1. Khondker, Sajani
1
Department of Global Health
Sex Workers in India:
Working Empowerment into the National Agenda
by Sajani Khondker
Advisors: Jennifer Beard and Frank Feeley

2. Khondker, Sajani
2
Abstract
Background: The Sonagachi Project is a community-based empowerment program run by and for sex
workers. Based in a famous red-light district in Kolkata, India, it has led to sustained improvements in
condomuse and reduced HIV prevalence.Incomparison,condomuse isinconsistentandHIV prevalence
considerably higher among sex worker populations in other prominent red-light districts across the
country. However, the Sonagachi model has not been scaled up by the National AIDS Control
Organization (NACO) of India. This article examines the empowerment approach of the Sonagachi
Project,andthe evidence thatempowerment of sex workers reduces HIV transmission. It analyzes the
essential components of Sonagachi thatcontributedtoitssuccess,andcomparesthe key componentsof
the model tothe currentpoliciesandprogramsfundedbyNACO,toshow the extentatwhich the model
isappliedata national scale. Finally,itmakesrecommendationsonspecificactionsNACO shouldtake to
develop a more effective national plan for reducing HIV transmission among sex workers.
Findings:The empowermentstrategies of Sonagachi are effective in reducing HIV transmission among
sex workers. Essential components of the project include: 1) flexibility in fitting the needs of the
community;2) addressingthe structural factors that make sex workers in India vulnerable to HIV, such
as poverty, laws for sex work, and stigma; 3) increasing participation of sex workers in program
implementation, from the role of ‘audience,’ to ‘implementers,’ to ‘decision makers.’
NACO does not emphasize empowerment or apply the essential components for empowerment
programs in policies for reducing HIV among sex workers. As a result, Ashodaya Academy seems to be
the largest empowerment program that NACO funds and learns from, while most other successful
programs – includingVeshyaAnyayMukti Parishad,the AvahanProject,andthe Sonagachi Project – rely
on external donors alone, and not on government funding.
Conclusion:Aligningnational policieswiththe empowermentapproachof the Sonagachi model willhelp
NACO halt and reverse the HIV epidemic among sex workers in India. NACO must commit to funding
interventions that empower sex workers.

3. Khondker, Sajani
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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
HIV in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
HIV among female sex workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Vulnerability to HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Sex workersinnational AIDSpolicies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The dynamic history of Sonagachi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Sequence of projectdevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Key components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Barriersto implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The Sonagachi model:definingandmeasuringmodel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Evidence:wasSonagachi effective? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
NACO’spoliciesandprograms:the limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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Introduction
Sex work is a major driver of the HIV epidemic in India. While prevalence in the general
population was 0.3 in 2013, prevalence in Maharashtra was found to be 24% among street-based sex
workers, and 29% in their brothel-based counterparts (1). In contrast, HIV prevalence among sex
workersin Sonagachi, Kolkata, has steadied to a constant prevalence of 11%, despite the thousands of
sex workers living there (2,3). Though data is not available on trends in HIV incidence, positive
prevention and treatment seeking behaviors have clearly been higher in Sonagachi than in other red-
light districts (4). For example, condom use in Sonagachi increased rapidly from 3% in 1992 to 90% in
1999, and has remained consistently high (5). Condom use has been consistently low elsewhere. One
study in Maharashtra found 48.4% of sex worker clients reported having anal intercourse with
inconsistent use of condoms (6,7).
The Sonagachi Project, founded in Kolkata’s famous red-light district in the early 1990s, has
achieved these sustained impacts on condom use and HIV infection. In this paper, I will analyze the
methods andoutcomesof the Sonagachi Projectandidentifythe components that made it successful. I
will then examine the extent to which the National AIDS Control Organization (NACO) policies have
integrated the Sonagachi model into the national plan to prevent HIV. Finally, I will make
recommendations toNACO on how to better incorporate key Sonagachi components into the national
strategy and take an empowerment approach to reducing HIV transmission among sex workers.
Background
HIV in India
Over 2 million people are living with HIV/AIDS in India. (8) In 2013 there were 130,000 deaths
due to AIDS (8), and 116,000 new infections among adults in 2011. In the past decade, there has been
an overall 57% reduction inestimatedannual new infections (6). However, much work still needs to be
done,especiallyinvulnerable populations: people who inject drugs, men who have sex with men, and
sex workers.
HIV among female sex workers
Sex workers are highly vulnerable to HIV.1
Globally, female sex workers are 13.5 times more
likelytobe livingwithHIV than other women. Sex workers in Asia are 30 times more likely to be living
withHIV as womenwhoare notsex workers,comparedto12 in LatinAmerica andin Sub Saharan Africa
1
In the context of this paper, a female sex worker is a woman whoengagesinconsensual sex inexchange for moneyor
payment inkind, as her principal source of income (26).

