitor the critical components ofan HIV programme. A one-month course typicallyfocuses on building capacities for a holistic approachto community empowerment and development.Some of the key components of a training programmeinclude:• developing self-awareness as a sex worker;• designing and implementing a community-led HIVprevention programme (a twelve-week course);Page 121

Example of a programming tool:‘capture-recapture’, mappingand enumeration methodsWith slight modifications, Ashodaya uses the‘capture-recapture’ method to investigatethe number of sex workers in different hotspotsand ascertain their needs. This was firstused by the organization in 2004, when theyinitially needed to determine the size of thestreet-based sex worker population. Usinga mathematical formula this method enabledAshodaya to calculate the total size of thesex work population in Mysore — includingscattered sex work populations — providingan entry point to establish a relationship withthe community before starting interventions.Ashodaya has since trained many sex workerorganizations in this method.“In Imphal (Manipur, India) an NGO had problemsin finding and reaching men who have sex withmen [the target population for the intervention].They did not know the numbers of men whohave sex with men needing services or where toconduct outreach. So, they came to Ashodayato learn about the ‘capture-recapture’ method.We trained them after doing a formativeassessment and provided support to conductthe mapping in Manipur. It was a great success.With this method, the NGO was able to identifythe hot-spots for intervention sites and alsoestimated the size of the populations of menhaving sex with men to inform their programmedesign.”Prathima, a female sex worker and faculty memberThe active participation of sex workers in thecapture-recapture method creates confidence,unity and a sense of responsibility. Othermethods taught have included zone and timewiseanalysis which helps analyse where, whenand how to best reach target beneficiaries andassists in planning outreach timings in specificlocations, and timings for clinics and drop-incentres.• identifying specific needs of community membersliving with HIV and providing support;• building community support systems andmechanisms to respond to crises;• advocacy skills for promoting and protectingsex workers’ human rights;• legal education;• developing skills in networking, public relations andpartnerships with relevant stakeholders;• CBO development and management; and• leadership development.Support through mentoringOver the years, Ashodaya has learned that trainingneeds to be implemented side by side with otherinterventions. Trainees need on-going support toreflect upon how they are practically applying theirknowledge and skills, identifying the challenges andstrategize to find solutions. The practice of mentoringwas introduced by Ashodaya Academy at the request oftrainees. It involves trainers maintaining contact withand supporting trainees’ learning beyond the initialtraining interaction. This helps individuals apply theirlearning according to ground realities. “We never sayno when community asks us for help. Even when wedid not have funds to provide handholding support,we found a way to provide help needed,” explained JayaLakshmi, a female sex worker and faculty memberIn 2008, mentoring support becameinstitutionalized as a core component of AshodayaAcademy’s work. Five individuals — two Academyfaculty members, two community members and onenon-community staff member, provide mentoring.MonitoringAshodaya has two methods of monitoring theimplementation of training:Page 122

Reflections on classroom andfield-based training“No community member likes being talkeddown to and if, as a faculty, we create thishierarchy than we cannot develop trustwith our trainees. Without this trust oneach other, we cannot properly learn andteach. So, we use a lot of personal stories,build empathy, share and exchange ourideas, create an environment of trust andfriendship to make learning a two-wayprocess. Although the topics we discuss areoften technical, we simplify these conceptsbased on our lived experiences, which helpsto gain understanding about the practicaluse of these technical concepts. This makesteaching and learning process much moreeffective.”A transgender sex worker and facultymember“There are a lot of differences between theoryand practice. We did not know if what they aresaying [in the classroom] is truly there in thefield, or not? But when we went to the field [inMysore], and we saw with our own eyes, thenwe understood and believed in the power ofcommunity interventions.” 239A female sex worker, Ashodaya Academytrainee“We want the academy to become a nationallevel university with proper accreditationand certification.”Prathima, female sex worker and faculty memberWork plan tracking. All trainees develop a time-boundwork plan. This outlines the follow-up activities tobe implemented and identifies support needed fromAshodaya and other partners. The work plan has a dualpurpose; it guides the follow-up to be undertakenby trainees and assists in monitoring each trainee’sindividual progress.Enquiry-based monitoring. Periodically, the Academyinformally contacts the programme partners, andsometimes stakeholders, to enquire about theimplementation of the training. This form of informalmonitoring helps in identifying challenges, informingongoing mentoring support and assistant to findsolutions.“We never say no when community asks usfor help. Even when we did not have fundsto provide handholding support, we founda way to provide help needed.”Jaya Lakshmi, a female sex worker and faculty memberPage 123

Increase in service utilization following introduction ofcommunity-to-community mentoring80%604020RegistrationClinic utilizationFSWClinic utilizationMSMAfterBeforeSource: Ashodaya Academy, 2010. Research Index and Research Reports, 2004-2010.Mysore, India. Presented at IAC at Mexico and Global Health Conference in Washington DCImpact snapshotsCommunity-to-community mentoring in Kolhapur, MaharashtraAshodaya Academy faculty members spent a week visiting the Kolhapur district in Maharashtra, India, wherean HIV prevention programme was underway among female sex workers. The team held discussions withsex workers, peer educators and staff, to identify gaps in their programme. A detailed twelve-week workplan was formulated, which included addressing violence and discrimination, as well as an outreach plan toincrease community mobilization, service utilization and build an enabling environment.The results were striking. Within six weeks, female sex worker registration with the HIV programme hadincreased to 70%, compared with 15% at the baseline. At the end of 12 weeks, clinic utilization by sex workersregistered with the programme had soared from 12% to 50%. Furthermore, there was a visible improvementin community cohesiveness to respond to crisis. This was evident in the ways that sex workers began takingan active role in advocacy and programme management. A clinic-based intervention for men who have sexwith men also noted utilization increasing from 21% to 67% in the 12-week period. 240Page 124

Prevention scale up in Andhra PradeshAshodaya Academy built the capacity of CBOs in Kakinada, Peddapuram and Warangal to design andimplement targeted intervention programmes for female sex workers under NACP-III. This led to rapid scaleup of prevention programmes in Andhra Pradesh. 241Community mobilization in RajasthanDuring 2010–2011, Ashodaya Academy with support from UNFPA organized a capacity building programmefor sex worker communities in selected targeted intervention (TI) sites where HIV prevention programmeswere being implemented by NGOs in Rajasthan. In seven months, Ashodaya was able to facilitate communitymobilization in two areas. This resulted in the formation of two sex worker CBOs where the TI was beingimplemented. In the first year, there was a clear shift from communities being passive recipients of servicesto being to being actively engaged in processes. 242 By the second year, the sex workers were able to form CBOsand mobilize their own community, which resulted in more sex workers accessing services and condoms. 243At the second site, Ashodaya Academy worked with the sex work community to restructure existing CBOsto become community led. In both places, the relationship of CBOs with other stakeholders such as serviceproviders and police improved significantly. 244These examples demonstrate the rapid application and impact of the community-to-community learningprogrammes. Sex workers with experience in handling the challenges inherent to running HIV preventioninterventions with sex work communities and with training and mentoring skills have been highly effective intransferring their knowledge and skills.Page 125

