Sex workers in India’s Chennai city demonstrate their skills in slipping condoms on a phallus. Credit: Stella Paul/IPS

By Stella Paul
CHENNAI/LONDON, Jul 11 2017 (IPS)

In a semi-lit room of a southern Chennai neighborhood, a group of women sit in a circle around a table surrounded by large cardboard boxes of “Nirodh” – India’s most popular condom.

Clad in colorful saris, wearing toe rings and red dots on their foreheads, they look like ordinary housewives. Slowly, one of the women opens a box, takes out a handful of condoms and a wooden phallus. Sound of laughter fills the air as each woman takes her trurn to slip a condom over the phallus. It’s a rare, happy hour for these women who live a hard life as sex workers – a fact they carefully guard from their families.“In our community, over 90 percent of people survive by begging. How can they ever afford any of these treatments?" --Axom, a 26-year-old transsexual man

Baby, who only goes by the first name, is in her forties and the most experienced of all when it comes to demostrating condom skills. A peer educator, Baby has been teaching fellow sex workers all over the city of Chennai how to practice safe sex and protect themselves from both HIV and sexually transmitted diseases.

Thanks to constant training and a generation of awareness, condoms are now part and parcel of almost all of the city’s 6,300 sex workers’ lives, she says. But their sexual health and protection from diseases still completely depend on their clients’ willingness to use a condom.

“We try our best to help the client understand that it is very important to wear a condom because that will keep us both safe from HIV and other infections like gonorrhea. But it needs some convincing. Most of them wear it only grudgingly,“ says Baby.

Female condoms – a mirage

India is one of the largest manufacturers and exporters of condoms in the world. The government-owned Hindustan Latest Limited (HLL) produces over a billion condoms annually, including Nirodh. Of these, 650 million Nirodh condoms are given away annually free of cost for the safe sex campaign. But when it comes to female condoms, there is no free lunch and one must buy the condoms from a store.

AJ Hariharan is the founder and CEO of the Chennai-based Indian Community Welfare Organization (ICWO), one of the largest NGOs in the country working for the welfare of sex workers. Hariharan says that female condoms could be of immense help for the sex workers, but are extremely hard to access because of steep pricing.

A pack of male condom costs around 25 rupees, while a female condom is priced at 59 and above. This is far beyond the reach of most sex workers whose daily earnings are 200-500 rupees, which goes to support their families.

“At the current price, a female condom is an out of reach luxury for poor women. They will never be able to able to use this which is a shame because the average sex workers really need female condoms,” Hariharan adds..

The reason behind the “great need” is both self-empowerment and money, he explains: it takes some time to explain to a client why he must wear a condom and then help him put it on. But this requires time and often, the couple may have to wait before the man has an erection again. With a female condom, business can be done faster as she can save both her time and energy and serve him quick. For those women who rent a place for work, this can be very helpful as she can be with multiple clients in few hours and spend less on rent.

Organizations like ICWO have asked the government for a free supply of female condoms, says Hariharan, but have not received any so far. “This is one of the biggest unmet needs and it must be looked seriously into,” he says.

Despite their inability to afford female condoms, the sex worker community is luckier than other marginalized people of the city as they regularly access sexual and reproductive health services.

“There are eight hospitals in the city where we can go for a regular health check-up that includes having an HIV and STI test and take condoms,” says Vasanthi, a sex worker.

Healthcare for the Transgender

But for another sexual minority – the 450,000 strong transgender community – even a regular health check-up remains a struggle.

“One of the biggest challenges is finding a doctor who can and is willing to understand our problems,” reveals Axom, a 26-year-old transsexual man.

“The moment you walk into a hospital or a private clinic, the doctor will start judging your character and rebuke you for your sexual choice, instead of advising you what to do. It always starts with ‘why do you choose to be this way?’ After this, obviously you will never feel like opening up about your health issues,” Axom says.

Besides the moral policing, transgender community members also face uphill battles to afford healthcare including feminizing and masculinizing hormonal treatment.

Axom has been undergoing hormonal treatment. He hopes to have sex reassignment surgery – a multilayered medical treatment that will give him a prosthetic penis – and is spending over 10,000 dollars on the treatment. Thanks to his job in one of the world‘s biggest e-commerce firms, he can afford it, but for most others, such procedures remain a distant dream.