5. Khondker, Sajani
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(9). In India, HIV prevalence has been concentrated in female sex workers (FSWs) at 2.67%, with great
variationbetweenthe states – for example, 9% in Andhra Pradesh compared to 0.1% in Chandgarh. (6)
Moreover,because sex workersare ahighlystigmatizedpopulation, they are often under-represented
innational HIV surveillance systems (9),sothese numbersmaybe underestimates.Accordingto Baral et
al., more than 20% of HIV prevalence in women in India is attributable to female sex work (9).
Preventionandcontrol of HIV transmissionbetweenthe sex workers andthe general population would
be a powerful step towards ending the epidemic in India.
Vulnerability to HIV
Structural determinants such as laws and policies, poverty, cultural norms, stigma, and
discrimination dynamicallyinteractwith community, interpersonalrelationships andindividualbehavior
to make sex workers in India vulnerable to HIV. For example, Indian federal law is ambiguous on sex
work.While transactional sex betweenconsentingadultsislegal, all activitiessurroundingit – operating
brothels, pimping, and soliciting in public – are illegal (10). The result is that sex workers are regularly
harassed, coerced and abused by law enforcement, and arrested for being a ‘public nuisance’ (11).
Sex workersinIndiaare heavilystigmatized andmarginalized; they are subjected to high levels
of physical andsexual violence frommadams,pimps,and clients;andmostare illiterate, impoverished,
divorced or widowed (12,13). Commonly reported reasons for entering sex work include: historical
traditions of dedication into sex work, financial insecurity, family discord, violence and coercion, and
desire for financial independence (14). Patriarchal culture norms, gender-based violence and stigma
place sex workers in a subordinate position, and unable to negotiate condom use and other healthy
practiceswithclientsandpimps. Abusive policing practices impede access to condoms and healthcare.
Thisleadsto poorhealthandeconomicoutcomes (15).A socioecological model for sex workers in India
is shown in Figure 1.
Sex Workers in National AIDS Policies
NACO builds the national response for HIV/AIDS prevention, treatment, and awareness. It is
responsible for creating policies and guidelines for the State AIDS Prevention and Control Societies to
implementatthe state-level.Itiscurrentlyimplementingthe fourthphase of itsprogram, NACP-IV (16).
The budget for NACP-IV is $2,325,147,500 for 5 years. For the first time in NACO’s history, the Indian
government is covering a larger share of this budget than international donors – about 63%. The
remaining funds are provided by the Global Fund to Fight AIDS and the World Bank (17).
NACP-IV sets strengthening of program planning and management as primary goals. It also
states that it will enhance activities to reduce stigma and discrimination against people living with

6. Khondker, Sajani
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HIV/AIDS ‘at all levels, especially the health care setting’ (16). Most importantly, the first program
componentemphasizesNACO’sstrongcommitmenttotarget ‘high-risk groups,’ including sex workers,
and ‘othervulnerable populations,’namely,migrantsand truckers. The NACP-IV states that it will scale
up coverage among ‘high-risk groups’ and vulnerable populations through behavior change
interventionsanddemandgenerationcampaigns(16).Clearly,reachingvulnerable populations like sex
workers is a high priority for NACO.
Figure 1: Socioecologicalmodel forsex workersinIndia [adapted from (15)].
The Dynamic History of Sonagachi
Sequence of Project Development
The Sonagachi Project was founded by Dr. Smarajit Jana and the All India Institute of Hygiene
and Public Health (AIIHPH) in 1991. Initially funded by the AIIHPH, and later by the Norwegian Agency
for DevelopmentCooperation (NORAD),the UK Departmentfor International Development (DfID), and
USAID (5), it began as a plan to set up a clinic for treating sexually transmitted infections (STIs) among
sex workers in the red-light district of Sonagachi, create uptake of clinic services by sex workers, and
consequentlyreduce STIsamongthisvulnerable population (18).Table 1illustrates the sequence forthe
stages of project development.