Lessons• Community-to-community capacitydevelopment is effective in rapid mobilizationand empowerment of key affected communities.It improves coverage and quality of HIV preventionprogrammes.• Ashodaya Academy has helped build thecapacity of CBOs of men who have sex withmen, people who inject drugs and sex workersin many locations across India. This has hada significant impact on increasing coverage of HIVprevention programmes and service uptake (seeImpact snapshots box on page 124).• The community-to-community capacitydevelopment approach fast tracks the learningprocess and encourages sustainability. Effectivecommunity capacity development requires activeparticipation and continuity and be firmly locatedin the lived experiences of the community andthe principle of equality. As Sushena Reza-Paul,Assistant Professor, University of Manitoba,Canada outlines: “In the process of capacitydevelopment, there are either individuals ororganizations that play the role of a catalyst.If the catalyst is the member of the samecommunity, the process of capacity developmentbecomes quicker and is more effective.”• Since Ashodaya became the national learningsite, it has built capacities of many other CBOsthat are now recognized as state-level learningsites. In turn, these learning sites have trainedCBOs at the district levels. 245 Hence, the learningprocess has been continuous and sustained.• Empowerment-oriented capacity developmentsignificantly contributes to strengtheningcommunity systems to handle HIV prevention.Ashodaya Academy’s aim is to provide knowledgeand skills that can be holistically applied toempower individuals and communities. Theseefforts generate more resources for communityledprogrammes and enhance programmeimplementation and management skills. 246 They areindicators of a ‘capable community’. 247• Capacity building programmes must be drivenby the needs and priorities of the implementingorganizations. More often than not, capacity developmentin the context of HIV programming is drivenby external factors and often do not build the skillsthat implementing organizations require. To increasequality of HIV programmes, needs and priorities ofimplementing organizations must be taken into consideration.248• Measure and advocate for community-to-communitycapacity building as both a means and anend. 249 The deeper impact of Ashodaya’s capacitydevelopment programme has been personal transformationamong a large number of sex workers.As Jaya Lakshmi, sex worker and Ashodaya facultymember underlines: “I am no less than an officerin a government office. I have excellent facilitationskills, research skills; I can teach well and communicatewith impact; I can analyse problems and articulatemy concerns. Because of the opportunity toteach and learn, I have an identity.”• Non-community actors play an important role inmaking community-to-community capacity developmenteffective. Ashodaya Academy receives a varietyof support from partners including the Bill andMelinda Gates Foundation, the Government of India,the University of Manitoba, UNAIDS and ADB. Moreover,cooperation and inputs from police officers,health care providers and lawyers add to the successof the Academy’s training programmes.Page 126

“We want to inspire, empower and build these communities so that they also becomesocially conscious about their rights, know how to claim these rights and assert a socialposition. This is our dream.”Jinendra, a male sex worker and faculty memberGaps, challenges and opportunitiesAshodaya reports that one of the greatest challengesthey face is power dynamics between NGOs andCBOs. In some instances, Ashodaya reports thatNGOs regulate the relationship with the sex workcommunity to a degree that obstructs the process ofcommunity mobilization.Male sex worker and faculty member Shivaramdetails some of the challenges faced: “NGOs do notwant to let go their role as the custodians of HIVprevention programmes. They feel threatened bythe presence of Ashodaya, especially when they seethat with the capacity development support from us[the faculty members], community members start toask NGOs questions and assert their opinions aboutthe programmatic approaches used. This sometimesthreatens the NGOs because it challenges the roles ofNGOs in HIV prevention for us and ultimately takesaway the financial resources they have been receivingto provide services for us.”Male sex worker and Director of the AshodayaAcademy concurs: “In one city in another state, whenwe initially started providing capacity developmentsupport, we were supported in our efforts. Butas the NGO implementing the female sex workerintervention realized that we were working withthe community to empower them through selfactualisationprocess and assertion of their rights, itstarted perceiving our work as threats, and not onlystopped us from contacting the community, but askedus to leave. So we had no choice but to go.”The financial sustainability of Ashodaya Academyis uncertain as support by Avahan comes to an end in2012. Hereafter the Academy faces the challenge ofsustaining its current programmes. In preparation, itis exploring the feasibility of introducing a user-fee.However, this may prove to be difficult for CBOs whousually do not have an operational budget for capacitybuilding. Ashodaya has already put into action a newstrategy of trainees sharing the cost of food andaccommodation during training programmes.In recent years, the use of social marketing topromote social, behavioural and environmentalchange has grown in the field of public health.Ashodaya has been discussing the feasibility ofimplementing a social marketing strategy for thecommunity-to-community capacity developmentapproach. 250 Principles of the ‘community-basedprevention marketing model’ could inform the designof this marketing strategy to ensure relevance forcommunity members. 251 Marketing its approachescould increase demand for Ashodaya Academy’straining services.The Academy aspires to becoming a nationallevel university with a formal accreditationsystem. Ashodaya Samithi has a long-term visionfor the Ashodaya Academy. It wants to extend thecommunity-to-community approach to empowerother marginalized groups and communities in India.“We want the others to learn what we learned by theprocess of coming together and providing supportto each other and learning about new things as weimplemented HIV programmes. We want to inspire,empower and build these communities so that theyalso become socially conscious about their rights,know how to claim these rights and assert a socialposition. This is our dream,” explained Jinendra,a male sex worker and faculty member.In the future, Ashodaya Academy plans toestablish a learning network in the Asia-Pacific regionwith a diverse range of actors to bring about socialchange. This network could serve as a referral systemfor Ashodaya Academy to attract new participants totake part in the training programme.Page 127

