In Mumbai's Falkland Road, at mid-day, women with painted faces pose like mannequins on either side of the road. A cosmopolitan mix, they come from different parts of the country, even Nepal and Bangladesh. They seem to be in their early 20s. A short distance away a group of street performers do a nukkad natak (street play) on safe sex. People stop to watch, a crowd collects within minutes. To take risk in sex is stupid, not macho, the actor says, adding, always carry a condom.
In India, in four of the six states with HIV prevalence higher than one per cent, the epidemic is driven by heterosexual encounters. Paid sex fuels the spread of HIV, its skewed power equation making it impossible for women to negotiate their own safety. While the women range from age 20-50, a majority of the clients are men, aged 17-35. Key HIV prevention strategies adopted for sex workers and their clients include actively promoting the male condom, and making treatment for sexually transmitted infections available to both men and women. (Presence of STI can increase risk to HIV upto 10 times).
More recently, the female condom has started seeing use, though in a limited way. In Mumbai, Population Services International (PSI) introduced the female condom among women in sex work two years ago. The female condom is a polyurethane sheath about 6.5 inches in length. It lines the vagina entirely and helps to prevent pregnancy and sexually transmitted infections (STIs) including HIV. Each end of the condom has a flexible ring. At the closed end of the sheath, the flexible ring is inserted into the vagina to hold the female condom in place. For women in sex work who may find it difficult to negotiate condom use with clients and partners, pilot interventions are exploring if the female condom can be used as an alternative. According to PSI, which maintains a database to track its work with the women, the intervention presently reaches out to over 6,000 women in redlight areas in the heart of Mumbai as well as suburbs Vashi and Bhiwandi.
The National AIDS Control Organisation (NACO), in association with Hindustan Latex Family Planning Promotion Trust (HLFPPT), is planning to introduce the female condom among women in sex work in the six high prevalent states. It has ordered five lakh pieces from the London-based manufacturer Female Health Company. These will be made available through NGOs working in select sex work locations. The product which is being bought from the company at a cost of Rs.45 will be social marketed at Rs 5 to the consumer. Says Dr Sanjeev Kumar, HLFPPT: "We know from evidence that despite active promotion of the male condom it is still not being used in 20-30 per cent encounters. The female condom, we hope, will cover this gap." He emphasises that the female condom should not be seen as a replacement for the male condom but as a women-controlled preventive device to bridge the gaps.
It is a tough world out there in Mumbai's redlight areas: Competition is stiff and businees is low. The women say police raids have increased in the last few months. Bhiwandi remains a communally volatile area while Vashi has its mafia and gang wars. In the suburbs, the communities are largely homogenous. The devadasi women from Andhra Pradesh and Karnataka live here, many of them are older women. In contrast, life in Mumbai's redlight areas is as cruel and aggressive as it can get: Fierce competition, uncertain earnings, pressure to send money back home in the village. To top it all, the worry about contracting HIV.
Mallika, a 40-something devadasi from Karnataka who has lived in Kamathipura over 20 years says, "Women are afraid of STI and HIV yet don't want to lose out on income. Even though condom use among men has increased over the years, still one in ten men refuses the condom." She says she uses the female condom with men who refuse to use the condom. Munni, 26, a cheerful and comely woman from Bihar working out of Kamathipura insists safety is of prime importance. She says she uses the female condom with her regular partner or 'husband', cleverly telling him it is a good contraceptive. 'Married' to a Bengali man, the couple dote on their 4-year-old perky son. "The truth is we cannot tell if either of us is infected, yet I cannot ask him to use a condom," she says. Munni does not see the need to test unless there are obvious symptoms of infection, but is conscious not to take risks even in a trusted relationship. She insists on the condom in every encounter and admits that using the condom in a marriage is difficult.
The women are aware of the harsh reality of HIV. Ensuring personal safety against the professional hazards remains a daily challenge. Munni says a middle-aged client who is a regular, insists on unprotected sex and gives her Rs 2,000 each time for it. "I know that good health is more important than money, so I use the female condom. He does not come to know he thinks it's unprotected, I know I am safe. Why turn away a well-paying client?" she asks.