7. Khondker, Sajani
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Table 1: The sequence forthe stagesof Sonagachi Project development[adapted from (18)]
Early Stage Intermediate Stage Late Stage
Action  Obtainfunding
 Buildclinic
 Train clinicproviders
 Identifyandtrainpeer
outreachworkers
 Advocate withthose in
power
Peereducators:
 encourage use of
clinic
 raise awarenessof STI
preventionand
treatment
 teachcondom
negotiationskills
 buildgroupsolidarity
 frame humanand
workers’rights
 encourage saving
Volunteers:
 teachliteracy
Non-sex worker
professionals:
 arrange local micro-
loanprogram
 Non-sex worker
professionalsleave,
FSWs take up
leadershiproles
FSWs:
 teachliteracyto each
other
 generate alternate
income through
condomsales,small
businesses
 publiclyadvocate for
theirrights
 forma trade union
Outcome  Providersare
supportive of
stigmatizedpopulation
 Peeroutreachworkers
engage withtarget
population
 Stakeholdersinvested
inprogram, creating
enablingenvironment
for reachingsex
workers
FSWs:
 enjoybetter
healthcare
 have increased
awarenessof STI
preventionand
control
 have bettercondom
negotiationskills
 supporteach other
 have increased
awarenessof their
rights
 have higherliteracy
rates
 have economicsafety
net
FSWs:
 have highereconomic
stabilityandcapacity
 have greatersense of
self-worth
 manage a sustainable,
supportnetworkfor
healthandhuman
rights

8. Khondker, Sajani
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Key components
Three critical characteristics of Sonagachi contributed to its success:
1. It was initiallyconceived as a relatively simple intervention for reducing STIs in sex workers. It
was not grounded in a specific behavioral theory or planned as a complex, multi-level
empowerment program, but instead evolved over time to meet the changing needs of the
community (18).For example, condomswere providedforfree atthe beginningof the program,
because FSWswouldneverhave boughtthem before they believed that using condoms was in
theirbestinterest.However, once peeroutreachworkers succeeded in promoting condom use
and changing social norms around using them with clients, condoms were sold at a small
subsidizedfee thatwomen were willing to spend to protect their well-being. Selling condoms
also provided peer educators with an alternate income (18).
The role and scope of the peer outreach workers also grew with the project. At first,
theyeducatedotherFSWs on STI/HIV prevention.AsFSWslearned,peerworkers progressed to
teachingcondomnegotiationskills,andthen literacy, alongside financial saving and budgeting
skills (18).
2. It targeted HIV as a structural problem, and not simply an individual problem. For example,
the projectnot onlybuiltaclinicto provide accesstocare, butinvesteda great deal of time and
moneyintotrainingprovidersto be caring and supportive of FSWs, thus addressing stigma and
discrimination. Aspeeroutreachworkersorganizedthe communityandbuiltgroup solidarity, it
was recognizedthatpovertyandilliteracywere majorstructural barriers that caused women to
entersex work,andretainsubordinate rolesinthe profession. Therefore, educational services
were provided, and an economic safety net created through a local microloan program. While
these programsdidnotsolve the problemof poverty,theydidaddress it.Most importantly, the
project implementers advocated on behalf of the FSW with law enforcement, other local
authorities, madams, pimps. They persuaded police not to persecute FSWs, and they got
madams and pimps invested in condoms first, to create an enabling environment for FSWs to
use them. When FSWs as a group were more educated, economically secure, and respected,
they had the power to make healthier choices at the individual level – negotiate consistent
condom use, and utilize healthcare services (18).
3. The increasing role of community participation in the project is likely the reason why impacts
have beensustained for over 23 years. Once peer outreach workers had built their knowledge
and skills, they were able to pass these on to others. As project leaders like Dr. Jana left the