226 Ashodaya Samithi implements HIV prevention, care and community support programmes in five districts of Southern Karnataka, with Mysore still functioningas the organization’s hub. Over 7 000 female, male and transgender sex workers from in and around Mysore are represented in the Samithi and benefit fromits services.227 The term ‘community-to-community’ capacity building refers to sex worker-led capacity building designed for and by sex workers.228 This is one of Ashodaya Academy’s working principles.229 Avahan is an initiative of the Bill and Melinda Gates Foundation that has been providing funding and support to targeted HIV prevention programmes inIndia’s high HIV prevalence states.230 Research and Innovation (RI) is an approach to design and implement a rapid response to HIV prevention among marginalized populations within a span oftwelve weeks. The RI approach utilizes community-driven HIV programme initiation, implementation and service delivery based on concrete understandingsof the local contexts where interventions are to be implemented, and is in partnership with the local community in identifying and assessing needs tomonitor and evaluate service delivery. Avahan started this initiative in the State of Karnataka and Mysore was the first city where this approach was piloted.231 Reza-Paul, S. et al, Declines in risk behaviour and sexually transmitted infection prevalence following a community-led HIV preventive intervention amongfemale sex workers in Mysore, India, AIDS 22 Suppl 5:S91-100 (2008) PMID 19098483; Dixon, V. et al, Increasing access and ownership of clinical services atan HIV prevention project for sex workers in Mysore, India, Glob Public Health 7(7):779-91 (2012) PMID 22424476.; Argento,E. et al, Confronting structuralviolence in sex work: lessons from a community-led HIV prevention project in Mysore, India, AIDS Care 23(1):69-74 (2011) PMID 21218278.232 This is the current phase of the National AIDS Control Programme in India.233 See for example, Wheeler, T. et al, Learning about scale, measurement and community mobilization: reflections on the implementation of the Avahan HIV/AIDS initiative in India, J Epidemiol Community Health 2012: 66 and references in endnotes 6 and 13.234 Position paper, Challenges Encountered in Capacity Development: Review of literature and selected tools. Management Sciences for Health/USAID, No.10April, 2010.235 Ibid.236 Centers for Disease Control and Prevention. (2011). Capacity Building Assistance Portal for HIV Prevention. Accessed from http://www.cdc.gov/hiv/topics/cba/CDC on 2 June 2012; Dixon, V. et al, Increasing access and ownership of clinical services at an HIV prevention project for sex workers in Mysore, India,Glob Public Health 7(7):779-91 (2012) PMID 22424476; Motamed, et.al.,2005; HIV prevention capacity building: A framework for strengthening and sustainingHIV prevention programs. Academy for Educational Development, Center on AIDS and Community Health. Accessed from http://coach.aed.org/Libraries/Capacity_Building/HIV_Prevention_Capacity_Building.sflb.ashx on 2 June 2011.237 Ghose et al.,2008. Mobilizing collective identify to reduce HIV risk among sex workers in Sonagachi, India: The boundaries, consciousness, negotiationframework. Social Science & Medicine, 67:311-20; Blankenship et al., 2010. Factors associated with awareness and utilization of a community mobilizationintervention for female sex workers in Andhra Pradesh, India. Sexually Transmitted Infections, 86 (Suppl 1):i69-i75.238 Wheeler, T. et al, Learning about scale, measurement and community mobilization: reflections on the implementation of the Avahan HIV/AIDS initiative inIndia, J Epidemiol Community Health 2012: 66. Report of the Woking Group on AIDS Control for 12th five year plan, Government of India, 2011. http://www.scribd.com/doc/73748037/1/NACP-III-Implementation-and-Achievements#page=10 accessed on 12 June, 2012;.239 As quoted in Community capacity building for HIV prevention: Lessons from a community-led sex worker initiative in Mysore, India by Elayne Vlahaki (2011).240 Programme data reported by Ashodaya as part of documentation interview.241 Andhra Pradesh State AIDS Control Society conducted an annual evaluation of these CBOs based upon which they decided to continue funding. This indicatesefforts in CBO capacity development have been effective.242 A project update on Rajasthan Project supported by UNFPA India, Ashodaya Samithi, 2011. Internal document, Unpublished.243 Ibid.244 See Annual Review Report, Capacity Building in Rajasthan. Supported by UNFPA, India.245 Vlahaki, E., 2011. Community capacity building for HIV prevention: Lessons from a community-led initiative in Mysore, India” Unpublished.246 Ibid.247 Laverack, G., 2004. The domains of community empowerment. In Health promotion practice: Power and empowerment, 86-98. London: Sage Publications.248 Management Sciences for Health/USAID, 2010. Position paper. Challenges Encountered in Capacity Development: Review of literature and selected tools.No.10 April, 2010.249 Ibid. p.17.250 Ibid.251 Bryant, et al., 2007.Community-based prevention marketing: Organizing a community for health behavior intervention. Health Promotion Practice, 8, 154–163.Page 128

Case Study10Including migrantsex workers in HIVprogramming:EMPOWERFoundation“We are sex workers. We are workers who use our brains andskills to earn an income. We are proud to support ourselvesand our extended families. We look after each other at work;we fight for safe and fair standards in our industry andequal rights within society. We are a major part of the Thaieconomy, bringing in lots of tourist dollars. We are activecitizens on every issue — politics, economics, environment,law and rights. We try and find the space in society to standup and be heard. Some see us as the problem makers butactually, we are part of the solution.We are sex workers, we are EMPOWER.” 252Page 129

Established in 1984, EMPOWER Foundation(EMPOWER) is the first sex worker organizationin the Kingdom of Thailand (Thailand) and,most likely, the oldest in the Asia and Pacific regionoutside of Australia. Started by a group of sex workersand women’s right activists, its goals are to promotethe human rights of sex workers and provide a spaceowned by the community; to belong, organize andassert their rights. While it promotes the human rightsof all sex workers, it provides health and social servicesfor female sex workers living and working in Thailand.With more than 50 000 members, these includesex workers from Thailand, and migrant sex workersfrom Lao People’s Democratic Republic, Myanmar,China and Cambodia. EMPOWER currently has centresin eleven provinces of Thailand — all managed bysex workers — reaching over 30 000 sex workersannually.EMPOWER has been one of the driving forcesbehind the founding of networks such as the ThaiNGO Coalition on AIDS (TNCA) and APNSW. Recipientof numerous awards, including the Thai NationalHuman Rights Award for Best Human Rights Organization2006 and the Freedom to Create Prize 2009,EMPOWER is recognized for its expertise in promotingthe labour rights of sex workers and the equal rights ofmigrant sex workers.Working with migrant sex workersIn 1991, EMPOWER opened an office in Chiang Maiwhich emerged as an inclusive and safe space for allfemale sex workers, regardless of their nationality,ethnicity or age. This began to attract many migrantsex workers. The space prides itself upon severalcore values: mutual support, friendship and respect.It ensures the opinions of migrant sex workers areexpressed and heard, and their needs are addressedboth in advocacy and services. It has nurtured somemigrant sex workers to become leaders, alongside theirlocal counterparts. Migrant sex workers comprise 33%of EMPOWER’s total membership. 253 In some locations,such as Chiang Mai, Samut Sakon, Mahan Chai, morethan 50% of participants are migrant sex workers.The SWING case study provides an overview of the HIVepidemic in Thailand, see page 57.Key programme componentsEMPOWER provides its members access to wide rangeof education and health programmes and servicesand a safe space for mobilization and collectivestrengthening and action. The organization undertakesboth community level and national level advocacy tocreate an enabling legal and policy environment forsex workers.Education servicesPrevention of HIV is an important theme of alleducational activities. Over the last two decades,more than 30 000 sex workers have participated ineducational programmes and for many, it has beentheir first occasion to study. EMPOWER provides a rangeof educational opportunities to meet the identifiedneeds of their members.Non-formal Education (NFE) 254 centreIn 1990, EMPOWER registered as an official NFE centre,authorised to conduct NFE day schools. This was thefirst school for sex workers in Thailand. Non-formaleducation classes follow the regular Thai curriculumand focus on increasing basic literacy skills. Subjectsinclude health and environment. Sex workers teachmost classes and the pedagogy is participatory.Sex workers who complete the NFE programmes receivecertification. The curriculum enables students toparticipate in study tours and camps. These are usuallythree-day thematic learning events approved by theNFE government department. Past themes for learningevents have included environment, health, politicalparticipation, art, history, drama and self-defence.Some sex workers find these difficult to attend, as theydo not get paid leave. 255 However, these opportunitiesare highly valued by sex workers as a time to make newfriends, relax and enjoy a hassle-free environment.For migrant sex workers, study tours are occasion toPage 130

