Strategies for Reducing Police Arrest in the Context of an HIV Prevention Programme for Female Sex Workers: Evidence from Structural Interventions in Karnataka, South India

"Our findings bolster growing evidence that even in an environment such as in India, where sex work is criminalized, structural approaches to address violence can be effectively delivered to scale, to reduce arrest of and violence against FSWs."

This study examined a structural intervention designed to prevent HIV infection by addressing violence against female sex workers (FSWs) in the form of police arrest in Karnataka, India. FSWs frequently experience violence in their work environments, violating their basic rights and increasing their vulnerability to HIV infection. Arrested FSWs may be sexually abused by police, engage in risky (including condomless) sex to pay arrest costs, have condoms confiscated by police, and move to avoid arrest - reducing their community support and increasing HIV vulnerability. This paper provides an in-depth description of the design and implementation of structural interventions that may play a role in reducing police arrest among FSWs in Karnataka. The primary intent is to provide guidance and direction to others wishing to develop similar programmes aimed at reducing police violence and arrest with the goal of reaching FSWs in other geographic and epidemiological contexts.

The University of Manitoba and the Karnataka Health Promotion Trust (KHPT) were lead implementing partners in Karnataka for Avahan – the India AIDS Initiative of the Bill and Melinda Gates Foundation – from 2003 to 2013. HIV prevention programmes were initiated in 18 of Karnataka's 30 districts, reaching approximately 60,000 FSWs, and by 2013 the interventions were handed over to the government of Karnataka and local FSW community-based organisations (CBOs) [4]. The initial design of the HIV prevention programmes mainly focused on reaching FSWs in Karnataka with HIV prevention information by: developing a peer educator scheme; increasing condom distribution; improving accessibility of HIV testing, sexually transmitted infection (STI) testing and STI treatment; and facilitating linkage to HIV care for anyone testing positive. However, consultations with FSWs at the beginning of programme implementation highlighted violence as a common and significant challenge in the daily lives of FSWs in Karnataka.

Structural interventions with police involved advocacy work with senior police officials, sensitisation workshops, and integration of HIV and human rights topics in pre-service curricula. Between 2005 and 2011, 85 senior police officials and 13,594 police officers were trained as facilitators, covering 60% of all members of the state police force. Specifically, the intervention included one-day sensitisation workshops with police to educate them on existing laws covering FSWs, human rights and abuse penalties, and FSWs' daily struggles. Post-sensitisation, the implementing partners regularly followed up with the police stations to maintain rapport with the officers and invited police officials to attend a variety of programme activities as special guests, including inaugural events for programme drop-in centres and clinics. This helped foster mutually beneficial working relationships between the police, implementing agencies, and the FSWs themselves. In addition, facilitators worked with police training academies to incorporate sessions on sex work and the Immoral Traffic (Prevention) Act of 1956 (ITPA) into pre-service and in-service curricula to sustain programme efforts.

In 2006, the violence reduction programme expanded to include interventions with FSWs. A central component of the interventions with FSWs was community collectivization. This step led to the establishment of support groups within each programme site and collectives at the district and sub-district levels, while fostering solidarity for collective action. This resultant "collective empowerment" has found to lead to greater autonomy and reduce experiences of violence and coercion among FSWs. Previous findings from Avahan programmes have shown that FSWs who are members of any peer group experience significantly less violence than non-peer group members. As such, a series of capacity-building sessions was organised with FSWs to clarify their rights, as protected by the Indian constitution and national laws, to familiarise FSWs with existing laws under which they can be arrested, and to facilitate their interpretation. As part of these capacity-building exercises, FSWs were taken to police stations to review the procedures for registering complaints against perpetrators of violence, and face-to-face interactions between FSWs and officers were organised to initiate an open dialogue. Finally, crisis response and management systems were set up in all intervention districts to respond to any violence reported by FSWs. Dedicated 24-hour phone lines were established, with telephone numbers distributed widely within the community to encourage FSWs to call and seek support in case of crisis or violence. Each crisis management system also included a 24-hour crisis management team, including a human rights lawyer, who provided legal counsel when the crisis management team dealt with issues such as providing bail to fellow FSWs and participating in court cases involving community members.

Three rounds of integrated behavioural and biological assessment (IBBA) surveys were conducted among FSWs from 2004 to 2011. As part of integrated biological and behavioural assessment surveys, FSWs were interviewed at 20-month intervals about their experiences. Interviews with 4,110 FSWs showed that, while 5.5% initially reported experiencing arrest, only 2.8% did 20 months later. Peer support also increased: 40.75% of FSWs initially reported having peer support, which increased to nearly 70% 20 months later.

In reflecting on these findings, the researchers note that, although sex workers collectives did previously exist in the study districts, the intervention was able to gradually create spaces where FSWs could regularly meet and share their experiences, which helped create a sense of solidarity and foster collective action. Notably, membership in local FSW collectives increased from 11,000 in 2007 to 36,000 in 2009. This study found that FSWs were more likely to report peer support following arrest in the follow-up round of IBBA surveys, suggesting that interventions with FSWs were successful in bringing them together and promoting solidarity. This finding is supported by previous work showing that FSWs who are part of peer groups have associated increases in 3 domains of empowerment, as conceptualised by Blanchard et al. and experience less violence overall. In particular, these peer groups provide opportunities for FSWs to meet and build a collective identity, which has been associated with reduced vulnerability to HIV.

The authors conclude that in settings where sex work is criminalised, structural interventions that educate police officers can be an effective approach for reducing HIV risk among FSWs. "While advocacy and activism for decriminalization continues, creating sustainable partnerships between law enforcement bodies and FSW communities is a pragmatic and effective approach for HIV prevention programmes to ensure that FSWs have a safe working environment and adequate access to health and social services. These structural interventions need to be multilayered and multifaceted, should involve collaboration between police and FSWs and should be implemented and scaled up in parallel with effective behavioural and biomedical HIV preventive interventions."