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program, the FSWs took up leadership roles and became implementers and decision makers.
While professionalstaff advocatedonbehalf of FSWsatfirst,the sex workerssointernalizedthe
messages of human and workers’ rights delivered by the peer outreach workers, that they
began to organize meetings and rallies and advocate for themselves. FSWs moved from being
simplytargetaudiences,tocontributorsandimplementers,toexpertsanddecisionmakers (18).
Figure 2 summarizes the increasing participation of sex workers in the Sonagachi Project.
Figure 2: The increasingcommunity participation inthe Sonagachi Project. [Hierarchy of community
roles adapted fromUNAIDS1999].
Target audiences - FSWs receive clinic services
- Peer outreachworkers receive training
- FSWs receive literacytraining
- FSWs receive accessto micro-loans
Contributors &
Implementers
- Peer outreachworkers teachother FSWs about STI interventions andcondom negotiation skills, and
encourage use of clinic
- Peer outreachworkers use rights-basedframingand build groupsolidarity
- Peer outreachworkers provide literacytrainingandencourage saving
Experts &
Decisionmakers
- FSWs generate alternate sources of income
- FSWs publiclyadvocate for rights
- FSWs form a trade union
- FSWs take up leadershiproles
Barriers during implementation
There were several challenges during implementation of the Sonagachi Project: initial
discriminatoryattitudesinstaff,overcrowdingof clinics,insufficientsupplyof condoms, andinadequate
followup,screening,andreferral, aswell as lackof rigorin monitoringvolunteers. The projectappeared
understaffed and underfunded (5). These factors continue to limit program efforts.

10. Khondker, Sajani
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The Sonagachi model: defining and measuring empowerment
Empowerment can be defined as five intervention strategies common to evidence-based,
effective HIV prevention programs. It can be measured in terms of 21 outcome measures, organized
underthese five factors (19).The empowerment strategiesandassociated variablesare listedinTable 2.
Table 2: Definingandmeasuringempowerment
Empowerment strategy Outcome measures
Improve knowledge of HIV/STD intervention - Know at least one STD
- Condoms prevent STDs
- Condoms prevent HIV
- At risk for HIV/STDs
Improve skills in sexual negotiations and workplace
autonomy
- Most important condom decision-maker
- Can refuse client for anysex act
- Ever refusedfor no condoms
- Condom use
- Can take leave if sick or unwilling
- Can change work contract
Provide a frame to motivate change - Sex work is validwork
- Want more education/training
- Ever disclosedprofession
Build social support to sustain change - Visitedwith sex workers outside ofwork
- Participatedinsocial functions
- Helped other sex workers
Address environmental barriers - Politicalparticipationto build social capital:Voted
last election;votedwillingly
- Reduce economic vulnerability:Save money;have
other income; work other places;take loans
Evidence: Was SonagachiEffective?
The Sonagachi model has been shown to promote consistent condom use through
empowerment strategies. Table 3 summarizes the evidence for the effectiveness of empowerment
strategies in reducing HIV transmission among sex workers.

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Table 3: Evidence forthe effectivenessof empowermentstrategiesinreducingHIV transmissionamong
sex workers
Authors
(year)
Studysite Studydesign Sample
size
Interventions
tested
Keyfindings Conclusions
Study1
Basu, Jana,
Rotheram-
Borus,
Swendeman,
Lee,
Newman,
Weiss (2004)
(20)
West Bengal,
northeastern
India
Randomized
control trial
Intervention The Sonagachi
model canbe
replicatedto
successfully
increase consistent
use of condoms,
and consequently,
incidence ofHIV
and other STIs.
100 STD clinic with
speciallytrained
staff, peer
educators,
community
organizing,
advocacy, rights-
basedframing
Over 15 months,
condom use
increasedby39%
Proportionof
consistent condom
users increased by
25%
Control
100 STD clinic Over 15 months,
condom use
increasedby11%
Proportionof
consistent condom
users decreasedby
16%
Study2
Swendeman,
Basu, Das,
Jana,
Rotheram-
Borus,
(2009) (19)
West Bengal,
northeastern
India
Quasi-
experimntal
intervention
trial
Intervention The Sonagachi
model creates
impact through
empowerment
strategies. Clinical
services andhealth
educationalone
could have negative
impacts.
110 STD clinic, in-clinic
peer education,
condom social
marketing,
community
organizing,
advocacy, rights-
basedframing, and
micro-finance
Over 16 months, all
outcomes across
five common
domains had
statistically
significant
interventioneffects
except for abilityto
take sick leave,
workinginother
locations, taking
loans, andvoting.
Control
110 STD clinic, in-clinic
peer education,
condom social
marketing
Over 16 months,
there were
downwardtrends in
condom attitudes,
STD risk
perceptions, skills
for sexual and
workplace
negotiation, & in
motivating frames
for change, social
support, andsaving
money.