“ In order to live and work safely and avoidexploitation we need to be literate in thelocal dominant language [Thai]… We alsoneed to know about and access Thai healthservices, public transport, shopping, andunderstand Thai law and culture.”Goy, EMPOWER language class student.learn about Thai culture and tradition that helps incultural integration. Moreover, enrolment of migrantsex workers in NFE programmes is strategic. It providesthem with a study card — sometimes recognized byauthorities — which can be used to access the Thaihealth care system or to avoid arrest.Language classesAttentive to the local context and needs of sex workers,EMPOWER conducts a range of language classes inits centres. These improve sex workers’ ability tocommunicate with employers and customers. Thailiteracy classes are provided for migrant sex workers.“For those of us who are the family breadwinner,who dream of buying land, building a house, owninga business, sex work offers us the best opportunities.In order to live and work safely and avoid exploitationwe need to be literate in the local dominant languageThai. Our bosses are Thai and most of our customersare Thai. We also need to know about and accessThai health services, public transport, shopping, andunderstand Thai law and culture,” explained Goy, anEMPOWER language class student. 256Skills-building workshops and trainingprogrammesWorkshops and trainings provide space and resourcesfor sex workers to be together, have fun and developnew skills or ideas. Workshops have been on numeroustopics including condom use, preparing cocktailsand computer skills. The community decides thetopics, duration and frequency of these workshops. Inaddition, EMPOWER offers ‘learning by doing’ trainingprogrammes which build sex workers’ practical skills:• The ‘Staying Healthy’ training programme coverssafer sex methods, testing and STI treatment; occupationalhealth and safety; managing emotional andpsychological health; legal entitlements as workersand citizens in accessing the universal health carescheme, and social security.• ‘Leadership, media, research and public speaking’:Advocating for the protection of sex workers’ humanrights is central to EMPOWER’s work. This trainingis designed to build leadership among sex workersto advance their rights. It focuses on hands-onactivities to develop skills in dealing with media,understand and critique research for use in advocacyinterests and master the art of public speaking.Health servicesEMPOWER is source of a wide range of accurateinformation — be it related to the occupation of sexwork or otherwise. It provides peer counselling ona range of health issues. Work-related health concernsare the focus of monthly workshops. At EMPOWERcentres, sex workers have access to free condoms andlubricants and IEC materials on various aspects ofwomen’s health such as menstruation, HIV/STI andSRH. EMPOWER provides accompanied support tothose accessing HIV and STI diagnostic and treatmentservices at government hospitals and clinics.“We believe that providing information andeducation to enable sex workers make decisions aboutHIV testing is more important than providing theactual testing facility,” said Noi, EMPOWER’s founder.Page 131

EMPOWER radio programmeTo reach migrant sex workers who are unable toaccess centres, EMPOWER operates a local communityradio programme which broadcasts out of ChiangMai. It provides information about living and workingin Thailand, and ways of accessing health care andsocial insurance. For this, EMPOWER negotiated withMAP Foundation, 257 an NGO that broadcasts multilingualradio for migrants in Thailand, for a timeslot which would reach the migrant sex workercommunity. The radio programme is broadcast inBurmese and Shan (Tai Yai) — languages spoken bymost migrant sex workers in Chiang Mai. It runs fortwo hours, three times a week and is managed entirelyby sex workers trained in broadcasting. An array ofhealth-related topics is discussed during interactivespots including HIV prevention, beauty tips, and socialissues facing migrant sex workers. Once a week, thesession focuses entirely on local services operatingHIV prevention and treatment of HIV and STI. Listenerscan dial in to ask questions, request music and leavemessages for friends. EMPOWER also invites guestspeakers onto the programme to discuss particulartopics.In 2012 EMPOWER started sharing broadcastingtime with M Plus and Violet Home, two CBOs basedin Chiang Mai. Both organizations run an hourlongradio programme once a week and provideinformation to men who have sex with men and maleand transgender sex workers about living with HIV,sexual health and rights.EMPOWER community radio programme has beena cost-effective tool to reach hidden populations ofsex workers, including migrants. Its running costs areapproximately US$ 100 per month. Five DJs are paidan honorarium of approximately US$ 20 per month.“When I listen to the radio programme, itgives me a sense that I am not alone andthere are many like me out there.”Muen, migrant sex worker, Chiang MaiPage 132

“ We ensure our community members have the right information and are properlycounselled before they decide to get tested at the health care facilities.”Noi, founder, EMPOWER“Often this [information and education] is lackingat the government hospitals and so, we ensure ourcommunity members have the right information andare properly counselled before they decide to get testedat the health care facilities,” she added.Between 2009 and 2011 EMPOWER implemented an HIVand STI prevention project with support from GlobalFund. This project provided HIV education, condomsand lubricants as well as counselling and facilitatingaccess to HIV testing.However, EMPOWER report a number of problemsthat were encountered due to target monitoring indicatorsimposed within the project. “As a part of theproject, we were required to recruit and test 1 600sex workers every year but although more than thiscame for counselling, only 500 sex workers went on tohave an HIV test. It led to problems because we werenot able to meet Global Fund VCT indicators. Ultimately,we were judged to be not effective, and amongmany others reasons, this led us to lose the grant wereceived,” recounted Noi. EMPOWER report that thissituation stemmed from a fundamental disagreementwith the Global Fund on the principle of sex workers’right to self-determination while accessing VCT.EMPOWER strongly believes that sex workers shouldneither be convinced nor recruited for testing in orderto meet imposed targets.Holistic approach to HIV, health andsocial issuesAlthough EMPOWER has been a solid partner in themovement against HIV in Thailand since the early 1990s,it does not implement stand-alone HIV projects. 258Rather, their guiding principle of sex workers’ rightto self-determination has led to an integrated systemof support for sex workers. For example, they do notprovide clinical services at their centres and outreachto sex workers is not conducted solely for the purposeof HIV prevention. In contrast, outreach aims to buildfriendship, trust and awareness, and offer trainingopportunities as well as provide referrals and supportto access HIV services. 259 EMPOWER collaborates withhealth care providers to ensure friendly and nonjudgmentalfacilities are available to sex workers, andoffer referral services to HIV and STI testing, diagnosisand treatment.Creation of safe spaces formobilization and collectivestrengthening‘Can Do’ BarA large majority of sex workers in Thailand work inentertainment venues. 260 Their work involves servingdrinks, dancing and singing, chatting with customers,massage and providing sexual services. 261 However,as workers their labour rights are seldom protected.They incur pay cuts for infringing rules and oftenwork under an oppressive system of imposed quotason the number of customers and drinks bought forthem. They do not receive paid or sick leave, andrarely get time off at weekends or for vacations. 262 Thecriminalisation of sex work undermines efforts toensure safe and fair working conditions in accordancewith Thai Labour laws. Sex workers are often targetsof raids and migrant sex workers face added rightsviolations if they are undocumented. 263 In response tothis, EMPOWER decided to establish the ‘Can Do’ Bar.Established in 2006 the Can Do is a bar owned andmanaged by a group of sex workers from EMPOWERin Chiang Mai. Disillusioned by the conditions in sexwork venues, the group decided to pool resources tocreate a work place that is fun, safe and fair. The baris financially supported by a community fund: anysex worker who contributes to this fund automaticallybecomes a collective owner. Can Do Bar is a uniquemodel of an entertainment venue with safe and reasonableworking conditions for both bar staff andsex workers.Page 133