“In our community, over 90 percent of people survive by begging,” Axom says. “How can they ever afford any of these treatments?“

FP2020, Commitments and Gaps

In 2012, India became a part of the FP2020 – a global partnership to achieve Sustainable Development Goals 3 and 5 and ensure universal access to sexual and reproductive health services and rights by 2030. India had committed among other things to invest two billion dollars over eight years to reduce the unmet need and address “equity so that the poorest and most vulnerable population have more access to quality services and supplies.“

On July 11, representatives from the FP2020 partner countries are participating in a summit in London again to inform and analyse the current status of delivering those commitments made four years ago.

For India, this is a good chance to tell the world what it has really done and recommit to achieve the goals that it had set, says Lester Coutinho, Deputy Director of Family Planning at the Bill & Melinda Gates Foundation.

“Governments, including India, are now responding to the gaps in the commitments that they made. Adolescents and youths are one area, supply chain is another, money for purchasing commodities is the third. Giving counseling and information to women and young people is another. There are tangible solutions in these areas that the government can adopt,” says Coutinho.

Meanwhile, in Chennai, transsexual men and woman like Axom hope that one day the government will subsidize the SRS and hormonal treatment for transgenders.

“The Supreme Court of India recognized the transpeople as a third gender in 2014, so we are now entitled to equal rights and facilities as other citizens do. If the government can offer free surgeries for life-threatening diseases, why can’t we expect it to offer us subsidies on treatments that can remove threats to our identities and the restoration of a normality in our life?” asks Axom.

Gender inequalities drive the disproportionate rate of HIV infection among young South African women aged 15 to 24. Credit: Mercedes Sayagues/IPS

By Nqabomzi Bikitsha
JOHANNESBURG, Dec 1 2014 (IPS)

When she found out that she had human immunodeficiency virus (HIV), Thabisile Mkhize (not her real name) was scared.

She knew little about the virus that had been living in her body since birth and did not know whom to ask. Her mother had just died and she lived with her grandmother in rural KwaZulu Natal, where the HIV prevalence is the highest in South Africa, at 17 percent.

Today, at the age of 16,  Mkhize is an enthusiastic peer educator at her school,  discussing HIV prevention, safe sex and sexual rights. “I want young women to be safe, to make healthy sexual choices,“ she told IPS.South Africa has a perfect storm of early sexual debut, inter-generational sex, little HIV knowledge, violence, and gender and economic inequalities that lead young women aged between 15 and 24 to have a disproportionately high rate of HIV infection

South Africa has a perfect storm of early sexual debut, inter-generational sex, little HIV knowledge, violence, and gender and economic inequalities that lead young women aged between 15 and 24 to have a disproportionately high rate of HIV infection.

They account for one-quarter of new HIV infections and 14 percent of the country’s 6.4 million people living with HIV, according to the ‘South African National HIV Prevalence, Incidence and Behaviour Survey’.

Alarmingly, HIV incidence – the number of new  infections per year – among women aged between 15 and 24 is more than four times higher than among their male peers.

Professor Sinead Delany-Moretlwe, director for research at Wits Reproductive Health and HIV Institute (Wits RHI) in Johannesburg, describes the factors that put young women at higher risk.

“Structural drivers – gender, social and economic inequalities – interact in a number of ways and influence behaviour such as choice of sexual partner and condom use,” she said.

Explaining that young women find it difficult to protect themselves against HIV, she noted that they “end up with controlling partners and fail to negotiate condom use or are forced to have sex.”

Tumi Molebatse, a 20-year-old student from Soweto, is an example. Years ago she had an HIV test and would like to have another with her boyfriend of two years, or at least to have safe sex.  “But my boyfriend will think I am cheating on him if I ask for condoms,” she told IPS.  “He supports me financially so it’s better to not bring it up.”

In South Africa, one of the most unequal countries in the world, relationships with older men often pen the way for young women’s social mobility and material comfort.

According to Kerry Mangold from the South African National AIDS Council, inter-generational and transactional sex increase the risk of infection because older men have higher HIV rates than young men.

“It’s not rare to see a young girl sleep with an older man for food or a little bit of money,“ said Mkhize. “Young women aspire to have nice things in life but they don’t have money, they don’t have jobs, and they go for partners who can provide those things.”

According to the ‘South African National HIV Prevalence, Incidence and Behaviour Survey’, one-third of girls aged between 15 and 19 reported a partner five years or more their senior.

Risk and choices

“At its most extreme, gender inequality manifests as gender-based violence,” says Delany-Moretlwe.

In South Africa, young women who experienced intimate partner violence were 50 percent more likely to have acquired HIV than women who had not suffered violence, according to the UNAIDS Gap Report.

Despite decades of awareness campaigns, less than one-third of young women know how to prevent HIV.

