Poverty and HIV in India

In India, among the most disadvantaged groups are sex workers, especially female and transgender sex workers. The two groups have time and time again reported facing stigma and discrimination at home, at work, in seeking healthcare, and in public spaces.

Income insecurity is a significant source of vulnerability that pushes female and transgender sex workers into risky sexual behaviors, increasing their vulnerability to HIV.

In my work with female and transgender sex workers in south India, the two groups reported continuous sexual and physical threats and violence from religious, health, and legal authorities. People in positions of power, including their male clients, often subject them to rape.

Even though sex work is not strictly illegal in India, sex workers remain one of the most vulnerable and marginalized groups, and continue to face criminalization. They experience discrimination and several forms of human rights violations, which increase their risk of acquiring HIV and restrict their access to healthcare and other services.

International data and research from India clearly demonstrates that even government officials misuse and target female and transgender sex workers and put them at further risks associated with HIV. For example, research carried out in Andhra Pradesh demonstrated significant links between specific police-related behaviors and HIV vulnerability. Female sex workers, the research found, at times end up having unprotected sex to avoid imprisonment. Sex workers also reported police officers seizing their condoms.

Social and Legal Exclusion

A high proportion of transgender people in India are engaged in transactional sex work, as this is one of the few reliable forms of income available to them. The proportion of transgender people who engage in sex work is estimated to be as high as 90 percent in India. That puts this group, which also faces barriers to receiving health care, at increased risk of HIV infection.

The Rights of Transgender Persons Bill in India – which was introduced in 2014 and passed in 2016 – guaranteed transgender people rights and entitlements to education and work, legal aid, pension schemes, unemployment allowances, and skill development. While the law is a welcome step, transgender people continue to face social barriers to accessing services due to the quality of service providers in the country and the stigma attached to the transgender community.

Meanwhile, laws on prostitution are vague and contradictory, further complicating matters for transgender sex workers.

It is a well-known fact that female and transgender sex workers experience high levels of stigma and discrimination due to their sexuality and life choices. They face gender-based violence and abuse, marginalization, and social exclusion. They lack the social support and social capital necessary to live in a healthy and safe environment.

Sex workers and transgender people have reported encountering problems accessing basic goods and services as well as public spaces. Sex workers often lack social safety nets. They are less likely to access education, move away from family and friends to avoid bullying and violence, and face discrimination in their work environment, which ends up further limiting their educational and economic opportunities.

Their experiences of rejection and exclusion make them less able (and less likely) to access health services and adhere to HIV treatment plans. This puts them at higher risk of not only contracting HIV but dying of it.

These conditions are further exacerbated by a lack explicit recognition of their sexuality, gender, and work at the societal level.

The Indian government recognized sex workers as a high-risk group for contracting HIV and designed interventions through India’s National AIDS Control Organization (NACO), in 2016. At the time, an estimated 2.2 percent of female sex workers in India were living with HIV. Female and transgender sex workers often suffer from income insecurity and they are prone to taking risks – such has having sex without a condom – to increase their earnings.

While the government has dipped a toe into the waters and introduced some social safety net schemes, the extent varies from state to state. People living with HIV can get anything from travel benefits to livelihood protection in the form of vouchers, but none of that takes away the financial loss incurred by those with HIV. In that context, the existing schemes almost feel like crumbs thrown at them.

It is clear that a lack of economic opportunities prevent female and transgender sex workers from refusing unsafe sex. In this context, social protection schemes with cash transfer programs are one way of preventing HIV and ensuring adherence to treatment. Such a program would reduce the stress caused by poverty and thus reduce risk-taking behaviors, which can lead to contracting HIV.

Political Commitment and Return on Investment

The links between poverty and vulnerability have been explicitly recognized and well documented around the world. Many of the poorest around the world are not able to meet their basic and immediate needs for food, education, and access to decent healthcare even in the best of times. People living in poverty time and again encounter economic stresses and shocks throughout their lifecycle.

Social protection, an evolving concept, is described as “all public and private initiatives that provide income or consumption transfers to the poor, protect the vulnerable against livelihood risks, and enhance the social status and rights of the marginalized; with the overall objective of reducing the economic and social vulnerability of poor, vulnerable and marginalized groups.”

HIV and AIDS are key examples of shocks that interact with other drivers of poverty that could simultaneously destabilize an individual’s livelihood systems, upsetting family and community safety nets and creating an intergenerational cycle of poverty.

Social protection has largely remained an underresearched area in India. However, examples from other countries have shown that giving cash to poor families helps with long-term sustainability. It give individuals and families opportunities to invest and meet their immediate and future needs.

More specifically, HIV-sensitive social protection programs recognize and aim to take action in addressing and removing legal, political, and social barriers that make accessing prevention and treatment difficult for female and transgender sex workers who are systematically marginalized by society and government.

Considering India has made little progress in the extension of social protection, it’s time that it steps up its game if the country is to meet the sustainable development goals 1.3 and 3.8 – namely implementing social protection systems to cover the poor and vulnerable and achieving universal health coverage for all.

Now is the right time to introduce unconditional social protection programs based on successes from other countries.

Although extending social protection can prove extremely challenging, social protection combined with behavioral change strategies provides a window of opportunity to see return on investment and cost benefits for the government.

Social protection has a direct objective in terms of social outcomes and human development, but it is also linked with economic development, and, hence, can be regarded as an economic investment.

In this light, social protection is no longer seen as a cost to the economy but as a source of resilience in tough times, a support for growth and productivity in good times, and a general mechanism for socioeconomic inclusion.

On one hand, such programs tackle poverty, ensuring the needs of the vulnerable groups are being met; on the other hand, they aim to ensure there is less burden from disease. Social protection programs can focus on both preventing and mitigating the impact of HIV. Providing social protection provisions will eventually reduce the healthcare needs of the population. It has the potential to remove or significantly reduce transactional sex, improving the prevention of HIV both among sex workers and in the general population.

Having a closer look at the links between government spending, social protection, human development, poverty and inequality, and economic growth helps make a stronger case for noncontributory social protection investments.

The value of “unconditional” cash transfers programs, where female and transgender sex workers are given freedom to make choices about where and how the cash should be spent to reduce the prevalence and impact of HIV, needs to be understood better in the Indian context. There is international evidence and evaluation studies that indicate cash transfers with prevention messages could lift people out of poverty. One example is the Graduation Program in Bangladesh.

Pioneered in Bangladesh, the Graduation Program aims to tackle poverty and vulnerability by enabling households to “graduate” out of extreme poverty and into sustainable and independent livelihoods. The approach is currently being tested out in other Asian countries and in African states as well. While the Graduation Program approach has some limitations, it has shown significant positive results, which could be replicated in India.

The “graduation” model provides a platform to develop HIV-sensitive interventions in order to protect the most vulnerable from the impoverishing effects of HIV and AIDS. A new intervention with elements of the Graduate Program promises to realize the rights of the most vulnerable and disadvantaged. It may empower female sex workers and transgender people to make use of their rights and entitlements to education and labor market access, both protecting and mitigating against HIV and AIDS.

An HIV prevention message is best when combined with increasing social capital, providing financial training, tackling stigma and discrimination, and ensuring at-risk groups adhere to HIV treatment. For its potential in addressing each of these areas, unconditional cash transfer programs are a concept worth pursuing.