It follows Thai labour laws and operates a socialsecurity policy in the management of the bar and itsemployees which include stipulations that: 264• all workers are paid at or above the minimum wage;• staff work a maximum of eight hours per night andhave one day off per week;• workers have 10 paid holidays and 13 days publicholiday per year;• overtime is voluntary and fully paid• no staff salary cuts or withholding of wages for anyreason;• staff are encouraged to form a worker’s associationor union;• workers are entitled to paid sick leave and can enrolin the Thai Social Security scheme; 265• any disputes over working conditions are settled inthe labour court;• premises comply with Thai building standards includingfor fire safety, cleanliness and hygiene.Can Do Bar promotes the safety and well being of itsemployees and customers. Staff members are trainedin first aid. Resting areas, first aid supplies and cleandrinking water are provided to workers. Alcoholconsumption by bar staff or visiting sex workers isnot promoted or encouraged. Employees, visitingsex workers and any other women leaving thepremises with new friends are encouraged to use theCan Do security system for their safety. 266 Condomsand lubricants are provided free of cost and all workersare trained in safer sex education.The experiences of operating Can Do Bar amplyillustrate that it is possible to apply labour standardsin the entertainment industry and develop strategiesto minimise occupational hazards. EMPOWER reportsthat working in a healthy environment that promoteslabour rights of all workers, including migrantworkers, reduces health risks, including exposure toHIV. In collaboration with the Ministry of Labour, andusing the knowledge they have gained, EMPOWER isadvancing Can Do Bar as a precedent in the drafting ofnew policy and proper standards for health and safetyat entertainment venues. With this, the model is beingpiloted in other parts of the country.Legal assistanceEMPOWER has two full-time in-house lawyers basedin Bangkok and Chiang Mai, who specialise in legalissues affecting sex workers and migrant workers.They provide legal assistance in cases of arrest andrights violations by the police, and are available tosex workers free of cost.Advocacy for protection and promotion ofsex workers’ human rightsEMPOWER’s primary advocacy message is therecognition of sex work as work and equal access toprotection and benefits. These messages have emergedthrough conversations with sex workers about theirrealities. They are conveyed creatively, powerfully andsimply, often using art, humour and performance todeliver the facts.One of EMPOWER’s biggest advocacyachievements is securing social insurance andbenefits for sex workers working in entertainmentvenues through the National Social SecurityScheme. This involved sustained lobbying with theMinistry of Labour and Ministry of Social Protectionand Welfare. For this campaign to be effective,EMPOWER formed alliances with other people whowere excluded from the scheme including tuk-tukdrivers, motorcycle taxis, factory piece workers anddomestic workers. In 2005, sex workers and twothousand other workers from these sectors, metwith the Department of Social Security to lobby forthe inclusion of sex workers in the scheme, whichspecifically secures the benefits of paid sick leaveand social insurance at retirement age.Page 134

The journey of KumjingThe journey of Kumjing is an international art project thatnarrates the stories of migrant sex workers’ and advocatesfor change in the way that society views and treatsmigrants. The project started in 2003 and involved making250 papier-mâché dolls, all given the name Kumjing. These‘Kumjings’ were taken to Bangkok to symbolically mark theplaces that migrant workers can only dream of. They werepresented and exhibited at various platforms to conveythe message that migrant sex workers have rights. Overtime, 150 Kumjing dolls ‘migrated’ overseas, adopted byorganizations, artists, sex worker groups and academics.Their journeys were emblematic of migrants’ right to freemovement across national borders. This project won anInternational Freedom to Create Prize in 2009.Advocacy to address theanti‐trafficking lobbyIn 2011, EMPOWER conducted a community-ledresearch that highlights the negative impact of antitraffickingpolicy and practice on HIV programmes andsex workers’ human rights in Thailand. The researchis the first of its kind in Asia. One of its key findingsis that raids, rescue and rehabilitation in the name ofanti-trafficking target adult consenting sex workers,including migrant workers, and inhibits sex workers’access to HIV prevention and treatment. The researchhighlights in detail the wide range of human rights violationsthat commonly occur as a result of these raidsincluding unlawful detention and mandatory HIVtesting. 267EMPOWER mobilized 206 sex workers, trained 36sex worker researchers and collected and analysedqualitative and quantitative data from 13 provinces ofThailand. EMPOWER has presented the findings andrecommendations to numerous stakeholders includingthe police, the National AIDS Programmes and theUnited States Government which funds anti-traffickingprogrammes in Thailand. EMPOWER will continueto build coalitions and advocate for law reform in thisarea and for sex work to be recognized as work.Page 135