Mkhize says that many girls hear about sex and HIV from friends and teachers, and often  the information is wrong. “I know girls who believe you cannot get HIV if you boyfriend has just come back from circumcision school and so they have sex without a condom,” she told IPS.

Mangold would like to see “an enabling environment for young women to make their own choices and reduce their risk.”

Since last year, the ZAZI initiative has been trying to do just that. A sassy campaign, ZAZI (from the Nguni words for “know yourself”) builds knowledge around sexual health through social media, video clips, poetry readings, street murals, music and fun activities that boost girls’ sense of self-worth.

“We hope to discourage them from opting for relationships with older men for material gain and give them confidence to negotiate condom use,” ZAZI advocacy manager Sara Chitambo told IPS.

ZAZI’s motto is “finding your inner strength”. On its website, girls can look up practical advice on what to do if they are raped, where to find contraception and how to prevent HIV.

(Edited by Mercedes Sayagues and Phil Harris)

According to a survey, one-third of Cubans between the ages of 12 and 49 believe they have little to no chance of getting AIDS. Credit: Jorge Luis Baños/IPS

By Ivet González
HAVANA, May 9 2013 (IPS)

“But I always used a condom!” was the sentence that played over and over in Jaime Roche’s mind when the young Cuban man tested positive for HIV in October.

“I couldn’t believe it. I’m an advocate of using condoms, even for oral sex,” the health worker, who preferred not to give his real name, told IPS. “This happened to me by accident: the condom broke during a casual encounter,” Roche said.

“Maybe I would have been protected if I hadn’t been with another person outside my stable relationship. That might be the ideal thing for total security,” said Roche, who is also a social activist. “My partner of 10 years is still with me. For now, I apparently haven’t infected him, although he has to get tested again.”

Young people, especially men who have sex with men (MSM), make up the majority of new HIV and AIDS cases detected in Cuba every year, even though young people use condoms more when engaging in sexual relations, according to recent studies.

A 2011 survey on prevention indicators for HIV infection conducted by the National Office of Statistics and Information (ONEI) found that 59.6 percent of MSM, 62.9 percent of other men, and 65.9 percent of women under the age of 20 practiced safe sex in their first sexual encounter – a rising indicator.

As of late last year, a little over 13,000 of Cuba’s 11.2 million people were HIV-positive. Of those individuals, 29.6 percent were 15 to 29 years old in 2011, when the ONEI conducted its most recent survey of people living with HIV/AIDS.

Meanwhile, the 15-19 year age group accounted for the largest number of new cases detected in 2012, unlike in previous years, said Dr. Jaqueline Sánchez, coordinator of the Line for Adolescents and Young People of the state-run National Centre for the Prevention of STDs (sexually-transmitted diseases) and HIV/AIDS.

For that reason, Sánchez said in a conversation with IPS, more needs to be known about this group, and comprehensive work needs to be done to foment “protective factors” – that is, behaviour, situations, environments and attitudes that will keep this population group away from the epidemic and other STDs.

Communication in the family and with one’s partner; positive relationships with parents, teachers and other adults in the community; social policies for comprehensive services for adolescents; a participatory environment free of violence and discrimination; and access to sex education from an early age are all elements that protect against the spread of HIV.

“Condom use is not enough to stop the epidemic,” said Sánchez.

Young people, defined by the experts in Cuba as the 15-30 age group, are considered to be at high risk for HIV-AIDS all over the world, to the extent that about five million people in that age group are now living with the disease, according to the United Nations.

In Latin America, the prevalence of the virus among 15 to 25-year-olds went down to 20 percent during the 2001-2011 period.

Drug and alcohol use, dropping out of school, unequal opportunities, unsafe environments, ignorance about sexuality, and under-use of health services are all risk factors for this age group around the world.

It is also typical during this period of life to change partners and depend more on one’s friends, often ignoring the advice of close adults and engaging in risky behaviour.

Studies show that today’s generations are assuming sexuality more freely, and that they often view casual and open relationships and even group sex as something natural.

The prevalence of HIV/AIDS in Cuba since the first case was detected in 1986 has been concentrated among young people aged 20-29. That increases possibilities for contact with the virus in this group, making it epidemiologically vulnerable, Sánchez said.
“Young people are the most likely to follow safer sexual behaviour if they receive guidance from an early age,” she said. “But that will depend in great measure on adults providing them with increasingly friendly information, knowledge, and services as a normal, healthy part of growing up.”

In a post on the Café 108 webpage of the IPS Bureau in Cuba, biologist Isbel Díaz said prevention campaigns should “shake people up a bit, even at the risk of shocking them a little.” He added, “We cannot let our young people be exposed simply because we are worried about looking like we’re exaggerating, or about shocking people when talking about the disease.”

