Barriers to condoms

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Barriers to condomsImplementing and documenting advocacy strategies


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2 ICASO BARRIERS TO CONDOMS IMPLEMENTING AND DOCUMENTING ADVOCACY STRATEGIES

Barriers to condoms - Implementing and documenting advocacy strategies

1st edition, 2009

ICASO 2009

Funding for this project was provided by Population Action International (PAI) through the Project

Resource Mobilization and Awareness (Project RMA), the Ford Foundation, and the Canadian

International Development Agency (CIDA) of the Government of Canada.

We gratefully acknowledge contributions from colleagues who generously accepted to share

with us their experiences in advocacy for improved condom access and use, especially

Anthony Hron (JN+), Meena Seshu and Cath Sluggett (Sangram) and Many Di (CACHA).

Special thanks to Andrew Hunter and Sally Low for their support in the Cambodian case study.

Project Manager: Mary Ann Torres

Writing: Rodney Kort

Editing: Kieran Daly, Callie Long and Mary Ann Torres

Translation: Arturo Marcano, MIA Communications and Jean Dussault, Nota Bene

Design: Tall Poppy

The images used within the body of the publication are of condom cover pins an initiative

by The Condom Project to reduce stigma against condoms and to promote safe sex. The

images of the female condoms were also provided by The Condom Project. For more

information visit: www.thecondomproject.org


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BARRIERS TO CONDOMS IMPLEMENTING AND DOCUMENTING

ADVOCACY STRATEGIES

INTRODUCTION

In 2007, the International Council of AIDS Service Organizations (ICASO)published an advocacy briefing, Barriers to Condom Access: setting an

advocacy agenda.1 The briefing was based on community research in 14countries and identified key barriers to condom access, organized around fourmajor areas:

Social and Cultural Barriers1.

Legal and Policy Barriers2.

Economic and Financial Barriers3.

Structural Barriers4.

The briefing and supporting research were part of a broader analysis undertaken

by civil society groups, aimed at assessing how commitments by theinternational community in the 2001 Declaration of Commitment on HIV/AIDSand the 2006 Political Declaration on HIV/AIDS were being implemented. Theadvocacy briefing on condom access included a number of recommendationsfor community sector advocacy regarding condom access within each of thefour areas listed above.

Following the publication of the advocacy briefing, ICASO funded threeorganizations to prepare case studies documenting their experience in planningand implementing condom advocacy, outreach and community mobilizationactivities, including (in the case of Cambodia) conducting an action researchproject. The organizations were: the Jamaican Network of Seropositives (JN+);Sangram (a sex worker peer education project in Southern India); and theCambodian Alliance for Combating HIV/AIDS (CACHA).

The purpose of the case study phase of the project was to provide illustrativeexamples of various aspects of community-based condom advocacy andrelated activities. In addition, the project also sought to identify lessons learnedfrom doing advocacy work in different settings and for different key populations,while linking the experience of these organizations to the relevant themes andrecommendations from the condom advocacy brief.

This report is an analytical summary of the three case studies2 and identifiesconsistent themes in the barriers faced by the populations they serve inaccessing condoms, as well as the process they followed to develop their

advocacy plans and activities.

More than 25 years into the AIDS epidemic, community-based organizationscontinue to struggle to maintain and expand access to the single mosteffective HIV prevention intervention for the vast majority of infections the useof condoms. The lessons learned from these three case studies will hopefullyinform and inspire similar efforts around the globe.

1 ICASO. Barriers to Condom Access: setting an advocacy agenda. Toronto, 2007. Available at http://www.icaso.org/publications/condom_access2007_eng.pdf.

2 The complete set of case studies is included in this briefing.


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Developing an Empowerment Practice to Support

Condom Advocacy Sangram

The Indian case study documents how Sangram,established by 16 peer educators in 1992, developed itspeer education and advocacy activities over the course of

16 years, focusing on peer education and empowermentwork among sex workers. It also illustrates how and whythis was necessary with regard to subsequent advocacywith their clients, and a wide range of public and privatesector stakeholders. Sex workers met regularly and wereencouraged to have their own bank accounts, propertyand other socio-economic markers of independence thatgave them a greater sense of self-agency when it cameto negotiating condom use. During this period, two othergroups, which now work in collaboration with Sangram,were established: Veshya AIDS Mukabala Parishad(VAMP), a collective that manages peer interventionsamong the sex worker community; and Muskan, a peer

education group for men who have sex with men (MSM).

FINDINGS BARRIERS TO CONDOMACCESS AND USE

The community-based organizations (CBOs) in the threecountries used a cyclical, peer-based approach to identifyand respond to condom access barriers for their respectiveconstituencies. Despite the differences in geography, culture,race and social relations, there is remarkable consistencyin the barriers these groups face in accessing and usingcondoms to prevent primary and secondary HIV infection,as well as other sexually transmitted infections (STIs).

3.1 SOCIO-CULTURAL BARRIERS

The three case studies identified similar socio-culturalbarriers that posed a significant challenge to condomaccess and use, consistent with the findings in the ICASOadvocacy briefing.

Gender Inequality: ChallengesTraditional gender roles in these countries where for a

variety of physical and socio-economic reasons men havesubstantially greater power in determining sexual dynamics are a significant barrier to condom access and use.

Examples include:

Resistance to condom use by male partners whooften perceive condoms as weakening or unnecessary(particularly with a long-term partner.)

Expectations that men can or should have multiplesexual partners (whether or not they have a wife orlong-term partner), as a badge of virility and masculinity,which the use of condoms undermines.

The potential threat of physical violence (and/or lossof revenue for sex workers) if women insist oncondom use.

Sex between men undermines accepted notions ofmasculinity and gender identity, thereby driving sexbetween men underground and creating additionalchallenges for prevention interventions.

Financial dependence of women on their male partnersand the risk of losing their financial security if they insiston condoms.

Gender Inequality: StrategiesChallenging and shifting cultural attitudes, which reinforcethe traditional gender roles that place both women andmen who have sex with men (MSM) at greater risk ofinfection, is a long-term process. The three case studiesreflected the importance of advocacy at both the individualand societal level to address this challenge:

Sangrams case study documented the need to developan understanding among sex workers that by actingcollectively rather than as individuals competing forthe same clients, it could result in increased condomuse and improved health benefits (and revenue) foreveryone.

Targeted education interventions with adolescents andyoung, sexually active adults in school (JN+), and withclients and partners (Sangram), about the negativeimpact of gender inequity on both women and men,including health risks to individuals, their sexual partnersand their family.

Advocacy with relevant government ministries andother key decision makers to address the vulnerability ofyoung women to HIV, as a result of gender inequity, and

to strengthen social supports for teenagers enablingthem to make informed decisions about their health andsexual behaviour.

There is a need to advocate with service providers tobetter integrate gender issues into peer education andoutreach programs, as well as HIV services (a family-centered approach) that address the complex ways inwhich gender inequity has an impact on vulnerabilityto HIV.


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Laws and Policies Governing Sexual Conduct: Strategies

The JN+ advocacy strategy included gathering information about (surveying)the attitudes and behaviours of health care workers as it relates to condomprovision to people living with HIV. It became clear that the advocacy strategyneeded to include sensitizing both health care workers and PLHIV on the

importance of positive prevention.3

Sangram wrote to the Parliament Review Committee and organizeddemonstrations at the national, state and local level, opposing amendmentsto the Act. It also joined other Indian organizations in advocating for the repealof section 377 of the Indian penal code.4

Cambodian sex workers and their advocates conducted an action researchproject in 2008, to document the impact of the legal and policy environmenton access to condoms and other HIV services for sex workers and theirclients. The results will inform an advocacy strategy aimed at addressingHIV stigma, changing enforcement practices of the anti-trafficking law andthe 100% CUP, and increasing the involvement of sex workers and AIDS

NGOs in the design and implementation of the 100% CUP. Although researchrespondents acknowledged the efficacy of the program in some areas,they also noted the serious human rights violations that have hampered itsimplementation. Fundamental to the advocacy strategy is the need for localand national authorities to recognize sex work as legitimate work that is notintrinsically exploitive.

3.3 STRUCTURAL BARRIERS

Sex Education and the Availability of Condoms: Challenges

Sangram and JN+ both identified the supply and distribution of condoms asa key structural barrier to condom usage. Rural areas of Jamaica, where HIVprevalence is the highest, is most disadvantaged, with many PLHIV havingto travel considerable distances to treatment sites, where free condoms areavailable. Issues for Sangram included:

The poor quality of condoms being supplied by the public health department.

