Life circumstances of women entering sex work in Nagaland, India.

BACKGROUND AND OBJECTIVES: The study objective was to enhance understanding of female sex workers' lives in Nagaland, India (one of the country's highest HIV prevalence states), to inform the development of interventions to reduce HIV transmission and assist women who want to leave sex work. METHODS: A cross-sectional survey (n = 220) and semi-structured interviews (n = 30) were conducted with sex workers. Topics included the following: life situation currently and at time of initial engagement in sex work, circumstances of first sex work occasion, and current patterns of sex work. RESULTS: Participants' lives at time of entry into sex work were socio-culturally and economically vulnerable as evidenced by the early age of sexual debut, low levels of education, unemployment, absence of protective male partners, and poor relationships with families. Participants experienced high levels of mobility, insecure accommodation, the need to financially support family, and the demand to give a portion of their income to others. The use of alcohol and other drugs, including heroin, was widespread. DISCUSSION AND CONCLUSIONS: For these women, sex work can be seen as a pragmatic option for earning sufficient income to live. The women's lives would be improved by strategies to promote their health, ensure their safety, and protect their rights as long as they are engaging in sex work. This is likely to benefit not only the sex workers but also their children, their families, and the wider community. The development of alternative employment opportunities is vital to protect against entry into sex work and to support women who want to exit sex work.

Pathways to sex-work in Nagaland, India: implications for HIV prevention and community mobilisation.

There are an estimated 1800-3500 sex-workers in Dimapur, the commercial capital of Nagaland, which is the second-highest HIV prevalence state in India. The HIV prevalence among these sex-workers has increased from 4.4% in 2004 to 16.4% in 2006, highlighting their vulnerability. The aim of this study was to contribute to understanding of the pathways to sex-work for women in Nagaland in order to inform the development of effective HIV prevention strategies. A convenient sample of 220 female sex-workers completed a cross-sectional survey, and 30 female sex-workers participated in semi-structured in-depth interviews during mid 2007. Participants were asked about their life situation at the time of initial engagement in sex-work and circumstances of the first occasion of sex-work. The four main pathways into sex-work were identified as: (1) to obtain money to meet basic needs for self and family (45% of survey and 43% of interview participants); (2) to obtain money to purchase drugs or alcohol (15% of survey and 27% of interview participants); (3) being coerced, tricked or forced into sex-work (13% of survey and 30% of interview participants); and (4) for pleasure (12% of survey and no interview participants). Women from each of these pathways were significantly different from each other in relation to a range of socio-cultural variables (e.g., ethnicity, marital status and education), and HIV risk factors (e.g., drug and alcohol use, age of sexual debut and HIV awareness). This diversity has implications for HIV prevention strategies, including the willingness and capacity of sex-workers to mobilise as a community and NGO capacity to ensure that the interests of all sex-workers are adequately captured and represented.

Injecting and sexual risk behaviours, sexually transmitted infections and HIV prevalence in injecting drug users in three states in India.

OBJECTIVE: To describe and compare sexual and injecting risk behaviours and sexually transmitted infections (STI), hepatitis C virus (HCV) and HIV prevalence in injecting drug users (IDU) in six districts in three states of India: Manipur, Nagaland, and Maharashtra. METHOD: The respondent-driven sample consisted of 2075 IDU. Consenting participants were administered a structured questionnaire and samples of blood and urine were collected to test for HIV and STI. Data were analysed using RDSAT. RESULTS: In two districts in Manipur, 77 and 98% of IDU injected heroin, whereas the main injecting drug in Nagaland was dextropropoxyphene (99%). In Mumbai/Thane, Maharashtra, the majority of respondents reported using chlorpheniramine (87%) and heroin (99%). In all districts, almost half of IDU reported generally sharing needles and syringes; consistent condom use with non-paid female partners was also low. Approximately one-quarter of IDU in Mumbai/Thane visited a paid partner in the past year. IDU with reactive syphilis serology were higher in Nagaland (7 and 19%) than in Manipur and Maharashtra. HIV in two districts of Manipur (23%, 32%) and Mumbai/Thane (16%) was greater than Nagaland (<2%). HCV prevalence was more than 50% in Mumbai/Thane and Manipur. CONCLUSION: Irrespective of regional differences, high-risk behaviour of needle sharing and low condom use makes IDU a critical subpopulation for HIV prevention interventions. Interventions need to address the differing drug use patterns in the regions and transmission prevention among non-paid regular and casual female partners of IDU in the northeast districts and paid female partners in Mumbai/Thane.

Some peace of mind: assessing a pilot intervention to promote mental health among widows of injecting drug users in north-east India.

BACKGROUND: HIV prevalence in north-east India is high and injecting drug use (IDU) is common. Due to HIV-related deaths there are increasing numbers of IDU widows, many of whom are HIV infected, and experiencing poor health, social isolation, discrimination and poverty, all factors likely to be compromising their mental health. There is increasing recognition of the links between HIV and mental health. METHODS: The aim of this study was to pilot a peer-facilitated, participatory action group (PAG) process and assess the impact of the intervention on the mental health of participants. The intervention consisted of 10 PAG meetings involving 74 IDU widows. Changes in quality of life (WHOQOL-BREF), mental health (GHQ12) and somatic symptoms were assessed. The value of the intervention from the perspective of the participants was captured using a qualitative evaluation method (Most Significant Change). RESULTS: Participants' quality of life, mental health and experience of somatic symptoms improved significantly over the course of the intervention, and the women told stories reflecting a range of 'significant changes'. CONCLUSION: This pilot intervention study demonstrated that a participatory approach to mental health promotion can have a positive impact on the lives of vulnerable women, and the potential to contribute to HIV prevention. Further investigation is warranted.