Lessons• Multi-sector and integrated approaches are moreeffective in sustaining migrant sex workers’access to health care and social services. Thisapproach has reduced costs associated withoperation and programmes, and enabled migrantsex workers to participate in the same forums asother Thai sex workers. It has helped EMPOWERto lobby with a range of stakeholders includingvarious government departments to secure socialand health benefits for migrant sex workers.• Funding for HIV prevention programmes need toensure resources for effective support to enablesex workers who test HIV positive to access HIVtreatment and care. In EMPOWER’s experiencethere is a need for greater attention and toensuring that sex workers who test positive aresupported to access HIV treatment and care.• According to Noi, founder of EMPOWER, “Thefunds that we received for HIV programmingthrough Global Fund resources did not coverthe costs associated to providing referral andtreatment services, such as CD4 count, viral load,access to HIV treatment leaving sex workerswho found out that they are HIV positive ina desperate situation. Most of the 30 sex workerswere migrants and because of this, it is very hardto find affordable HIV treatment schemes. We haveto work hard to find referral services for affordabletreatment and support them to receive timelytreatment.”• Migrant workers are more responsive toprogrammes that are holistic in addressinghealth and social issues. For migrantsex workers, HIV prevention of HIV is only one ofthe many concerns they face. Holistic educationprogrammes, that integrate HIV within a widerapproach, that is responsive to wide range ofissues migrant sex workers, is more effective thanstand-alone HIV interventions.• Improving working conditions of sex workersenables them to negotiate safer sex. In theexperience of the Can Do Bar, it is possibleto adhere to occupational health and safetystandards in entertainment venues at nominalcost. Better working conditions reduce mentalstress and significantly improve the psychologicaland physical well being of workers. This enablesbetter evaluation of risk, and creates a supportiveenvironment for sex workers to negotiatecondoms use and prevent violence.• Providing education, information on labourrights and health issues increases self-esteemand confidence of sex workers. The EMPOWERexperience sufficiently illustrates that sex workersprovided with educational opportunities rapidlyachieve greater self-confidence. As a result, theycommunicate more effectively, better understandtheir labour rights and entitlements, and are ina stronger position to bargain for safe workingconditions and fair treatment by managers andcustomers.Page 136

Gaps, challenges and opportunitiesThe criminalisation of sex work continues to bea major barrier to effective HIV response amongsex workers 268 and complicates using a labour rightsframework for the protection of sex workers. Withoutlegal recognition that sex work is work, sex workers inThailand continue to face exploitative situations in theworkplace. Exploitative work environments and policecorruption fuel economic and social vulnerability,269, 270, 271increasing the risk of HIV transmission.EMPOWER reports that mandatory HIV testing ofsex workers — and especially migrant workers — withoutfollow-up support and treatment continues to be practisedin Thailand. 272 Interacting with government healthfacilities is precarious for undocumented migrants;even those who are officially registered face challengesaccessing ART under the Universal Health Insurance. 273When sex workers are arrested it is common for possessionof condoms to be used as evidence of soliciting.As a result sex workers are often reluctant to carrycondoms, and this poses serious challenges for ensuringsafe sexual practices.The year 2012 marks 27 years of EMPOWER. Duringthis time as a leading sex worker organization, it hasgained a plethora of experience, developed leadershipskills of many sex workers, managed and operatedsuccessful programmes and conducted invaluableadvocacy. EMPOWER has continued to evolve andexpand to meet the changing needs of its membersdespite the many challenges, of which finance is one.EMPOWER believes in finding creative solutions toovercome these challenges, as explained by founderNoi: “We don’t receive specific budget for the operationof our office, it is generally allotted from the programmemoney. We have been proactive to expand ourdonor base and we don’t only go to the traditional HIVdonors. If we need to build our office, we might seekdonors who help build infrastructure for our office.EMPOWER envisions the future inclusion ofmigrant sex workers in the migrant worker registrationpolicy. 274 Though this scheme has many pitfalls,being registered would provide some respite from fearof arrest and extortion, and would possibly open up accessingUniversal Health Insurance and social welfarebenefits. It would require employers to abide by Thailabour laws when employing migrant sex workers.However, EMPOWER cautions that registration mustnot be linked to sex work either directly or by implication.They recommend that migrant sex workers berecorded under the term ‘general worker’ which currentlycovers other informal work domains.Finally, providing treatment to migrantsex workers living with HIV is urgently needed. WhileEMPOWER raises funds to cover treatment costs at thecommunity level, this support is limited.Page 137

252 See EMPOWER website at http://www.empowerfoundation.org/index_en.html accessed on 28 May, 2012 in Bangkok, Thailand.253 Currently EMPOWER has approximately 50 000 members across the country.254 Non-formal education is a distance education programme of the Ministry of Education in Thailand. It provides education to those unable to accessmainstream schooling e.g. adult learners, children in remote areas, people in prisons etc.255 http://www.empowerfoundation.org/education_en.html# accessed on 28 May in Bangkok, Thailand.256 Ibid.257 MAP Foundation (formally known as Migration Access Programme) is an NGO that seeks to empower migrant communities from Myanmar living and workingin Thailand. Their mission is to improve the health and social well-being of migrant communities in Thailand by increasing their participation in advocacy andpolicy making, thus creating space for them to exercise their rights and eliminate discrimination and exploitation.258 The exception to this was the GFATM project referred to above.259 EMPOWER reports that their outreach activities are mainly to mobilize community, building trust and friendship so they have a support system for help andemergencies. They also conduct condom outreach activities at the community level, which is not only for sex workers but for employers and managers ofentertainment venues as well as customers of sex workers.260 EMPOWER Foundation, 2012. Hit & Run, Sex Worker’s Research on Anti-trafficking in Thailand; Sex Work and the Law in Asia and Pacific, UNDP & UNFPA, October2012, see Section 4.9 Thailand.261 Ibid.262 Ibid.263 Ibid.264 See http://www.empowerfoundation.org/barcando_en.html265 This is jointly paid by the bar owners, employee and the government.266 This is a system using local contacts and mobile phones to safeguard workers.267 EMPOWER Foundation, 2012. Hit & Run, Sex Worker’s Research on Anti-Trafficking in Thailand. EMPOWER Foundation: Bangkok, Thailand.268 Sex Work and the Law in Asia and Pacific, UNDP & UNFPA, October 2012, see Section 4.9 Thailand.269 See Aids 2031 Social Driver Working Group working papers series on Social Driver Synthesis Report and Addressing Social Drivers of HIV: Some Conceptual,Methodological and Evidentiary Considerations from http://www.aids2031.org/working-groups/social-drivers. Accessed on 18 May, 2012.270 Commission on AIDS in Asia Report, 2008. Redefining AIDS in Asia, Crafting an Effective Response. Report of the Commission on AIDS in Asia. OxfordUniversity Press, New Delhi.271 EMPOWER Foundation, 2012. Hit & Run, Sex worker’s Research on Anti-trafficking in Thailand. EMPOWER: Bangkok Thailand.272 Sex Work and the Law in Asia and Pacific, UNDP & UNFPA, October 2012, see Section 4.9 Thailand.273 During the documentation some organizations reported that only a limited numbers of documented workers can access ART, and only under programmessupported by GFATM, not under the government scheme. Other groups said that documented skilled migrant workers can access ART under the governmentscheme but unskilled workers cannot. There does not appear to be an articulated government policy on migrant access to ART under Universal HealthInsurance.274 Under the migrant worker registration policy, undocumented migrants from three neighbouring countries — Cambodia, Lao People’s Democratic Republicand Myanmar — were given legal status to live and work in Thailand as employees strictly limited to six sectors; fishery, construction, plantation (agriculture),factory, domestic work and manual labour. Their right to stay and work in Thailand is contingent upon being employed. There is anecdotal evidence of abuseof migrants working in these sectors by employers and corrupt officials. Although there is little this policy can do about this, it does provide some protectionand benefits. For instance, documented migrants have access to social insurance and universal health scheme (excluding ART treatment). Unfortunately, itis not yet possible for migrant workers in the entertainment industry to access worker registration documents. As a result they have no access to Thai socialwelfare and remain undocumented.Page 138