The lack of sexual health education (particularly within the school system.)

Lack of integration of HIV programs with sexual and reproductivehealth services.

3 Recently, under the leadership of the Global Network of People Living with HIV (GNP+), the term positive prevention as been reviewed as there are limitations and conflicunderstandings of the term. GNP+ and other networks and organizations of people living with HIV have preliminary agreed on the term Positive Health, Dignity and

Prevention (PHDP). The term encompasses the following key elements: Health promotion and access, sexual and reproductive health and r ights, prevention of transmisshuman rights, including stigma and discrimination reduction, gender equality, social and economic support, empowerment and measuring impact.

4 Chapter XVI, Section 377 of the Indian Penal Code is a piece of legislation in India introduced during British rule of India that criminalizes sexual activity against the order nature. The section was read down to decriminalize same-sex behaviour among consenting adults in a historic judgement by the High Court of Delhi on 2 July 2009.


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Sex Education and the Availability of Condoms:

Strategies

The JN+ advocacy strategy to address problems in theequitable supply and distribution of condoms included:

Submitting a proposal to the National AIDS Programoutlining the urgent need for more condom distributionsites in rural parishes, including via treatment centers.

Establishing stakeholder meetings to work collectivelywith health care workers, social workers and others oncondom access issues.

Sangram successfully advocated with schooladministrators and teachers to allow the organizationto deliver sex education programs in schools, using avariety of traditional ways to convey HIV awareness andprevention messages in both secular and religious venues.

In summary, Sangram was successful in:

Advocating with local politicians to ensure the PublicHealth Department addressed condom quality issues.

Advocating with health officials and clinic administratorsto have a Sangram staff person in the public healthclinics to strengthen the integration of HIV and sexualhealth services and ensure greater accountability inthe system.

For Sangram, creating a network of community insiders(sex workers, their children and men who have sex withmen) and supporting their capacity to develop and deliverstrategies in a grassroots, peer-driven approach, hasbeen key to the success of their condom advocacy. Bymeaningfully involving these key populations, Sangramensured that the advocacy strategies respond to theirneeds and address their concerns.

3.4 ECONOMIC AND FINANCIAL BARRIERS

Cost of Condoms: Challenges

Cost is a major barrier for Jamaican PLHIV (most of whomare low-income earners) an issue exacerbated by somemerchants who (contrary to government policy) levy a 16.5percent tax on top of the retail cost of condoms. In Sanglidistrict in India (where Sangram is located), free condomdistribution to sex workers was discontinued twice (in2002 and 2006), on the grounds that they were onlyfor contraceptive use and not for prevention of sexuallytransmitted infections. In Cambodia, an interruption infunding for the 100% CUP resulted in a decline in coverageof both brothel and non-brothel-based sex workers.

Cost of Condoms: Strategies

JN+ is planning advocacy work with the Ministry of Healthand Environment and the Ministry of Finance and Planningon cost issues, including a campaign advising merchantsthat condoms should not be subject to additional taxes or

levies, while also advocating for free condoms to be madeavailable at more treatment sites and other venues.

In 2002, Sangram advocated with local governmentofficials, and in 2006, with state government officials,to re-establish free condom distribution to sex workers.

They argued successfully that as a life-saving intervention,it should be free. Cambodian advocates are pushing forbetter funding of the 100% CUP, in addition to fundamentalchanges in how sex workers are involved in its designand implementation.

CONCLUSION

Although the three countries reflect different approachesand different stages in their condom access advocacyprocess, there are strong consistencies in their approach.

The importance of having a peer-based model in whichidentifying barriers and planning and implementingcondom advocacy activities are undertaken by theaffected population, which informs the delivery of HIVprevention services, including condom use programs.

The need to address pre-existing stigma, discriminationand other human rights issues at the individual,institutional and societal level, as a prerequisite toexpanding condom access and use.

The need to have a practical, evidence-based approachto advocacy that reflects the realities of the lives of theconstituencies represented by the three organizations.

The need to integrate condom advocacy efforts withother HIV and non-HIV health services advocacy, suchas integrating HIV with sexual and reproductive health

services, health care worker sensitization and training,and legal and policy reform efforts.

More than 25 years into the AIDS epidemic, community-based organizations continue to struggle to maintain andexpand access to the single most effective HIV preventionintervention for the vast majority of infections the useof condoms. The lessons learned from these three casestudies will hopefully inform and inspire similar effortsaround the globe.


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CAMBODIA

CASE STUDY CONDOM ADVOCACY: ESTABLISHING THE

EVIDENCE FOR AN ADVOCACY CAMPAIGN - CAMBODIAN

ALLIANCE FOR COMBATING HIV/AIDS (CACHA)

BACKGROUND

This case study reviews the process to build an evidence-based advocacystrategy aimed at ensuring the needs of sex workers and entertainmentworkers are incorporated into the design and implementation of AIDSprograms in Cambodia, particularly as it relates to condom access. The studyfocuses primarily on how recent changes in the legal and policy environmentin Cambodia, in particular the implementation of the Law on Suppression ofHuman Trafficking and Sexual Exploitation, is affecting access to HIV services(including the availability of condoms) for this key population. By understandingthe impact of the legal and policy environment on HIV services, sex workers andtheir advocates are better able to design and implement advocacy strategies

aimed at increasing access to condoms.

In Cambodia, HIV prevalence among adults aged 15-49 years declined froma peak of 2.0% in 1998 to 0.9% in 2006.5 The total number of people livingwith HIV (PLHIV) (adults and children) at the end of 2006 was 71,100 people(67,200 adults), with annual new adult infections declining from a peak of12,700 in 1997 to 1350 in 2006.6

Recently however, entertainment workers and sex workers in Cambodia havefaced new challenges, including national efforts to combat human traffickingthrough the Law on Suppression of Human Trafficking and Sexual Exploitation,passed in February 2008. The law makes almost all aspects of buying andselling sex illegal and this potentially includes most forms of association with sexworkers, for example renting premises or rooms and introducing consentingadults to sex work.

Sexual transmission remains the primary source of HIV transmission, withgender inequity contributing to the vulnerability of both men and women. Withmen, vulnerability is heightened by prevailing peer pressure. Going to karaokesessions and having sex with entertainment workers (such as singers or beergirls) after dinner is often expected as a social norm.7 Housewives often feelpowerless to initiate discussions with their partners about concerns regardingtheir risk of infection as a result of gender inequity.

The 2005 Cambodian Demographic Health Survey (CDHS) found that 10% (or

342,000) of Cambodian men have multiple concurrent sexual partners. HIV isalso increasingly affecting people who inject drugs and men who have sex withmen (MSM). The 2005 STI Sentinel Surveillance survey found HIV prevalenceof 8.7% MSM in Phnom Penh and 0.8% among MSM in Battambang andSiem Reap. HIV prevalence was significantly higher among male-to-femaletransgender compared to MSM, and higher among MSM aged 25 years and

5 National Center for HIV/AIDS, Dermatology and STIs, 2007, cited in UNAIDS 2008 Report on the Global AIDS Epidemic.

6 Ibid.

7 Sexual services can be purchased from singers or beer girls at karaoke bars.


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over compared to MSM aged 16-24. Consistent condomuse was low, particularly in the provinces, with a highnumber of sexual partners. Forty five percent of PhnomPenh MSM and 84% of provincial MSM had unprotectedanal sex in the past month.

ESTABLISHING THE EVIDENCE: METHODOLOGY

In the second half of 2008 a group of AIDS and sex workerorganizations began an action research project aimed atassessing the impact of the legal and policy environmenton universal access to HIV prevention, testing andtreatment services and the right to work of entertainment/sex workers in Cambodia. This research was seen asfoundational to informing advocacy to protect the humanrights of sex workers, including the right to health and

the right to work.8 A total of 1,700 sex workers andentertainment workers were surveyed (female, male andtransgender) in four provinces (Phnom Penh, Sihanoukville,Siem Reap and Banteay Meanchay) on issues connectedto access to HIV-related services (including condoms),policies and laws that impact this access, programs inplace to address their needs, human rights abuses andother relevant issues. The survey was complemented bykey informant interviews, legal comparative research andresearch of secondary data.

THE CAMBODIAN MODEL 100% CUP

The National AIDS Program was looking for a betterapproach to further reduce HIV transmission followingsignificant increases in prevalence among sex workersin some areas of the country. Previously, police and localauthorities in Cambodia had tried unsuccessfully to closedown brothels and other sex work venues. This approachwas not only unsuccessful, but resulted in reduced accessto condoms and other HIV services for both sex workersand their clients. In October 1998, the 100% CondomUse Program (100% CUP) was introduced in Sihanoukville

as a pilot project, based on the success of the 100%CUP in Thailand.