For women like Munni and Mallika, the female condom has helped ensure safety on their own terms. Older women like Mallika say competition is so stiff, they find it difficult to insist the client use a condom. Be it Mumbai's Kamathipura, or Kolkata's Songachi, or the devadasi community in Bagalkot, Karnataka, women in sex work say that with AIDS awareness condom use has gone up in the last few years. However, it remains low with drunken and abusive clients. Those working in the field add condom use is also low with regular partners. The women feel condom use is inappropriate in a trusted relationship -- intimacy implies trust, trust implies no condom. Interpersonal communicators however say that women don't see themselves at risk from the regular partner and end up getting infected through them. They tell the women they must use the condom with their regular partner while they are in sex work; once they leave sex work and are sure neither is infected, they can stop using the condom if they so wish. Saira, a 20-something interpersonal communicator with PSI in Mumbai says that interestingly, discussions with men reveal that not just the men, women also don't want to use the condom in a 'marriage'.
Programme managers see this glaring gap in condom use as worrisome. Arundati Muralidharan, PSI, says, "We believe the female condom can help bridge this gap." The response so far has been mixed. At present, PSI is social marketing it at Rs 2. Those buying the female condom are in the age group of 25-30; they say it is very useful and customers approve of it. There are others who say it is a good product but why use it when the male condom is so much simpler and available for free. Some give the choice to the customer asking him to choose between the male and female condoms. Others refuse to entertain any discussion on the female condom at all. It's unwieldy size and shape, fear of initial discomfort and anxiety about partner response have left many women closed to the idea.
Programme officers say two years down the line, sales are low, but that is not the main concern. "We want greater number of women to try the free samples we are distributing. Breaking into this difficult terrain has been challenging, even frustrating, and yet there has been the odd success story that told us it was important to keep at it. The male condom has taken 20 years to normalise, we had no illusions that this would be readily accepted," says Arundati.
Communication materials developed by the interpersonal communicators catch a slice of life from the women's experience. For example, the Seeta and Geeta story: Seeta is in her early 20s, madly in love with a client, dreams of marriage. Geeta is pragmatic, 35-year-old, one who has seen the world. Although Geeta has a partner, she realises he will not leave his wife and children to marry her. She is aware she must secure her own future and dreams of building a house. The story goes why are they in Mumbai? 'Everyone is here to earn money. And yet, every woman is looking for love. How did the female condom help both women to fulfil their dreams Seeta was able to protect herself from infection while in sex work and married her boyfriend; Geeta protected herself and her partner and was able to build a house.' Says Arundati: "We know women like Seeta and Geeta exist young, attractive, hopeful, want to secure their own future. We want to pitch the product to them."
Users like Renu, 25, who moved from Kolkata's Sonagachi to Kamathipura in Mumbai last year, says she has been using the female condom for about a year. Client response has been good, with one of her 'regulars' insisting she use it each time. It has its advantages: Polyurethane is a better conductor of heat than latex, of which the male condom is made. It is well lubricated on the outside and the inside so it does not cause any abrasion. Unlike the male condom, it also protects the external genital area from STI and RTI. The women say it is particularly useful during the menstrual cycle, although it has its problems too: It needs to be held in place, inserting it and disposing it is cumbersome, it is visible. The women have devised their own ways and means to deal with these issues.
Marketing the female condom hasn't meant that the male condom will be de-emphasised. Recognising the importance of reaching out to male clients of sex workers alongside, PSI is actively promoting the male condom through game shows and quiz programmes in the redlight areas. It is also disseminating information on the female condom. "Worldwide, research shows that introducing the female condom reduces overall incidence of unsafe sexual encounters," says Arundati. Greater awareness and discussion, increased choices, clearly results in less risky behaviour. As Dr Sanjeev Kumar, HLFPPT, puts it: "Our campaign for promoting the female condom is 'Yours or mine, either is fine'."
Meanwhile, young women in the trade like Munni and Renu who are now buying the female condom encourage other women to try this option. It certainly works for them, they say it keeps them safe, gives them an edge over the other women in times of stiff competition. The customer is not complaining either.