AIDS and Behavior

, Volume 22, Issue 12, pp 4034–4047 | Cite as

Consistent Condom Use by Married and Cohabiting Female Sex Workers in India: Investigating Relational Norms with Commercial Versus Intimate Partners

  • Anne E. Fehrenbacher
  • Debasish Chowdhury
  • Smarajit Jana
  • Protim Ray
  • Bharati Dey
  • Toorjo Ghose
  • Dallas SwendemanEmail author
Original Paper


This study examines determinants of consistent condom use (CCU) among married and cohabiting female sex workers (FSW) in India. Although CCU with clients is normative in the study area, most FSW do not consistently use condoms with intimate partners. Multiple logistic regression models indicated that condom use with intimate partners was associated with relationship status, cohabitation, HIV knowledge, STI symptoms, and being offered more money for sex without a condom by clients. Additionally, more days of sex work in the last week, serving as a peer educator, and participating in community mobilization activities were associated with higher odds of CCU across all partner types. Although improving economic security may increase CCU with clients, mobilization to reduce stigma and promote disclosure of sex work to non-cohabiting partners may be necessary to increase CCU overall.


Sex work Condom use Commercial partners Intimate partners Community mobilization Structural interventions 


Este estudio examina los determinantes del uso constante del condón (CCU) entre las trabajadoras sexuales (FSW) casadas y en cohabitación en la India. Aunque la CCU con los clientes es normativa en el área de estudio, la mayoría de las FSW no usan condones con sus parejas íntimas. Múltiples modelos de regresión logística indicaron que el uso del condón con parejas íntimas se asoció con el estado de la relación, la cohabitación, el conocimiento del VIH, los síntomas de infecciones transmitidas sexualmente (ITS), y que los clientes les ofrecieron más dinero para tener relaciones sexuales sin un condón. Además, más días de trabajo sexual en la última semana, sirviendo como educador inter pares, y participando en actividades de movilización comunitaria se asociaron con mayores probabilidades de CCU en todos los tipos de socios. Aunque la mejoria de la seguridad económica puede aumentar la CCU con los clientes, puede ser necesaria la movilización para reducir el estigma y promover la divulgación del trabajo sexual a parejas que no viven en concubinato para aumentar la CCU en general.



This research was supported by a pilot grant from the UCLA Center for HIV Identification, Prevention, and Treatment Services (CHIPTS, NIMH Grant MH058107) to the anchoring author. A fellowship from the American Institute of Indian Studies also supported the anchoring author. The first author was supported by an institutional training grant at the California Center for Population Research through Award Number T32HD007545 from the National Institute of Child Health and Human Development and a training grant at the Semel Institute for Neuroscience and Human Behavior through Award Number T32MH109205 from the National Institute of Mental Health. Additional support was provided by NIH Grants 5P30AI028697, UL1TR000124, and R21AI094666. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funders. We are grateful to the sex workers who participated in this study and the Durbar evaluation team who implemented the study. We also acknowledge the University of California Global Health Institute’s Center of Expertise in Women’s Health, Gender, and Empowerment for supporting the intellectual environment related to this work.

Compliance with Ethical Standards

Conflict of interest

All authors declare no conflict of interest.