Case Study11Improvingsex workers’ accessto health, rightsand freedom fromviolence: experiencesof Fiji’s SurvivalAdvocacy NetworkPage 139

Survival Advocacy Network (SAN) is one of twonetworks of transgender and female sex workersfounded by and for sex workers in the Republicof Fiji (Fiji). 275 Established in 2009, SAN’s mission isto gain social recognition for sex workers, ensuringtheir equal rights as citizens particularly in the areaof health care. Although SAN is in its early stages ofdevelopment, its leaders and staff have been activelyengaged in the sex workers’ movement in Fiji formany years. Rani Ravudi, SAN’s Transgender ProjectCoordinator, and a transgender sex worker, has beenworking consistently on the issue of violence againstsex workers. Women’s Action for Change (WAC) 276a grassroots feminist organization has mentoredmany of SAN’s leaders and continues to guide theorganization’s development. WAC have helped SAN gainskills in performance art and social media to mobilizethe sex worker community and promote their rights.Although WAC provides administration and technicalsupport for resource mobilization, SAN has itsown governance, organizational and managementstructures and functions as an autonomous organization.In its short journey, SAN has played on criticalrole in mobilizing sex workers in Fiji and advocatedfor policy and legal changes and sex workers’ humanrights. It has become a nationally recognized voice forsex workers in Fiji representing them at internationaland national levels. 277 However, challenges remaingiven the criminalisation of sex work in Fiji, includingthat SAN Fiji is unable to be registered as an independentorganization. 278This case study documents SAN’s efforts in mobilizingand empowering sex workers highlighting twokey programmes — legal rights education and addressingstigma and discrimination in health care settings.Sex work and HIV in FijiFiji is classified as a low HIV prevalence country. Theestimated number of people living with HIV in 2009was about 500 and prevalence rate for 15–49 age groupsapproximately 0.12%. 279 HIV prevalence continues tobe low with 43 new confirmed cases of HIV infectionin 2009. However this was about one third higher thanthe annual figures for the previous six years. 280 Thenumber of new infections in 2010 and 2011 were 33 and54 respectively. 281Very little data exists on HIV and AIDS amongsex workers in Fiji. At present the country’s first IntegratedBiological and Behavioral Study (IBBS) isunderway, which will examine HIV prevalence and therisk and vulnerability factors of sex work. This is a collaborativeeffort involving the Ministry of Health, SANwith technical support from WHO and UNAIDS. TheIBBS will generate data that will assist in guiding effectiveHIV prevention, treatment and care and supportinterventions among sex workers.As is common in many countries in the region,criminalisation of sex work fuels stigma anddiscrimination, including in health care settings. 282It is unfortunate too, that the Crimes Decree2009 undermines the effectiveness of supportiveprovisions in the HIV/AIDS Decree 2011. The HIV/AIDSDecree, for example, prohibits discrimination againstpeople living with or affected by HIV, it provides theright to voluntary testing and counselling and hasmade it unlawful to deny a person access, withoutreasonable excuse, to a means of protection fromHIV. 283Page 140

Key elements of the SANprogrammeAddressing stigma and discrimination athealth care settingsOne of SAN’s most successful projects has been traininghealth care providers to enable sex workers’ access tohealth care without stigma and discrimination. Theproject was initiated in 2011 in collaboration with FijiSchool of Medicine and the Australian HIV Consortium,rolled-out in three phases:Developing training materialSex workers developed a play as a tool to explorethe barriers sex workers face in accessing healthservices. A highly participatory approach was usedfor developing content and songs and throughout theproduction rehearsals. The process took three monthsstarting with the selection of three stories. Involvingsex workers in developing the material brought thegroup together and increased their self-esteem.Training health care providersThe goal of this project was to increase health serviceproviders’ understanding of sex workers’ humanrights and the effects of stigma and discrimination onsex workers access to health services. Initially a threedaytraining programme was piloted in Suva with twenty-fivecommunity health care workers from regionalgovernment clinics and hospitals. The play was useda catalyst for sex worker and health care provider discussionand engagement. Within a few months, thetraining programme was conducted in Lautoka andSuva, involving health care workers from four districts— Ba, Lautoka, Nasinu, and Nausori. Initially, thehealth care workers were resisting their portrayal as intolerantand discriminating of sex workers. Now, RaniRavundi says, “they are more open-minded, friendlytowards us and our community feels more comfortablein accessing services where these providers work.”SAN reports that there has been an increase in thenumber of sex workers accessing VCT and sexual andreproductive health services in the clinics where thedoctors who were involved in the training are located.The Fiji School of Medicine is collaborating with SANto integrate this training into their curriculum in thenear future. This gives hope for improved quality ofservices for sex workers in Fiji.Developing referral linkages for STI and HIV,VCT, diagnosis and treatment.The training has helped establish referral linkageswith a pool of sensitized health care workers. SANCoordinator Rani Ravundi reports that, “all it takes isa phone call from us and this is a direct result of ourraising awareness with the health care providers.”Another important outcome of the project is the establishmentof a working group to develop a non-discriminationpolicy in health care settings. The workinggroup involves representatives from the Ministry ofHealth, the Fiji School of Medicine, Key Affected Populations(KAP) and the church. Thirdly, a night clinicfor sex workers has opened in Suva. Commencing inMarch 2012 at a local government hospital, the clinicfunctions between 5 and 9 pm, making it convenientfor sex workers to drop in when they are working. Thishas proved a success with over 10 people attending onthe first day. The Ministry of Health is planning to establishthese clinics in other locations.Legal rights education and provision oflegal aid servicesThe Government of Fiji enacted the Crimes Decree2009 commencing in 2010, making many aspectsof sex work illegal including soliciting, living on theearnings of prostitution and keeping a brothel. 284Although few sex workers have been prosecutedunder the decree, 285 recent research has found that theintensity and frequency of violence by the police andmilitary has increased 286 and the safety conditions ofsex workers have worsened. 287 Due to concerns for thesafety of outreach workers, HIV outreach activities,particularly the distribution of condoms andlubricants, were severely impeded. SAN Fiji found thatmany sex workers had limited knowledge about theirhuman rights including relevant laws and mechanismsfor redress in case of unlawful arrest, harassment andviolence including rape.Page 141