Other health promoters, such as Liana Trelles, who teaches English at the Saúl Delgado high school in Havana, advocates empathy with teens and young people. “I started out by observing them, asking them what their concerns were, and addressing them directly,” she told IPS.

Trelles, who is also a psychologist, and other teachers at her school created spaces for conversing about these issues with students 15 to 18 years old. “I was alarmed when I heard about the ‘descarga,’ a type of relationship that may or may not reach sex, and where there is no commitment or stability,” she said.

“Practices of that type also make a group vulnerable,” she said, noting that studies are needed about that behaviour to understand how widespread it really is. Therefore, she said, she promotes protective factors, such as “increasing knowledge about condom use and responsible behaviour.”

The HIV/AIDS rate in Cuba is just 0.19 percent of people aged 15 to 49. But since the start, it has slowly but steadily grown. It mostly affects men, especially MSM, but since 2004 the figures have risen for women, especially young women.

Condom promotion campaign in Male: Credit: SHE

By Feizal Samath
MALE, Sep 22 2012 (IPS)

For an orthodox Islamic country, the Maldives has made remarkable progress in halting the spread of HIV in the Indian Ocean archipelago through bold awareness programmes and the distribution of condoms.

A few years ago, condoms were available in the Maldives only at drug stores and on production of a doctor’s prescription. Anyone found carrying a condom in the streets  was liable to be arrested by police.

But, a five-year project mounted by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), reports progress in creating awareness of safe sex issues and the use condoms by providing them free. The GFATM is supported by the Bill and Melinda Gates Foundation.

The GFATM programme in the Maldives addressed the sexually active among the 300,000 Maldivians, but focused on the 110,000 foreign workers in the country – mostly Bangladeshis, Indians and Sri Lankans employed in construction and in the country’s famed luxury resorts.

“We did a lot of work in the five years of the programme, which ended in August,” Ivana Lohar, HIV/AIDS project manager at the United Nations Development Programme in the Maldives, told IPS. “We believe that one more round of global funding would help to sustain the momentum.”

The challenge, Lohar said, is to ensure that the Maldives remains a low HIV prevalence country despite the presence of high-risk groups. As of December 2011, only 15 HIV cases were reported among Maldivians, while there were 289 cases among the foreign  labour force.

At the spanking new Voluntary Counselling and Testing Centre set up in the heart of capital by the Society for Health Education (SHE), a local non-government organisation (NGO), both local residents and foreign workers can avail of the free services.

Asna Luthfee, programme associate at SHE, says her work has included training 40 migrant workers as peer educators to promote awareness at hotspots where foreign workers congregate and provide condoms on request.

SHE offers a range of services through a sexual and reproductive health clinic, including screening for thalassaemia, DNA testing, counselling and psychosocial support. “We distribute oral pills, emergency contraceptives and condoms. We don’t ask people whether they are married or not – we distribute on request,” Luthfee said.

“There is also counselling if testing for HIV shows positive, and these cases are referred to the government,” Luthfee said. The programme, in which SHE and UNAIDS are partners, has been successful enough to be seen as a model for the region, she added.

Mohamed Yahiya, an accountant from Bangladesh who also works as HIV peer educator, said a government decision made earlier in the year to allow workers who contract HIV in the country to stay on and get free treatment, has helped immensely.

“Many were scared to talk about their HIV status fearing deportation, but the new government guidelines have eased those concerns,” he said. Foreign workers, however, undergo mandatory testing on arrival and those testing positive are refused entry.

The campaign has had its ups and downs because of pressure from the public and  religious groups that accused organisers of promoting promiscuous sexual behaviour.

“Though religion has its own inhibitions, Maldivian society is open and able to understand the need for awarenesss,” says Lohar. “We are not trying to interfere with religious beliefs, but flagging a serious public health issue. AIDS is a devastating condition that can impact the economy.”

A spokesman (officials may not be named under briefing rules) for the National AIDS Programme (NAP) said stigma and discrimination are still prevalent and public surveys in 2008 and 2009 showed that them to be  barriers to effectively addressing HIV and AIDS.

The UN-funded Biological and Behavioural Survey on HIV/AIDS – 2008 had noted that the potential for HIV transmission is “accelerated by non-use of condoms and the sharing of unsterile needles and syringes among injectors.”

Unprotected sex is high in all the risk groups. Aside from the risk behaviours themselves, a growing concern is the early age at which commercial sex and injecting drug use start in the Maldives, the study found.