After a feasibility study, Sihanoukville was selected as the pilotprogram site because of its high HIV prevalence and goodcooperation among the provincial authority, the NationalCenter for HIV/AIDS, Dermatology and STI (NCHADS),Municipal Health Department and the local authority of

Sihanoukville. It did not include the cooperation or involvementof sex workers or organizations working with them.

In theory, the main feature of the Cambodian model is thecombination of both social and behavioural approaches toreduce HIV transmission, including working with sex workerson life skills, self-esteem and empowerment. As well, unlikeprevious efforts, the 100% CUP aimed to establish strongcoordination and collaboration between stakeholdersresponsible for different components of the AIDS response,connecting existing interventions such as outreach andpeer education to sex workers, voluntary counselling andtesting (VCT) services and condom social marketing.

This approach required close collaboration not only amonghealth care workers, local authorities and police but alsobrothel owners and sex workers. Regular meetings withthe owners of entertainment establishments resultedin their support and active participation in the program.However, meetings with sex workers and their advocateswere not that regular.

The result of these combined efforts to address sex workers,clients and partners has been a significant increase incondom use and a reduction in HIV prevalence amongboth brothel based and non brothel-based sex workers.

However, the 100% CUP in both Cambodia and Thailand,was widely criticized for its human rights violations. In2007, ICASO called for changes in this approach in theBarriers to Condom Access Advocacy Briefing.9 Althoughthe program was designed as a collaboration betweenlocal authorities and the sex entertainment establishment,it was developed without consulting sex workers and theiradvocates, and included a variety of coercive measures bypolice and military, who were responsible for enforcing theprogram. The program also failed to protect sex workerswho were dismissed from establishments (either for non-

compliance with the program or because they testedpositive for STIs, including HIV), which resulted in theseworkers ending up in more vulnerable work situations andat higher risk of HIV infection.

8 The information contained in this case study only pertains to issues related to access to condoms by sex workers and entertainment workers.

9 Available at: http://www.icaso.org/publications/condom_access2007_eng.pdf


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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

120

100

80

60

40

20

0

Consistent Condom Use

HIV Prevalence Rate

Condom Use, HIV prevalence, Brothel Based SWs

1993-2007, Cambodia

ICASO provides first-hand evidence on how these issuesact as barriers to condom access and use. Sex workersand entertainment workers interviewed provided importantinsights on these barriers that should inform advocacystrategies aimed at increasing access to condoms and

other HIV/STI services for sex workers.

Although ICASO grouped the barriers to condom accessinto four categories (see graphic below) the sex workersgroups in Cambodia decided to focus on three: socio-cultural, legal-policy, and financial-economic barriers (theydid not address structural barriers, such as condom supplyand distribution systems or the integration of sexual andreproductive health services with HIV services.)

Figure 1: Condom use, HIV prevalence, Brothel Based

Sex Workers, 1993-2007

1997 2003 2005 2007

20000

18000

16000

14000

12000

10000

8000

6000

4000

2000

0

Non Brothel Based

Brothel Based

5300

6000

10300

5000

9785

2977

13723

3430

From the figure above it is clear that sex workers in brothelsincreased condom use and reduced HIV prevalence.Between 1997 and 2007, as indicated above, there was asignificant shift in sex work from brothel-based sex workersto non brothel-based (freelance) sex work (see Figure 2)which may result on sex workers not using condoms andtherefore with result in increased HIV prevalence. This shifthas accelerated since local authorities and police beganimplementing the Suppression of Human Trafficking andSexual Exploitation law in early 2008.

Entertainment Workers in the sex industry,

1997-2007

Barriers to condom access and use by sex workers andentertainment workers are not only related to the policyand legal environment; they include personal beliefsand values, structural challenges (such as supply andprocurement), financial/economic issues (such as price),and socio-cultural norms. The project supported by

Socio-Cultural Barriers

norms of culture, religion,

and personal belief

Structural Barriers

infrastructure and human

resources

Legal and Policy Barriers

national legislation

and policies

Economic and

Financial Barriers

cost and investment

Figure 2: Number of Entertainment Workers in the Sex Industry,

1997-2007

Socio-cultural barriers

Social stigma and discrimination are the main barriersfor sex workers and entertainment workers in accessingHIV services. This hinders outreach efforts by NGOs andCBOs that cannot access their visible and hidden peers.

Although the percentage of sexual acts using a condomhas increased (while with a client), peer education andoutreach programs do not sufficiently empower sex workersto challenge their beliefs and values related to condomuse with all sexual partners, particularly sweethearts (thepartners of sex workers.) It is important that any advocacy

strategy takes into consideration this fact so that preventioninterventions can focus on changing social norms andencouraging positive perceptions of condom use.

Gender issues are not addressed in the AIDS response,which focuses on high-risk men (including uniformedservices personnel, construction workers, moto-taxidrivers and other high-mobility labour groups.) Reducingthe vulnerability of women and girls to HIV, and promotingpartner communication, family and social cohesion andpartner communication, were not very well-integrated


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10 Article 25 defines the offence of recruiting, inducing or training a person with a view to practice prostitution, which could apply to safe sex training and HIV prevention.

11 Overs, Cheryl. Caught between the Tiger and the Crocodile (2009). http://apnswdollhouse.files.wordpress.com/2009/03/caught-between-the-tiger-and-the-crocodile.pdf

12 Rasmei Kampuchea Khmer Daily Newspaper, 2007, National Assembly Discusses New Anti-Human Trafficking Bill, Year 15th, Issue 4466, Wednesday, 19 December2007, p. A2.

13 See, Prostitution gets government OK, by Phelim Kyne, Phnom Penh Post, Friday 10 November, 2000. E:\Trafficking law\report\summary report\ppp articles\The PhnoPenh Post - Prostitution gets Government okay.mht

14 Huckerby, Jane United States of America (USA), in Collateral Damage: The Impact of Anti-Trafficking Measures on Human Rights Around the World, Global AllianceAgainst Trafficking in Women, Bangkok 2007. pp 230-256, p 234.

15 In awarding funds, USAID focuses its program funding primarily on countries identified in the annual Department of State (DOS) report as needing to improve their efforts

combat TIP, while DOL uses the TIP report as one of several criteria when awarding funds. The DOS report has focused considerable diplomatic and political attention onthe issue of trafficking in persons. It rates countries in tiers (Tier 1, Tier 2, Tier 2 Watch List, or T ier 3) according to their efforts to combat trafficking and is used by DOS toencourage reform of laws and practices to more effectively combat trafficking.

16 Huckerby. Op.cit. note 4, p 235.

17 The upgrade to Tier 2 watch list resulted from Cambodia not fully complying with the Trafficking Victims Protection Acts minimum standards for the elimination of

trafficking but making significant efforts to do so.

into peer education programs addressing high-risk men.HIV services lack a family-centred approach that includespromotion of partner notification and spousal referral inSTI clinics, antenatal clinics and VCT programs.

Legal and Policy BarriersA new law aimed at eliminating the sexual exploitation andtrafficking of women and girls is now in force in Cambodia.

The law makes almost all aspects of buying and selling sexillegal. This potentially includes most forms of associationwith sex workers. A literal reading of the law results in theconclusion that any relationship with sex workers or sexwork is punishable.10 Additionally, by using the wordscommercial sex act together with sexual exploitation,the anti-trafficking law includes voluntary acts betweenconsenting adults. This research found that consentingadult sex workers make up the overwhelming majority ofsex workers. When arrests are made, there is usually no

attempt to determine who has been trafficked and who isa voluntary sex worker (except in Sihanoukville.) This leadssome people to equate sex work with human trafficking andcreates the misconception that all sex workers are criminals(or victims of exploitation). The law itself deals with both sexwork (considering it as sexual exploitation) and traffickingand does not clearly differentiate between them. Thus thelaw encourages the equation of sex work with trafficking.

Since early 2008, an accompanying anti-traffickingcampaign has generated a wave of brutal crackdownson both commercial sex venues and street-based sexworkers across the country. Sex workers and human rightsorganizations have published evidence of human rightsabuses including rape, violence and unlawful detentionby police, prison guards and NGO staff.11 Although thecrackdowns were at their most intense in early 2008, theycontinue and public officials now often openly say that theirintent is to cleanse cities of sex workers, which they variouslydescribe as a public order issue, an attack on the dignity ofCambodian women and culture, and a threat to tourism.