12. Khondker, Sajani
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Study 1
In Basu etal’s randomizedcontrol trial,acontrol communityreceivedstandard interventions in
the form of a free reproductive and sexual health clinic, in which staff were trained to be culturally
sensitive (20). The intervention community also had access to a free clinic with specially trained staff,
with the addition of empowerment programs modelled after Sonagachi: services from local peer
educators(initiallytrainedbySonagachi staff).Peereducatorsengagedwithsex workers, advocated for
them,builtgroupsolidarity,andraisedconsciousnessonworkerrights.Additionally,professional staff –
the clinicians, research team, program staff – conducted advocacy work with local police, elected
officials,appointedpolicymakers,shopowners,civicandsocial clubs, and other gatekeepers in the sex
worker community (e.g., madams, pimps, local gangs) to effect changes in the structural barriers to
condom use by sex workers (20).
The study showedthat empowermentstrategies modelled after the Sonagachi Project led to a
significantly greater increase of consistent condom use than provision of clinical services alone (20).
Since increasedandmore consistentcondomuse results in lower infection rates (21), the intervention
community is more likely to have lower HIV prevalence compared to the control.
Study 2
In Swendemanetal’s study,the control communityreceivedan STDclinicwithfree services, in-
clinic peer education, and condom social marketing (19). The intervention community received the
same,plus the followingempowermentstrategyinterventions: communityorganizing,advocacy, rights-
basedframing, andmicro-finance.The researchersmeasuredchange inthe 21 empowerment variables
organized under the 5 common factors described in the previous section.
The intervention community showed statistically significant positive effects for almost all
variables compared to the control community. This showed that the Sonagachi model improved
knowledge of STDs,providedaframe to motivate change,improvedcognitive, affective and behavioral
skills,builtsocial supportamongsex workers,andaddressedenvironmental barriersbasedoneconomic
vulnerability and insecurity (19). Furthermore, the control community showed downward trends in
condom attitudes, STD risk perceptions, and skills for sexual and workplace negotiation, as well as
motivatingframesforchange,social support,andsavingmoney. Thisindicatedthatclinical services and
healtheducationalone could theoretically have negative impacts because emphasis on disease and risk
reduction alone can reinforce stigma and discrimination, undermine autonomy and negotiating
capacities,orreduce acceptance of services (19).By contrast,the Sonagachi Projectenabledsex workers

13. Khondker, Sajani
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to take greatercontrol overtheirincome,theirhealth,andtheir rights as humans, and only by doing so
could they create sustainable change.
NACO’s Policy and Programs: theLimitations
Policies
One of the primarygoalsof NACP-IV istotarget vulnerable populations, including sex workers.
Interventionstargetedatsex workersinclude:behaviorchange programs to raise awareness of risk and
vulnerability, and to increase safe practices, testing, adherence to treatment, and demand for other
services;promotionandprovisionof condoms;andcounsellingto increase ‘compliance with treatment
(16).’ TargetingHIV preventionprogramsatIndia’smostvulnerablepopulationsisalaudable firststepin
curbing the epidemic. However, there are several ways to integrate the Sonagachi model into NACO
policies to empower sex workers and prevent HIV more effectively.
First,targetedinterventions couldaddress multiple levels of the socioecological model, rather
than onlyindividual behavior.Behaviorchange campaignsanddemandgeneration programs imply that
sex workers can freely choose to use or not to use condoms, and that HIV can be controlled simply by
addressing a sex worker’s decision to use condoms consistently. They do not take into account the
structural and community level factors that the Sonagachi Project acknowledged and attempted to
address– poverty, illiteracy,gendernorms, stigma, andthe lackof worker’s rights. Though the NACP-IV
emphasizes the need to reduce to stigma towards people living with HIV/AIDS, it does not address
stigma towards vulnerable populations like sex workers (16).
Second,current policies donotstressthe importance of community mobilization and capacity-
building as a strategy for reducing HIV transmission (16). As the Sonagachi Project demonstrates,
sustained impacts on condom use and HIV incidence are best achieved when sex workers are
empowered to take charge of the intervention on their own. Emphasis on increasing community
participationandaddressingstructural barriers inNACOpolicies wouldmake themmore consistentwith
the Sonagachi empowermentmodel. Thisemphasiscan be workedintothe development of NACP-V for
2018.
Third,NACO’s language usedinthe contextof sex workerscouldbe developedto deflectstigma.
For example,sexworkersare referredto as a ‘high-risk group’ versus a vulnerable population (16). We
are beginningtounderstand that referring to a marginalized population as ‘high-risk’ can imply blame
and be perceived as stigmatizing. Sex workers in India face severe stigma, and this issue must be