The Maldives, warned the report, “is showing signals of a possible future epidemic which need to be closely monitored by the national programme, including injecting drug use in prisons and rehabilitation centres and risk behaviours found among the 18-24 year age group (selling and buying of sex, group sex, male-to-male sex, sex with non-regular partners, and injecting drug use).”

The NAP spokesman said that religious groups and scholars are supportive of public health efforts to prevent diseases and in this context using condoms is advised. “Prevention efforts are well supported by the religious scholars, and recently they have been involved as partners in HIV prevention work,” he added.

A major component of the programme was the conduct of migrant fairs where free testing for HIV/AIDS was provided. The latest of these fairs, which was held in August,  had collaboration from  government agencies, embassies and high commissions.

“Though most workers don’t understand English, these cultural shows break barriers and provide foreigners access to services, overcoming stigma and discrimination,” Luthfee said.

“Workers are provided information in their own language and when they return to their home countries they go back armed with knowledge on health issues,” said Yahiya.

How many condoms is it legal to carry around in your pocket? That’s the question sex workers in the United States are asking after being routinely targeted by police for having prophylactics – not in itself a crime.

On Thursday, Human Rights Watch launched “Sex workers at risk: Condoms as evidence of prostitution” at a press conference in Washington. The report includes more than 300 interviews, with 200 current and former sex workers as well as outreach workers, advocates, prosecutors, public defenders, police, and health department officials.

The “criminalising” of condoms has left sex workers in New York City, Los Angeles, Washington DC and San Francisco wary of carrying condoms, and exposed them and their customers to the threat of HIV.

Tanya B, a Latina transgender sex worker from NYC, recounts her harrowing experience with the police.

“I was stopped and threatened. The cops said ‘empty your purse.’ I cleared out everything but left the condoms at the bottom – I got caught. They said ‘how come you didn’t pull out the condoms? I can arrest you because of this.’ I said ‘it’s not a problem, I have no weapons, no drugs’ and the police officer said ‘next time, I will arrest you because this is evidence you are a prostitute’.”

Andrea Ritchie, coordinator of AT Streetwise and Safe (SAS), and a lawyer specialising in police misconduct, gave insight into this unofficial but prevalent practice. The most common victims in New York are women of colour and lesbian, gay, bisexual and transgender (LGBT) people, she said.

Between 20 to 40 percent of homeless youth identify as LGBT, and many turn to “survival sex” to earn enough money to eat and get a place to sleep.

“The police believe it is doing their job. The order to confiscate condoms, though unofficial, comes from district attorneys,” Richie told IPS. “NYC is the epicentre for AIDS, and these practices put countless women, LGBTs and men at risk.”

The New York City Department of Health and Mental Hygiene (DOHMH) launched a safe sex campaign in 2007, ultimately distributing more than 40 million free condoms across the city.

The actions of the police directly counteract the city’s initiative to protect people from disease, and can be seen as a huge waste of resources, rights advocates say.

In Washington DC, the AIDS epidemic is one of the most widespread in the United States. Of the 17,000 people with HIV, 75 percent were African American males. African American women in DC are 14 times more likely to be infected than their white counterparts.

Groups such as Rubber Revolution in DC and Get Some! in NYC are taking the fight for condom use to the media, using popular social media platforms. They worry that the “condom as evidence” practice is seriously undermining these efforts.

If bills such as one pending in the New York State Assembly are passed, condoms will not be allowed to be used as evidence of prostitution. The bill specifically states, “Provides that possession of a condom may not be received in evidence in any trial, hearing or proceeding as evidence of prostitution, patronizing a prostitute, promoting prostitution, permitting prostitution, maintaining a premises for prostitution, lewdness or assignation, or maintaining a bawdy house.”

For Megan McLemore, a senior researcher at Human Rights Watch, the issue at hand is clear. If someone has to be arrested for prostitution, it should be because law enforcement officials saw them agreeing to a sexual act for money. Condoms should not figure into the debate.

At the launch of the report, all the speakers stressed that criminalising condoms is a public health issue. It endangers the general public, and exposes them to diseases which can be easily prevented.

The report provides insight into the ordeals faced by sex workers, which include police harassment of transgender people such as vulgar insults, mockery, and disrespect. In one case, a police officer grabbed a woman’s wig, threw it to the ground and stepped on it. Such behaviour points to a pattern of discrimination that goes beyond simple stop and search tactics.

“We have a saying in NYC. If on one side of the West Village a frat boy is standing with 10 condoms in his pocket, he is hopeful and practicing safe public health. If on the other side stands a gay man with condoms in his pocket, he is obviously engaging in prostitution,” says Ritchie.