Thus anti-trafficking measures are also conflated with public

order and morality. The trafficking/sexual exploitation lawreflects this confusion, in the way that it penalizes solicitingin public an action that bears no identifiable connectionto trafficking or sexual exploitation. The sex workerorganization, Womens Network for Unity, also alleges that

closing down the sex industry displaces women, pushingthem into situations in which they are poorer and morevulnerable to trafficking, abuse and disease.

The Law on Suppression of Human Trafficking and SexualExploitation (the Anti-trafficking Law), supersedes the 1996Law on Suppression of Kidnapping and Trafficking/Sale of

Human Persons and Exploitation of Human Persons.12

In enacting the 1996 law, Cambodia led the region intaking legislative action against human trafficking. In theyear 2000, the Royal Government also considered highlyinnovative approaches to combating human trafficking,

which included the decriminalization and regulation ofcommercial sex work.13 However, from the late 1990sonwards, human trafficking received intense attentionfrom a number of international agencies and governments,many of whom opposed the right to work of sex workers.Under former President George W. Bush, the United Statesgovernment adopted strong anti-trafficking measures thatfocused on control of migration and strong opposition tothe concept of sex work as legitimate work.14

In 2001, the United States State Department began issuingannual Trafficking In Persons (TIP) reports, categorizingcountries into tiers.15 Because of the US governmentsability to impose sanctions, they are able to use the

TIP reporting process to influence policy developmentin many countries, despite the fact that in 2006, theUS Government Accountability Office questioned theaccuracy and transparency of the TIP process.16 In 2005,Cambodia was downgraded to Tier 3 with the threat ofsanctions, and then for two consecutive years Cambodiawas placed on the Tier 217 watch-list and urged to takeimmediate action to avoid again being dropped to Tier 3.


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hotels used by street-based sex workers are also lesslikely to provide condoms for fear of being designated asillegal brothels. It is also illegal to assist sex workers andconsenting adults that resist being placed in rehabilitationcenters, which could be used against outreach workers.

Research from the survey and key informant interviewsindicate that stigma and discrimination, lack ofrepresentation in the policy and program developmentprocess, lack of coordination between central and locallevels, lack of involvement in the 100% CUP and lack ofsupport from partner organizations are key factors thatare hindering sex workers right to health, and will in turnimpede achieving universal access.

Recognition of the right to sex work and empowermentof sex workers are the most important requirements forpreventing abuses against sex workers. Sex workers

are vulnerable to violence and exploitation. However, it isimportant to recognize that not all commercial relationshipssurrounding sex work are or need to be exploitative orviolent. Empowerment of sex workers helps to combatreal exploitation and violence. It also helps to guaranteethe very real needs to support their families. Recognizingthe rights of sex workers and empowering them to protectthose rights is the best way to reduce their vulnerability.

There is currently no strategy to ensure the expansion of the100% CUP beyond brothel-based sex workers, nor is therean opportunity to incorporate the voices of sex workers andthe various organizations that represent them (such as theCambodian Prostitutes Union or Womens Health Network)within the existing national AIDS response structure.

The Condom Use Coordination Committee (CUCC),which is chaired by the Provincial Governor, has difficultyimplementing two controversial and contradictoryobligations: the 100% CUP and the Suppression ofHuman Trafficking and Sexual Exploitation law, which aimsat suppressing human trafficking and sexual exploitation.

The 100% CUP has been criticized because it has notinvolved sex workers in its design and implementation,

its lack of human rights protections for sex workers and,more importantly, because of the role of police officers in itsimplementation. The Anti-Trafficking Law is controversial,among other reasons, because it equates consensual adultsex work with trafficking and sexual exploitation. Becausepolice monitor the 100% CUP and enforce the Anti-

Trafficking Law, this has resulted in documented human

25 See, David Lowe, Perceptions of the Cambodian 100% Condom Use Program: Documenting the experience of sex workers, Report to the Policy Project, March 2003.

26 Rights-Based Sex Worker Empowerment Guidelines: An Alternative HIV/AIDs Intervention Approach to the 100% Condom Use Programme, CASAM, July 2008. p 5.

rights abuses, including the persecution, imprisonment,beating and rape of sex workers.

The law and program are also contradictory in thatenforcing one (the anti-trafficking law) requires closure

of the brothels that are the focus of the 100% CUP.The 100% CUP reflects the governments commitmentto reducing HIV transmission and its commitment toprotect sex workers against HIV, but in many casesit fails to address human rights violations faced by sexworkers. The research indicates there are many positiveaspects of the program, while documenting some of theoutstanding challenges. For example, the survey foundthat the majority of female sex workers and entertainmentworkers said that staff of STI and VCT centers are veryfriendly. The experience of male and transgender sexworkers, however, was less positive. This indicates astrong improvement since 2003, when many sex workers

reported poor treatment at clinics.25 However, it is difficultto determine if this change in attitude is a result of the100%CUP or if it is the result of raising awareness amonghealth care providers.

The Centre for Advocacy on Stigma and Marginalisation(CASAM) published a set of guidelines for sex workerempowerment and alternatives to the 100% CUP. Theguidelines are based on research into 100% CUPs inseveral countries in the Asian region, and recommend thatto be effective, condom use programs for sex workersmust be based on three principles:26

Sex worker involvement and leadership in all aspects ofi.the program design and implementation.

Encourage a sense of community among sex workersii.in order to facilitate collaborative action.

Eliminate stigma and discrimination against sex workers.iii.

The 100% CUP and laws and policies, which have animpact on its effectiveness (including the Anti-TraffickingLaw and laws governing drug use and control) need tobe revised to ensure that all programs support access

to HIV services and prevention interventions, respecthuman rights and combat trafficking. All stakeholdersshould then be educated regarding these laws, especiallylocal authorities and uniformed services. This will requireestablishing a National Working Group on EntertainmentWorkers to help revise current policies and programs,especially in clarifying the role and responsibilities ofdifferent stakeholders, including the police.


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JAMAICA

CASE STUDY CONDOM ADVOCACY: CONSENSUS BUILDING ON

CONDOM ACCESS BARRIERS FACED BY PLHIV JN+

BACKGROUND

Jamaicas prevention program revolves around condoms as the main toolavailable to prevent the spread of HIV. Although there are various strategiesbeing undertaken by the National HIV/STI Program and NGOs to halt thespread of the virus, condoms are the only prevention tool that is part of thecountrys National Strategic Plan 2007 2012.

Jamaica is the third largest Caribbean island, with a population of 2.6 million,and spans 11,424 square kilometres. An estimated 26,000 or 1.6 per cent ofthe adult population are living with HIV.28

Between 1982 and the end of December 2007, 12,520 persons living with HIVwere reported in Jamaica and of this number, 6,993 have subsequently died.

Seventy three percent of all AIDS cases reported in 2007, are in the 20-49 yearold age group, while 87% of all reported AIDS cases are between 20 and 60years old.29 There are reported to be approximately 5,527 persons who arecurrently living with AIDS.

Both male and female condoms are available in Jamaica. However, while themale condom is widely available in most pharmacies, shops and in clinics,female condoms are available only in select pharmacies and non governmentalagencies involved in prevention work. In 2007, just over 5.3 million condomswere sold in Jamaica and another 6.8 million were distributed by the governmentthrough clinics and other public health facilities.

A single female condom now costs about US$1.59. Most people are still notable to afford it. The male condom on the other hand is generally sold in packsof three for about US $0.70.

A condom distribution survey done in Jamaica in 2008, found that in termsof availability, coverage and costs, all Jamaicans could access condoms.

The study noted that condoms were highly visible in outlets, that they wereavailable in all parishes and that the cost of 100 male condoms was less thanthe average monthly minimum wage, therefore, they were affordable.

While, there is no doubt about the availability of condoms in Jamaica, what thestudy failed to highlight are the social, cultural, legal, structural and programmaticfactors that may reduce access to condoms, particularly for people living

with HIV (PLHIV). This case study highlights some of the challenges faced bypeople living with HIV in accessing condoms and includes actions suggestedby support group leaders to address those challenges. The final result was thedevelopment of an advocacy plan aimed at increasing condom accessibilityamong people living with HIV.

28 UNAIDS 2008 Report on the global AIDS epidemic

29 Jamaica HIV/AIDS Update, 2007, Monitoring and Evaluation Unit, Ministry of Health and Environment


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METHODOLOGY

The information in this case study represents the viewsof approximately 16 PLHIV support group leaders fromfour regions in Jamaica Western Region, Southernregion, South East Region and North East Region whomet in 2008.