Ethical Approval

All procedures performed involving human participants were in accordance with the ethical standards of the Institutional Review Boards of the University of California, Los Angeles and the Durbar Ethical Review Board in West Bengal, India.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    National AIDS Control Organization (NACO). HIV facts & figures: Government of India: Ministry of Health & Family Welfare. (2016).
  2. 2.
    National AIDS Control Organization (NACO). Annual report 2015-2016: Government of India: Ministry of Health & Family Welfare. (2016).
  3. 3.
    Wilson D. HIV programs for sex workers: lessons and challenges for developing and delivering programs. Plos Med. 2015;12(6):e1001808.CrossRefGoogle Scholar
  4. 4.
    UNAIDS. The gap report (2016).Google Scholar
  5. 5.
    Beattie TS, Isac S, Bhattacharjee P, Javalkar P, Davey C, Raghavendra T, et al. Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India. BMC Public Health. 2016;16:660.CrossRefGoogle Scholar
  6. 6.
    Bhattacharjee P, Raghavendra T, Doddamane M, Nair S, Isac S (eds). “All in the name of love”: Understanding the relationship between female sex workers and their intimate partners. Sexual Violence Research Initiative (SVRI); 2015.Google Scholar
  7. 7.
    Dandona R, Dandona L, Gutierrez JP, Kumar AG, McPherson S, Samuels F, et al. High risk of HIV in non-brothel based female sex workers in India. BMC Public Health. 2005;5:87.CrossRefGoogle Scholar
  8. 8.
    Basu I, Jana S, Rotheram-Borus MJ, Swendeman D, Lee SJ, Newman P, et al. HIV prevention among sex workers in India. Jaids-J Acq Imm Def. 2004;36(3):845–52.CrossRefGoogle Scholar
  9. 9.
    Isac S, Parkash R, Halli SS, Ramesh BM, Rajaram SP, Washington R, et al. Understanding low levels of condom use between female sex workers and their regular partners: timing of sexual initiation in relationships as a differentiating factor in Karnataka, South India. J HIV/AIDS Soc Serv. 2017;16(2):113–26.CrossRefGoogle Scholar
  10. 10.
    Newmann S, Sarin P, Kumarasamy N, Amalraj E, Rogers M, Madhivanan P, et al. Marriage, monogamy and HIV: a profile of HIV-infected women in south India. Int J STD AIDS. 2000;11(4):250–3.CrossRefGoogle Scholar
  11. 11.
    Swendeman D, Basu I, Das S, Jana S, Rotheram-Borus MJ. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases. Soc Sci Med. 2009;69(8):1157–66.CrossRefGoogle Scholar
  12. 12.
    Swendeman D, Fehrenbacher AE, Ali S, George S, Mindry D, Collins M, et al. “Whatever i have, i have made by coming into this profession”: the intersection of resources, agency, and achievements in pathways to sex work in Kolkata, India. Arch Sex Behav. 2015;44(4):1011–23.CrossRefGoogle Scholar
  13. 13.
    Fehrenbacher AE, Chowdhury D, Ghose T, Swendeman D. Consistent condom use by female sex workers in Kolkata, India: testing theories of economic insecurity, behavior change, life course vulnerability and empowerment. AIDS Behav. 2016;20(10):2332–45.CrossRefGoogle Scholar
  14. 14.
    National Association of People with HIV in Australia (NAPWHA). India's ART Shortage 2014. Available from:'s-art-shortage.
  15. 15.
    Kalra S. Poor Patients in India Facing HIV/AIDS Drug Shortages: Reuters; 2014. Available from:
  16. 16.
    Mahapatra B, Lowndes CM, Mohanty SK, Gurav K, Ramesh BM, Moses S, et al. Factors associated with risky sexual practices among female sex workers in Karnataka, India. Plos One. 2013;8(4):e62167.CrossRefGoogle Scholar
  17. 17.
    Wang C, Hawes SE, Gaye A, Sow PS, Ndoye I, Manhart LE, et al. HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers. Sex Transm Infect. 2007;83(7):534–40.CrossRefGoogle Scholar
  18. 18.
    Elmes J, Nhongo K, Ward H, Hallett T, Nyamukapa C, White PJ, et al. The price of sex: condom use and the determinants of the price of sex among female sex workers in Eastern Zimbabwe. J Infect Dis. 2014;210:S569–78.CrossRefGoogle Scholar