14. Khondker, Sajani
14
addressedinorderto construct effectivepoliciesandreverse the HIV epidemic.A first step is the use of
non-stigmatizing language in national policies.
Programs
Effective empowermentprogramslike Sonagachi are limitedbyinadequate funding and rely on
philanthropicorganizationssuchasthe Ford Foundation (22). Similarly, the Avahan Project, the largest
official attempt at replicating Sonagachi in India, was funded entirely by the Bill and Melinda Gates
Foundation. The Avahan Project was initiated in 2003 throughout six states: Tamil Nadu, Karnataka,
Andhra Pradesh, Maharashtra, Nagaland, and Manipur (23). The initiative has been associated with
lowerHIV prevalence in3southIndianstates, butthe evaluation was not rigorous: there is no baseline
data, and no control group (24).
The Veshya Anyay Mukti Parishad (VAMP), however, has been recognized as an ‘innovative
response’ by UNAIDS and the Asia-Pacific Network of Sex Workers (25). It is a registered collective of
5000 female sex workersfromsevendistricts in Western Maharashtra and North Karnataka. Led by sex
workers, it applies many of the empowerment strategies common to Sonagachi: improved access to
clinical services, including testing, treatment, and counselling; peer outreach; a network of consistent
economic and social support; stigma reduction activities; and advocacy. Funding is from external
charitable organizations only (25).
On the otherhand, NACOhas takenthe opportunitytolearnfromthe empowerment strategies
of a prominentcivil societyorganization (CSO):the AshodayaAcademy,the capacity development wing
of Ashodaya Samithi, a community-based organization of sex workers in Mysore, Karnataka (25). The
Academyisa facultyof sex workerswhotrainothersex workersonhow to design, implement, monitor
and evaluate HIV prevention programs in their own communities. The Ashodaya model has since
reachedover5000 people,includingcommunitymembers,NGO staff and government officials of India
and empowered sex workers in Gujarat, Maharashtra, Rajasthan and Andhra Pradesh. The Academy
officiallybecame aNACOlearningsite in2008. Fundingis provided by the government of India, the Bill
and Melinda Gates Foundation, the University of Manitoba, UNAIDS, and Asian Development Bank
(ADB) (25). This partnership with NACO has amplified the success of Ashodaya and contributed to the
learning process.

15. Khondker, Sajani
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Recommendations
NACO has committed to targeting interventions at sex workers and other highly vulnerable
populations. It can effectively reverse the HIV epidemic in these vulnerable populations by using the
Sonagachi model for empowerment.
1) Reduce stigma and discrimination
 Engage sex workers as partners in policy development, program design,
implementation, and evaluation
 Create local forumsforopendiscussionbetweenlaw enforcement,healthprofessionals,
sex workers, NGOs, CSOs, and CBOs
 Create a national campaigntoraise awarenessof the human rights and worker rights of
sex workers
 Train lawenforcement officials andhealth professionals on empathy and human rights
in the context of sex workers
2) Develop NACP-V policies to incorporate empowerment strategies for sex workers. The policy
should aim for interventions that:
 Address structural factors that affect sex worker health and make them vulnerable to
HIV
 Increase community participation in programs
3) Identify and fund programs practicing empowerment strategies
 Engage academicinstitutionsinresearchingandidentifyingexistinginterventions which
apply empowerment strategies comparable to the Sonagachi model
 Provide funding for implementation of these programs
4) Create a formal systemforcollaboration with and between different empowerment programs
across the nation
 Develop partnerships with empowerment programs by building learning sites at
program locations
 Organize national conferences for sex worker organizations to share innovation and
expertise
5) Monitor and evaluate funded empowerment programs
 Enlist public health professionals to monitor and evaluate empowerment programs
 Engage sex workers as partners in monitoring and evaluation

16. Khondker, Sajani
16
 Disseminate information to all stakeholders and modify strategies accordingly
6) Scale up effective programs across the nation
 Provide funding for scale-up of effective programs
Conclusion
If leftunchecked,HIV will quicklyspreadbetweensexworkersand the rest of India through the
bridge population. Condomswill preventthistransmission,butunlessthe structural barriers to condom
use insex workersare addressed, simplebehavioral change interventionswill be ineffective. NACOmust
highlightthe empowermentstrategiesof the Sonagachi model,andfundthe scale-upof empowerment
programs across India. By revising national plans for action to recognize the human rights and worker
rights of sex workers, India can begin reversing the epidemic in one it’s most vulnerable populations,
and ultimately build a healthier public and a stronger economy.

17. Khondker, Sajani
17
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