Group leaders met for six hours, during which theydiscussed their own experiences and that of othermembers of their support groups as it relates to condomuse and accessibility. Then the group separated intothe four regions, within which there was discussion onbarriers to condom access for members in each region.

The regional groups then presented the results of theirdiscussion to the entire group. The group then spenttime on interactive learning on advocacy and developingadvocacy plans, followed by group work where they wereasked to choose one priority area of concern around whichthey would like to develop an advocacy plan. Following

full group discussion, two priority areas were chosen andan advocacy team was chosen with the responsibility ofdrafting and circulating an advocacy plan that addressedthese two priorities. That advocacy plan is included as anannex to this case study.

Additional time was needed to get feedback from a widercross-section of PLHIV, especially those in rural Jamaicaand individuals beyond JN+ leadership in each region.

THE ROLE OF JN+

The Jamaican Network of Seropositives (JN+) is the onlynon governmental organization comprising PLHIV inJamaica. The Network has a membership of 500 PLHIVfrom all 14 parishes in Jamaica. More than 75% of themembership are low income earners and a significantnumber is unemployed. Jamaica has embarked on anaggressive campaign to promote prevention among PLHIVand JN+ is expected to play a major role. However, PLHIVare unable to participate fully in prevention strategies,which employ condoms as the main tool due to variousbarriers which lessen their ability to access condoms.

BARRIERS TO CONDOM ACCESS


Clinics/treatment sites

A significant number of persons living with HIV in Jamai-ca and who are represented by the Jamaican Network

of Seropositives are low income earners or unemployed.They depend to a large extent on the public healthsystem or non governmental organizations to providecondoms necessary to prevent HIV transmission or re-in-fection. Of the 16 support group members present at the

meeting, 10 persons stated that they accessed condomsat clinics or treatment sites, with the remainder access-ing them from NGOs. Healthcare workers at these clinicsor treatment sites pose a major difficulty in terms of ac-cess. PLHIV are denied condoms consistently and as aresult those who want to use condoms end up practicingunsafe sexual behaviours, putting both themselves andtheir partners at risk of infection or re-infection.

When we ask for condoms at the health centre we are

told no. If the condoms are available, it should not be so

difficult to give them to PLHIV, because many of us cannot

afford to buy them at the pharmacies... Our perception is

that health workers feel we should not be having sex andso we should not get condoms. female participant

Healthcare workers, who often feel PLHIV should not behaving sex, sometimes refuse to give them condoms.Other cultural norms also make it very difficult for PLHIVto access and use condoms effectively.

Health care workers have issues with [same sex] sexual

orientation, hence condoms are not readily distributed to

PLHIV who are MSM. The reality is that some MSM do

not go to healthcare workers to access condoms because

they feel uncomfortable with the health provider. Condom

site needs to be user friendly for all PLHIV including MSM.

male participant

Limited access to condoms by PLHIV from healthcare

workers is real. They preach prevention everyday and

still we can only get four strips for 500 people. JN+ is

the authentic voice of PLHIV and one of the things we

keep hearing about is positive prevention, but the only

time we get condoms is during World AIDS Week. It

should not be only the week leading up to World AIDS

Day that we get condoms. When we request condoms

we should get it because the Ministry is saying we should

prevent the spread of HIV and we are not getting that. female participant

It is obvious from the discussion that there is concern andfrustration on the part of the PLHIV regarding their abilityto access condoms from the Ministry of Health. PLHIVfeel that they have the right to the commodity and that thisbasic right is being violated. Apart from the limited numberof condoms available, there are also cultural issues, whichmake rural folk hostile to the use of condoms.


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There is some ignorance in the rural areas because of how they have been

socialized... Personally I grew up with my grandparents and they never

discussed with me anything about sex. They would not talk about condoms

skin to skin sex is the norm and still continues. In urban areas there is more

education. female participant

You have these areas where men are not supposed to use condoms, man

a man and his friend is not supposed to see him using a condom. If a man

is having sex, he is not to use a condom It is all about image. maleparticipant

A lot of country folk believe in the saying that man must multiply. Condoms

then are a deterrent to them when their manhood is defined by the number

of children they have. male participant

Gender and HIV

Women are bearing the brunt of the HIV pandemic in Jamaica: adolescentgirls 19 24 years old are twice as likely to be infected than boys of the

same age. In addition to womens increased susceptibility to infection dueto biological differences, socio-cultural and economic factors appear to beat the heart of the persistent risk among young females, thus contributing totheir vulnerability.

A Participatory Ethnographic Evaluation and Research (PEER) Study carriedout among young women on sexual relationships in Kingston, Jamaica,found that having multiple sexual partners has become the norm and was arational response to economic realities.30

Traditional gender roles can also determine mens use of condoms or thenumber of partners they have. It is culturally accepted in Jamaica that menshould have more than one partner, should have many children with severalwomen and be heterosexual. Women are expected to conform to this culture;many women are unable to make decisions regarding whether, when or howto have sex. If they insist on condom use, they are seen to be loose or to beinvolved in sex work. This has a significant impact on prevention efforts.

In addition, widespread homophobia affects condom distribution in prisonsand hinders community-based interventions that target interventions amongMSM. There is also growing evidence that violence in relationships bothheterosexual and homosexual - is a factor that contributes to unsafe sexualbehaviours.

Males perception of women who use condom is that they are loose. The

length of the relationship can be a deterrent to condom use. It is not easyfor women to introduce condoms in a long term relationship. For example

you are in a relationship for a very long time and then suddenly you want

to introduce condoms immediately you are seen as loose. It is easier to

introduce it if you are in a shorter relationship. male participant

If you introduce condom into the relationship, it is seen as if you dont

trust your partner. Sometimes this leads to violence or one partner leaving.

- female participant

30 Options Consultancy and Hope Enterprise, She sweet up the Boopsy and nuh get nuh wine: Young women and sexual relationships in Kingston, Jamaica, 2007


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Many women do not tell their partners that they are

infected for fear that they will leave them. The same applies

to the males. So they will have sex with each other without

condoms and neither of them disclose.- male participant

Attitude to condom use among PLHIVA mini survey of attitudes towards condoms among thesupport group leaders was instructive and reflected theattitude of the wider PLHIV community.

Most liked condoms because they prevent STIs, andprevent HIV transmission and re-infection. However, mostalso indicated they did not like condoms because of thesmell, the fact that they reduce pleasure, and were difficultto put on or (in the case of female condoms) were noisy.

In order to enhance current programs around womensempowerment, regional leaders suggested conducting a

program that focuses on men living with HIV. The programwould deal with sexual and reproductive health, values andattitudes towards sex and sexuality, violence and other lifeskills that would reduce unprotected sex. Leaders alsosuggested that advocacy efforts should focus on teenagersand young, sexually active adults, a population that, due toa variety of socio-cultural factors, are often not supported inaccessing condoms. Advocacy targets should include keygovernment ministries (Ministry of Health and Environmentand Ministry of Industry and Commerce) as well as shopsthat sell condom. Strategies should include:

Empowering women through workshops, media andsupport groups.

Billboards focusing on PLHIV.

Providing teenagers with opportunities to participate indecision-making opportunities that affect their lives.

Training youth in advocacy.

Developing pamphlets and other education materials,as well as developing communication strategies andmessages with print and broadcast media.

School-based interventions (e.g. with guidance counselors.)

4.2 LEGAL AND POLICY BARRIERS

Perhaps one of the major challenges impacting on HIVprevention activities in Jamaica are legislative and policyissues that put PLHIV at risk of re-infection. Laws and

policies in Jamaica continue to be out of sync withthe national response to HIV. Several policies andguidelines have been passed and include the NationalPolicy on HIV and roll out of the Health and Family LifeEducation program.

Infected minors are not able to get tested. When I

was doing voluntary counseling and testing (VCT) at a

clinic, a youth in uniform came there asking for condoms

and everybody was afraid to give him the condoms. female participant

Due to our legal situation, our managers do not have

access to condoms. male participant

There is a policy in place to provide persons under 16 withcontraceptives: the Reproductive Health Policy (CircularNo. 182/26 Reproductive Health Policy Guidelines for

Health Professionals). However, under these guidelines,health care providers must report cases in which theysuspect children under 16 are having sex or if they have asexually transmitted infection, as it is not legal for personsunder 16 to consent to contraceptive services. This putspressure on health care providers, who is legally obliged toreport cases brought before them. Criminal charges underthe Child Care and Protection Act could also be laid againstparents and health care providers who provide condoms.