“[Our legal training] educates sex workers on topics such as what is Crime Decreeand how does it affect us sex workers… we teach our members ways to respondusing legal language.”SAN Coordinator Rani RevundiIt is in this context that SAN pioneered a legal rightsproject in collaboration with WAC. This aimed to reduceviolence, improve sex workers’ knowledge of theirrights and access to legal redress and police protectionwhen their rights were violated.The programme focuses on three components,legal rights training, access to legal services andworking with police.Legal rights trainingA five-day training programme was designed to raisesex workers’ awareness of human rights, legal issuesin relation to sex work and avenues for redress whentheir rights were violated. Training programmes wereorganized in the six cities where SAN works. They arejointly planned and facilitated by SAN and lawyersat WAC. The training demystifies the law, impartspractical knowledge of laws and develops sex workersskills to use this knowledge in practice.“[The training] educates sex workers on topicssuch as what is Crime Decree and how does it affect ussex workers,” explained Rani Ravundi, SAN TransgenderProject Coordinator. “If police ask a sex workerto strip, as is common practice for transgendersex workers, we teach our members ways to respondusing legal language. For example, sex workers couldsay, ‘Sorry if you need to search me, please take me tothe other room so others can see what is going on. Accordingto this law, you cannot search me here’,” shesaid.The methodology for training is participatory.“During trainings, we rehearse these situations usingrole plays so they are better prepared to deal with suchsituations in real life,” said a transgender staff member.Impact: Empowerment, respectand self-determinationThe challenge of reaching and mobilizingsex workers in Fiji is significant. However,there are clear indications that sex workers arenetworking in towns and centres, have greateraccess to their rights, information on HIV, betterhealth care, and are more engaged in processesand programming that affect their lives. Thishas contributed to building a more empoweredcommunity, who demand respect and willaccess health care if they are confident it willbe provided in a safe environment and in a nondiscriminatorymanner.Another indication of change is that sex workersin Fiji are asserting their right to ‘self-determination’— the exertion of free choice of one’s ownacts without external compulsion. SAN and PacificRainbow Advocacy Network (PRAN), sex workershave decided to be independent from parentorganizations. This sym bolises a new movementof community empowerment in Fiji. Further, sexworker networks are working together to forma coalition. This alliance has brought aboutchanges in ways that sex workers relate to oneanother; allowing each member the space tospeak, be heard, share opinions and developshared vision and common goals.Referral to legal services:SAN provides referrals, where needed, to lawyers atWAC’s legal aid centre. Legal assistance is provided freeof charge.Working with policeSex workers experience considerable violence withinthe community and at the hands of police. With thehelp of WAC’s Director Peni Moore, a well-knownPage 142

Lessons• Comprehensive training for health careproviders reduces discrimination againstsex workers seeking health services. This hasthe potential of changing attitudes over time,improving quality of health services.figure in Fiji, SAN has begun collaborating with thepolice to curb both police and public harassment ofsex workers, and establish mechanisms for ensuringpolice protection. At the time of this documentation,plans were underway to conduct training of policeofficers in two districts. SAN is adapting the modelused with health care providers for this.Sex workers report that physical violence by thepolice has reduced. This is, in part, a direct outcomeof sex workers having better knowledge of their legalrights and being able to negotiate with police, makingthem less vulnerable to unlawful arrest and detentionand exploitation and extortion. 288 As Rani Ravundiremarks, “sex workers are more tactful in handling situationsrelated to arrest and harassment by now. Theyknow how to stand up for themselves and tell a policeofficer to stop harassing and beating.”• Fostering partnerships with non-HIVorganizations creates a broader structure toalleviate violence against sex workers. Forginga strong relationship with WAC has had multipleadvantages including an influential partnerand ally who can support their advocatingefforts, provide mentoring and support, andhas improved sex workers’ access to resourcesincluding legal services.• Providing legal rights education impactsat micro and macro levels. This directlycontributes to advancing sex workers’ rights,both systemically and individually, includingimproving sex workers ability to negotiatewith police and prevent extortion and unlawfularrest.Page 143

“ In Fiji, there is so much stigma againstus, everywhere. From the church to themedia, we are viewed as the ‘sinners’.We face psychological and physicalviolence. It limits everything we areand can do as human beings. It limitsour entitlements of freedom, dignity,and respect. It limits the work we wantto do within our community and itlimits our protection and safety.”SAN Coordinator Rani Revundi275 The other network is Pacific Rainbow Advocacy Network (PRAN). This is a charitable trust of sex workers, borne out of a HIV project called ‘Sekoula Project’implemented by Pacific Counselling and Social Services (PCSS) in the Western Division of Fiji. Sekoula Project was started in 2007 and will continue until 2013.In 2010, sex workers involved in this project decided to form their own organization called the PRAN. Since then, PRAN has been registered as a charitabletrust with the support from PCSS and received its first funding support 2011. PCSS is also providing support to build organizational and leadership capacity ofPRAN.276 Women’s Action for Change (WAC) is a collective of feminist women in Fiji. Established in 1993, its main vision is to provide a safe space for women, girls andmarginalized communities, to network and advocate around their issues, concerns and rights using creative media and communication techniques such asstreet theatre, drama, blogging, mime etc. WAC has offices in six cities and is renowned in Fiji for its activism and advocacy.277 For example, SAN is part of a high-level working group of Key Affected Populations (KAP) set up by the Ministry of Health of Fiji.278 Under the Crimes Decree 2009 sex work in private is not specifically criminalised. However, many aspects of sex work are, including soliciting and keepinga brothel. See Sex Work and the Law in Asia and the Pacific, section 5.2 Fiji, UNDP and UNFPA, October 2012.279 Fiji UNGASS Report 2012 (for reporting period 2010-2011). This report notes that there have been no epidemiological HIV sero-surveys of the generalpopulation conducted, but the number of HIV positive results detected among thousands of HIV tests undertaken each year supports the estimatedprevalence of 0.12%.280 Ibid.281 Ibid.282 Sex Work and the Law in Asia and the Pacific, section UNDP and UNFPA, October 2012.283 Ibid.284 Ibid.285 Ibid.286 McMillan, K. et al., 2011. Sex workers and HIV Prevention in Fiji – after the Fiji Crimes Decree 2009. International HIV Research Group, UNSW, Sydney, 2011.287 Bates, Nicholas, 2011. Evaluation of the counselling training program implemented by the Pacific Counsellling and Social Services (PC&SS) in selected PacificIsland Countries and Territories (PICT). International Health Services, Albion Street Centre. Sydney, Australia.288 In addition the introduction of the HIV/AIDS Decree 2011 may also be a supportive factor. The Decree prohibits discrimination against people living with oraffected by HIV. It also provides the right to voluntary testing and counselling and has made it unlawful to deny a person access, without reasonable excuse,to a means of protection from HIV. This provision may discourage police from confiscating condoms as evidence of sex work. See Sex Work and the Law in Asiaand the Pacific, UNDP and UNFPA, October 2012.289 McMillan K., Worth H., 2011. Sex workers and HIV Prevention in Fiji – after the Fiji Crimes Decree 2009, Sydney: International HIV Research Group, UNSW.290 Ibid.291 Sex Work and the Law in Asia and the Pacific, UNDP and UNFPA, October 2012.292 Ibid.Page 145