The Offenses Against the Person Act, known as thebuggery law, criminalizes all anal intercourse withpenalties of up to ten years hard labour. This law has beencited by correctional officials to support policies that prohibitthe distribution of condoms in prisons; correctional facilitiesare therefore unable to provide condoms to prisoners. Thelaw also supports the common practice of health careworkers who refuse to issue condoms to men who havesex with men.

A key advocacy goal identified by group leaders is toincrease access to condoms within the PLHIV community,with full access by 2010. Health care workers would bethe target of advocacy, with activities including:

Surveying health care workers to explore their attitudes and behaviours as it relates to giving condoms to thePLHIV community.

Sensitize health workers on the importance of condomsto positive prevention (including men who have sexwith men.)

Sensitize PLHIV community on the importance ofcondom to prevent re-infection.


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Unavailability of condoms in rural communities

The 2008 Condom Audit and Market size Reportnoted that condom availability within individual parishesfluctuated, with seven parishes showing an increaseddistribution while six declined. St. James recorded the

sharpest decline in condom distribution despite havingthe highest HIV prevalence rate in the country. Otherparishes include Trelawny, Hanover, St. Mary, St. Catherineand Manchester.

Key barriers in rural communities include the location andnumber of treatment sites. For example, treatment sitesin the Southern region are located in the town centre ofthe parishes. It means that people living with HIV haveto travel long distances over difficult terrain to get to thesites. Transportation to treatment sites where most PLHIVreceive condoms and other contraceptive tools is also aproblem, as transportation in many rural communities is

rather weak.

JN+ group leaders suggested that increasing the numberof treatment sites and diversifying the number of venues(e.g. sports clubs, community centers, etc.) would bean important condom access advocacy goal. Advocacyactivities could include:

Sending a proposal to the National AIDS Programoutlining the need for more treatment sites and morecondom distribution sites in rural parishes.

Establishing stakeholders meetings with leaders ofnetworks, adherence counselors, contact investigatorsand social workers regarding condom access.

Requesting that treatment site employs a clerk that logscondom disbursement.

4.4 FINANCIAL AND ECONOMIC BARRIERS

Cost of condoms

As noted earlier, persons who are affected and infectedwith HIV and other STIs are mostly from poor backgrounds.

Those who have jobs earn very low salaries and thereforepurchasing condoms is very low on their list of properties.

A strip of three condoms sold at private pharmacies cancost around US$0.70.

The lack of income is a barrier to the community (of

persons living with HIV). They find it difficult to spend

money on buying condoms. The condom price is too high.

It costs more than essential items such as flour and oil and

if the person had to choose between buying a condom

and food, he would choose the latter. male participant

In the southern region we had a workshop and a gentleman

got up to say he washed the condoms because of lack of

access to condoms. He washed it and put it on the line

to dry and then he reused them. When we questioned him, he said he had no problems using the condoms,

but he cant get them where he lives and so as far as he

was concerned he was practicing safer sex as he washes

them after using. We had to explain to him that this was

not so and that he was damaging the condoms and not

offering any protection. female participant

To address cost as a barrier to condom access, particularlyin ensuring merchants do not charge the 16.5% GCT onthese items, including advocacy with the Ministry of Healthand Environment and Ministry of Finance and Planning.

Activities could include:

Flyers and stickers in school which identify wherecondoms can be accessed (either at no charge or for anominal price.)

Training persons to lobby the government to advisemerchants that condoms should not be subject to the16.5% GCT.

Workplace sensitization.

TV and radio or billboard ads that reach rural communities.


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CONCLUSION AND RECOMMENDATIONS

Having identified the major barriers facing the PLHIV community, the nextchallenge facing the group was arriving at possible solutions to some of theissues raised. A session focusing on advocacy planning was done to ensurethe participants had a good understanding of the process.

The JN+ condom advocacy meeting highlighted the need for increased condomaccess among the PLHIV community. Citing high levels of unemployment andan inability to meet the current costs of condoms, the community wants theNational HIV/STI Program to increase the provision of condoms to its members.Linked to this, the community would like to see a change in attitude amonghealth care workers as it relates to condom distribution to HIV-positive MSMand PLHIV in general. To address the many cultural and structural barriers tocondom access, JN+ would like to develop an educational campaign amongits membership on the importance and benefits of condom use to prevent HIVand re-infection among its members.

Condom barriers focused around three issues:

Empowerment: users empowered to use condom despite sociocultural barriers.

Availability: limited distribution sites, high cost (including taxation of condoms),limited variety available in rural, reluctance of HCPs to distribute condoms.

Education: how to use condoms, which condoms to use.

JN+ leaders determined that empowerment issues were going to beaddressed in programming activities scheduled for the following year. Withregard to availability, it was suggested that JN+ should lobby for condoms tobe made available to members free of charge, or at a reduced cost, and toadvocate for changes in the attitudes and behaviour of health care providerswith regard to providing condoms to people living with HIV. The participantsalso decided that further research was necessary to determine assess thetaxation status of condoms and the possible merits of advocacy on this issue.One suggestion for addressing availability was to request that the National

AIDS Program assign condom distribution and monitoring duties to the newlycreated positions of Support Group Coordinators. This could quickly bring freecondoms to members in all parishes. These Coordinators were also identifiedas the likely candidates to help ensure that support groups include routineeducation on condom use.

Based on these discussions, the Advocacy Officer at JN+ was charged withresearching the tax codes applicable to condoms and then preparing a draftadvocacy plan that would incorporate the comments received. This draft plan

would be circulated to the Advocacy Team for review and finalization at alater date.31

31 The draft plan can be found at the end of the publication as annex 1


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INDIA

CASE STUDY CONDOM ADVOCACY:

DEVELOPING AN EMPOWERMENT PRACTICE

TO SUPPORT CONDOM ADVOCACY SANGRAM

BACKGROUND

Sangram was established in 1992 in Sangli, a District ofWestern Maharashtra, at a time when the AIDS epidemicin India was largely focused on HIV transmission via sexwork. Typical approaches to HIV prevention at the timetreated sex workers as vectors of disease with little orno capacity to change the circumstances that increasedtheir vulnerability to HIV. They were rarely involved in thedesign and implementation of HIV interventions focused ontheir community.

Within this context, Sangram established a fundamentallydifferent approach to responding to the spread of HIV.First, Sangram viewed the women as agents of change.

As Chanda, a sex worker, explains, When other peopledo advocacy, it is to stop sex workers. When sex workersstarted to do advocacy, we said that we couldnt stop sexwork, but we could stop HIV from spreading.

Secondly, discussions with women about HIV andcondoms did not emphasize protecting others, butrather protecting themselves from infection. Sangramsapproach made economic sense to the women: if theyprotected themselves from HIV, they would not need tospend money on their health or take time off work.

Sangram began with sixteen peer educators in a red lightarea of Sangli. The peer education program has sinceexpanded to cover six districts in Maharashtra and theborder areas of North Karnataka. There are now more than120 peer educators distributing over 350,000 condomseach month to 5,000 women.

In 1996, the women in the peer education program decidedto establish an independent collective called Veshya

AIDS Mukabala Parishad (VAMP). VAMP manages the peer

interventions in the sex worker community, with Sangramproviding administrative support and collaborationas required.

In 2000, a small group of men from Sangli approachedSangram, asking for a program focused on men who have

sex with men (MSM); they established Muskan, a peereducator group for kothis and jogappas.32

Sangram is the parent organization, with VAMP and Muskanfunctioning as branch organizations. They are independent,

but get administrative support from Sangram.

CASE STUDY METHODOLOGY

This case study provides insights into overcoming barriersto condom access and use in Sangram, and documents theways in which Sangram is advocating with both governmentand the community to address these barriers.

The ICASO Advocacy Brief identifies four major barriers tocondom usage:33

Socio cultural

Legal and policy

Structural

Economic and financial

Focus group discussions and individual interviews wereheld for members of VAMP (including gharwalis),34 Muskanand the staff of Sangram. A detailed brief of the researchand the objective of the case study were provided toparticipants, with interviews conducted primarily in Hindi.

The interviews were recorded.

Sangrams condom advocacy work since its inceptionwas reviewed, including annual reports, other relevantreports (including media stories), photographs andcorrespondence, and focusing on public demonstrations by

VAMP and Sangram as part of their advocacy program.

THE SANGRAM APPROACH

In many HIV prevention programs, condoms aredistributed with little or no community involvement inthe development of such programs. However, Sangramemphasized building an identity as a community, andthis required a slow and sometimes painstaking political

32 Kothi is a self-identifying label for males who may feminize their behaviors. Jogappas is a term used in relation to temple prostitution linked to the Hindu religion.

33 http://www.icaso.org/publications/condom_access2007_eng.pdf).

34 Gharwalis are brothel owners who also engage in sex work.


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mobilization around sex work and health. Women who traditionally competedwith each other for clients and resources were enabled to explore commonexperiences of discrimination and human rights violations. Durga, one of thewomen, explains this process:

There was a lot of jealousy between the women. Everyone was afraid of HIVbecause we knew that there was no cure. People started using nirod (condom)

out of fear. It was important that as a group we stopped the infighting so that

the others [could] see that we are united and we can persuade them.

This approach resulted in a growing understanding of the womens collectiveinterest in using condoms consistently: if every woman insists on condom use,it will help all women stay healthy and continue to work. This has enabled sexworkers to be the strongest and best advocates of condom use. The peereducation approach employed by Sangram breaks down the divide betweeneducators and educated and this in turn fosters a common identity withinthe sex worker community.

Sex workers are offered training to upgrade their skills, including how to prevent,identify and treat sexually transmitted infections (STIs) in addition to HIV. Thewomen are further trained in communication skills. As Sapna pointed out:

It is difficult to talk to truck drivers. We had training on how to speak to

these people.

Human rights education has also been crucial, including training on publicservice accountability and sex worker rights vis--vis the police, inheritanceand property.

The strategy of the organization is to develop an understanding among itsmembers in the way that vulnerability to HIV is linked to gender, sexuality andclass. The organization links HIV to issues of violence and other human rightsviolations and helps the women deal with violence from the police, clientsand partners. VAMP members now have an extremely cordial and mutuallybeneficial relationship with the police and public, although this has been theresult of much work and education, given how police and the general publicoften view sex work. Chanda spoke about the change in this way:

We used to go to a cinema hall to speak to the sex workers there. The theatre

owner used to throw buckets of water on us. We spoke to them. We were able

to negotiate with them and came to a compromise with the owner. The police

took us from the theatre. We told them they had no jurisdiction and so were

able to negotiate with the police too. Now we have a good relationship with the

police. When a kothi was murdered, we were able to help them.

From the beginning, founder activist Meena Seshu, demonstrated that sexworkers are first and foremost people. She never made us feel that we weredifferent. She ate from the same plate as us, says Shabana.


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Secondly, Sangrams approach is to view sex workers asagents of change, both of the health landscape and theirown lives, rather than as victims. As Durga said:

It made a difference that Meena sat with us and explained

things to us. Meena used to listen to all our problems. Notjust about sexual health. In hospitals they dont give HIV

positive people treatment. She told us that this civil hospital

is ours. In this way we started believing in ourselves.

Sangram staff members who attend VAMP meetings takea passive role in order to build leadership amongst thewomen. This further encourages solutions to be foundwithin the community.

CONDOM ADVOCACY

Sangram believes that for any condom advocacy strategyto be successful, it needs to be multi-pronged and addressa diverse range of stakeholders.

The definition of advocacy used by Sangram is also broad,and includes training on HIV and condom use, mediatrainings, one on one talks on health and condom use,meetings, public rallies and protests. These are all toolsused to provide information as well as to change policy.

To simplify, we present the two dominant strands of

Sangrams advocacy strategy. The first distinct strand is

advocacy with non-government actors. Next, we present

the advocacy with the State, be it health authorities, the

local government (the Panchayat Raj Institutions), the

police, or legislators.

The four areas (socio-cultural, legal and policy, structuraland economic/financial) which present barriers to condomuse were echoed in discussions among VAMP, Muskanand Sangram members.


Gender equality

One of the central tenets of Sangrams work is theempowerment of sex workers, which includes not onlydeveloping their knowledge of human rights, but alsoencouraging financial independence and decision-making

for women. Kamala Bai says:

We have bank accounts in our names and our nominees

are our children. We have no accounts either in the partners

name or in a joint account. We have cars, property and

land. All this is from our earnings as sex workers. We

encourage other sex workers to open accounts, invest,

and buy land, TV, fridge and things like that. We are

sex workers, earning our living; we are under no ones

control. If the malik35 wants to buy a TV or a fridge or a car

he can do so. We can do the same. We make our

[own] decisions.

Religion and morality.Both Christian and Islamic clergy in India forbid men fromusing condoms, so sex workers must convince theirclients to use condoms.

Some Muslim clients say that it [the condom] is dirty and

dont want to touch it. They look at us badly if we ask them

to use it. We tell them to look at the number of people it

has saved and [ask] how can it be dirty? Which is dirtier

people dying or the condom? I tell them to go and have

sex with someone else. Then [a client] came back to me.

Now he uses condoms and takes some to give his friends

in the cement factory. They too fear AIDS.

In India, and particularly in small towns and villages, sexand sexuality is not spoken about. There are moral codesattached to sexual activity that result in double standardswhen it comes to men and women. Also, because ofsocial mores that dictate that sex should be free andoccur within the context of love and an intimaterelationship, sex for money is deemed offensive. KamalaBai from VAMP explained:

They are operating on double standards. Men can [have

sex] with many women; why cant we? Why do they

say we are wrong? They think sex should be in love.Shouldnt be for money. If we have love for everyone,

where will the money come from? There is sex between

husband and wife. Why does [sex] become dirty because

there is money?

35 A malik is a long term lover/partner of a sex worker.


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Given the pervasive perceptions about their immorality,the members of VAMP have had to devise strategies toalter their self-image. This has led the women to see sexwork not as wrong or sinful, but as a business enterprise.

As Durga tells us:

The stress is on business. We are businesswomen. Since

I came to VAMP, I believe I am good. I am earning and

that is good. I like doing sex work, I decided. Who are they

to decide?

Challenging social norms and dominant notions of moralitygoes hand in hand with creating a better environment forcondom use. Not only does it bring sexuality out in theopen, but also it promotes a norm of high self-esteemamong the women.

Personal beliefs and pleasure

Clients say that they dont get pleasure if they usecondoms. I explain the need to save our lives and the lives

of our children. - Chanda

The emphasis, as highlighted by Chanda, is on negotiationwith the client and convincing him to use condoms.

The members of Muskan (the kothi group) use differentstrategies to convince their clients to use condoms.

When someone comes who doesnt want to use a

condom, I tell them you may not want to save your life,

but I want to save mine. Sometimes I tell them I have HIV

and they will get it from me.

Members of both groups have devised innovative waysof convincing their clients to use condoms. Sometimesthey use gruesome images of STDs to show the clients.Sometimes they anticipate the reasons for not usingcondoms and challenge it. They tell the client, Think ofyour wife and kids. I dont know if I have AIDS or not.

Another example of convincing clients to use condomsis by saying that if you use a condom, the rest of yourlife can be enjoyed. If your two minutes of pleasure arereduced by five percent, what is the big deal?

Predictably, it is easier to negotiate with clients than with themalik. Members of both VAMP and Muskan have this to say:

There are some difficulties to get maliks to use condoms.

It took us a long time to get the message across. It took

almost years to get them to agree.

4.2 LEGAL AND POLICY BARRIERS

Marginalization, Discrimination and Criminalization

of Vulnerable Populations

Even though the public health system is free, it is seldomused, partly because public health services are inadequatein semi-rural areas and partly because sex workers face

discrimination from medical staff, which is worse if they areHIV positive. As a result, women who are positive turn to thepublic health system only at the last stages of their illness.

Sangram initiated contact with the Directorate of HealthServices, which led to the introduction of the Red CardSystem. This is an identity card that gives free and promptservices to sex workers. Unfortunately this had the adverseeffect of immediately identifying the women as sex workersand they faced further discrimination. Sangram overcamethis by appointing a person to sit at the Civil Hospital duringworking hours. This person identified good doctors (whodid not have negative attitudes toward patients) and their

outpatient hours. This information was then provided tothe peer educators who refered women to these doctors.

The political understanding that the public health systemhas to be accountable to all the people was imparted intraining sessions to the women.

Another problem faced by sex workers was that the workinghours of the outpatient department often did not suit them.

They worked nights and often slept late. Usually the outpatientdepartment was open in the morning. The members of VAMPlobbied with the hospital administration, resulting in newoutpatient hours to accommodate the unorthodox workinghours of the women. This advocacy effort resulted in a policychange which not only supported VAMP members, but alsohad a wider impact of providing other vulnerable and at riskpopulations with increased access to the clinic.

In 2006, the Government of India proposed to amend theImmoral Trafficking Prevention Act (ITPA). Immediately,

VAMP members and Sangram wrote a letter to thechairman of the Standing Committee on Human ResourceDevelopment, pointing out the possible adverse impactof the proposed amendments, which proposed a newdefinition of sex work, would punish people living off theearnings of the sex worker, and penalise clients of sex

workers. In addition, Sangram and VAMP also wrote tothe Parliament Review Committee and organized protestrallies, meetings and demonstrations at local, state andnational levels to protest against the amendment.


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36 On July 2, 2009, the Delhi High Court decriminalized homosexuality by striking down Section 377 of the Indian Penal Code. The judgement, however, will not bebinding outside Delhi.

37 A coalition of organizations of sex workers and sexual minorities.

38 A group of litigation lawyers.

39 Referring to common, ordinary men

40 Sangli district has a population of 23,000,00 in 713 villages.

41 The pre-school programme of the government.

42 The Primary Health Centres in rural areas.

Section 377 of the Indian Penal Code36 criminalizes any carnal act against theorder of nature, effectively making MSM criminals and placing interventionswith these men in legal jeopardy. Muskan participated in a protest marchagainst Section 377 in Delhi. The march was organized jointly by RainbowPlanet37 and Lawyers Collective38.

A member of Muskan articulated the problem caused by the law: Because ofsection 377, many pant and shirt men39dont come out. So it takes time to speakto them about HIV.


Availability and quality of sexuality education

In India sex education in schools is extremely controversial and a low priority forthe government. As a result, there are no standards for sex education, nor is itcompulsory. To address this gap, Sangram has developed education strategies

for a broad range of age groups and has delivered many HIV awareness andsafer sex programs with the district of Sangli.40 While these programs may nothave a direct impact on condom usage, it certainly creates an environment thatpromotes the use of condoms.

As Durga of Karad says:

Building a dam at only one site will not stop a massive flood. If we really want

to stem the tide, we have to build dams at different bends of the river.

Sangram has delivered school programs since 1997. Initially there was someresistance from the principals, teachers and parents. However, after lobbyingand advocating for sex education, Sangram was allowed into schools to deliverits program.

Sangram has done HIV/AIDS awareness campaigns in the villages. It has trainedanganwadi41 teachers and private hospital staff in villages in the district.

As Shashikant Mane of Sangram says:

In every PHC42 we have done a district campaign. In six months we have

trained 80 PHC staff members about AIDS.


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Members of VAMP use traditional ways to get their messagesthrough to mass audiences, using both secular and non-secular sites for their performances. Durga explains:

We do a lot of puppet shows and plays. We do them in our

areas, market places and other public places. Everybody sees it, not just sex workers... During the Ganapati43

festival, we go and perform where the idol is kept very

public places. We also go to fairs and see if can reach out

to sex workers there. The general public come and ask us

questions and we give them advice.

Sangram believes that to overcome socio-culturalbarriers to condom use, society at large must be thetarget for advocacy. This approach has proven effectivein raising HIV awareness and condom use. Sangram hascreated a network of community insiders (the womenin prostitution, their children, MSM and jogappas), and

developed their capacities. Programmatic decisions aremade in a decentralized manner, depending on the needsof the community. Because sex workers understand theircommunity, they are able to design strategies that aresocio-culturally appropriate. This has contributed to thesuccess of their condom advocacy.

Supply and distribution systems for condoms

Beginning in 1993, Sangram raised concerns withlocal politicians about the poor quality of condomsbeing supplied by the Public Health Department of theMaharashtra Government. The problems included holes inthe condoms, which made them useless, while some hadno lubricant. The United Nations Development Programtested these condoms in Australia and issued a report,which identified the condoms as being sub-standard.Sangram enclosed a copy of this report and a poor qualitycondom, and lobbied local politicians to take up the issuewith the Public Health Department. The lobbying focusedon recommending that each batch of condoms be checkedand not, as was the practice, randomly sampled. As aresult, the quality of the condoms improved and their useincreased. This was a major success for the organization.

Integration of Sexual and Reproductive Health and

HIV/AIDS Services

The Zilla Parishad distributes condoms to Primary HealthCentres (PHC). Here however, condoms are advocated morefor contraceptive use than for safer sex. As Sapana explained:

In the PHC they dont talk much about condoms and HIV.

They speak more about family planning. If someone wants

sterilization, they... dont push condoms at all. In the PHCs

there is no talk about condoms because couples go together

and they think this will provoke marital disharmony.

At Sangram, we believe that reproductive and sexual

health care should be integrated. As a result of work with

PHCs, each centre now has a Sangram staff member to

provide information about HIV, AIDS and condom use. In

addition, staff members ensure that HIV-positive patients

get necessary care and treatment. At Sangram, we believe

that the public health system should indeed belong tothe public and be accountable to the public; having staff

members in the PHCs has increased the accountability of

the system.

These kinds of interventions are not always met withsupport. Initially the doctors at PHCs were opposed to aSangram staff member being posted in the clinic. Sangramsought and obtained support from the President of theGram Panchayat44 for the posting of a local staff person inPHCs.45This has ensured the sustainability of the program.

Consistent with this approach, a Sangram social workeris based at the Voluntary Counselling and Testing Centreat the Sangli Civil Hospital. The advantages of this parallelsystem are succinctly pointed out by Kamala Bai:

Our counseling is different. We do home visits. We are

more concerned holistically. Their [the PHC) approach is

very moralistic. The government officers say dont go to

sex workers. Stop doing sex work. We say do sex work

and use condoms.

43 This festival is very public in Maharashtra, lasting for 10 days. There are huge idols and thousands of people congregate every day.

44 Gram Panchayat are local governments at the village or small town level in India.

45 This is the village level body of the Panchayat Raj Institutions.

46 The district level body of the Panchayat Raj Institutions (local government).


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4.4 FINANCIAL AND ECONOMIC BARRIERS

In 2002, the Zilla Parishad46 in Sangli District stopped distributing free condomsto the sex workers, stating that the condoms were only for contraceptive use.

Three hundred and fifty sex workers rallied in protest against this decision.The women said that it was their right to get free condoms and demandeda supply. The next morning a hundred thousand condoms were delivered to

VAMPs office.

In 2006, condom supplies again were reduced due to government policy.Sangram lobbied with the Maharashtra State AIDS Control Society (MSACS)to prioritize the distribution of free condoms to female sex workers andorganizations working with them.

In both of these cases, VAMP used a two-pronged approach to the right tohealth, insisting that condoms should be included in Schedule R.47

To quote Amina: Each box of condoms costs Rs 45. If we have to pay for this,women will stop buying and using condoms and begin to die of AIDS. This is

a life saving [intervention] and so it is our right to get it free.

CONCLUSIONS

Condom advocacy, like other advocacy, does not happen in a vacuum. As thiscase study indicates, the challenges facing sex workers are a complex webof inter-related issues. As a result, Sangram and VAMP have advocated witha number of different sectors, with the overall goal of increasing condom useby the clients of sex workers and in improving the overall quality of the lives ofsex workers.

Sangram and VAMP continue to bring the skills and tenacity of their staff andmembership to bring about policy changes that will ultimately have an impacton the lives of millions of sex workers.

47 A list of free drugs issued by the government.


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ANNEX: The Condom Advocacy Plan

Date Started: November 23, 2008Dates Revised: December 1, 2008; December 5, 2008

Goals:To increase condom use by members of JN+

Objectives:

Increase availability of condoms to JN+ membersby reducing cost and creating more convenient,user-friendly access pointsImprove knowledge of proper condom use byJN+ members

Supporters:

Name Why in support of the plan?Joy Crawford because advocacy goal and

objectives are consistent withthose of employer

What can be done to get more supporters?Share goals and objectives with agencies that havesupported JN+ and its members in the past including RedCross, Jamaica AIDS Support, Regional Health Authorities,National AIDS Committee, Parish AIDS Associations

BarrierLimited funding/human resourcesHow do you overcome it?Focus on email and telephone consultations

Opponents:Name Why in opposition?None identified yet

What, if anything, can be done to change

opponents mind?

Anticipate objections/reservations (such as limitedavailability of free condoms, unspoken belief that PLHIVshould abstain from sex, etc.) and prepare talking pointsto address these.

Decision-makersName PositionDr Kevin Harvey Head of National HIV/STI

Program (NHP)Lovette Byfield Program Manager,

Prevention, NHPDr. Debbie Carrington Program Manager,

Treatment, NHPFaith Hamer Program Manager, Policy/ENV &

Human Rights, NHP

Resources

Name of Supporter Talent/Skill/ResourcesPat Watson Writer, research, networking

What is needed but not available?

Improved means of communication between advocacyteam members, especially thoseoutside Kings

Barriers to condoms

Documents

Transcript of Barriers to condoms