  19. 19.
    Ghose T, Swendeman D, George S, Chowdhury D. Mobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: the boundaries, consciousness, negotiation framework. Soc Sci Med. 2008;67(2):311–20.CrossRefGoogle Scholar
  20. 20.
    Ravishankar S. The many men of Sonagachi—India’s largest red light district: QUARTZ India. (2015).
  21. 21.
    Tan SY, Melendez-Torres GJ. A systematic review and metasynthesis of barriers and facilitators to negotiating consistent condom use among sex workers in Asia. Cult Health Sex. 2016;18(3):249–64.CrossRefGoogle Scholar
  22. 22.
    Murray L, Moreno L, Rosario S, Ellen J, Sweat M, Kerrigan D. The role of relationship intimacy in consistent condom use among female sex workers and their regular paying partners in the dominican republic. AIDS Behav. 2007;11(3):463–70.CrossRefGoogle Scholar
  23. 23.
    Stoner BP, Whittington WLH, Aral SO, Hughes JP, Handsfield HH, Holmes KK. Avoiding risky sex partners: perception of partners’ risks v partners’ self reported risks. Sex Transm Infect. 2003;79(3):197–201.CrossRefGoogle Scholar
  24. 24.
    Mukandavire Z, Mitchell KM, Vickerman P. Comparing the impact of increasing condom use or HIV pre-exposure prophylaxis (PrEP) use among female sex workers. Epidemics-Neth. 2016;14:62–70.CrossRefGoogle Scholar
  25. 25.
    Kerrigan D, Ellen JA, Moreno L, Rosario S, Katz J, Celentano DD, et al. Environmental-structural factors significantly associated with consistent condom use among female sex workers in the Dominican Republic. AIDS. 2003;17(3):415–23.CrossRefGoogle Scholar
  26. 26.
    Gertler P, Shah M, Bertozzi SM. Risky business: the market for unprotected commerical sex. J Polit Econ. 2005;113(31):518–50.CrossRefGoogle Scholar
  27. 27.
    Ranjan A, Bhatnagar T, Babu GR, Detels R. Sexual behavior, HIV prevalence and awareness among wives of migrant workers: results from cross-sectional survey in rural North India. Indian J Commun Med. 2017;42(1):24–9.CrossRefGoogle Scholar
  28. 28.
    Ghosh P, Arah A, Talukdar A, Sur D, Babu GR, Sengupta P, et al. Factors associated with HIV infection among Indian women. Int J STD AIDS. 2011;22(3):140–5.CrossRefGoogle Scholar
  29. 29.
    Saggurti N, Raj A, Mahapatra B, Cheng DM, Coleman S, Bridden C, et al. Prevalence and correlates of non-disclosure of HIV serostatus to sex partners among HIV-infected female sex workers and HIV-infected male clients of female sex workers in India. AIDS Behav. 2013;17(1):399–406.CrossRefGoogle Scholar
  30. 30.
    Gaffey MF, Venkatesh S, Dhingra N, Khera A, Kumar R, Arora P, et al. Male use of female sex work in India: a nationally representative behavioural survey. Plos One. 2011;6(7):e22704.CrossRefGoogle Scholar
  31. 31.
    Deering KN, Bhattacharjee P, Bradley J, Moses SS, Shannon K, Shaw SY, et al. Condom use within non-commercial partnerships of female sex workers in southern India. BMC Public Health. 2011;11:S11.CrossRefGoogle Scholar
  32. 32.
    Batra R, Reio TG. Gender inequality issues in India. Adv Dev Hum Resour. 2016;18(1):88–101.CrossRefGoogle Scholar
  33. 33.
    Sen A. When misogyny becomes a health problem. The many faces of gender inequality. New Repub. 2001;225(12):35–40.Google Scholar
  34. 34.
    Verma RK, Saggurti N, Singh AK, Swain SN. Alcohol and sexual risk behavior among migrant female sex workers and male workers in districts with high in-migration from four high HIV prevalence states in India. AIDS Behav. 2010;14:31–9.CrossRefGoogle Scholar
  35. 35.
    Jain AK, Saggurti N, Mahapatra B, Sebastian MP, Modugu HR, Halli SS, et al. Relationship between reported prior condom use and current self-perceived risk of acquiring HIV among mobile female sex workers in southern India. BMC Public Health. 2011;11:S5.CrossRefGoogle Scholar
  36. 36.
    Ulibarri MD, Strathdee SA, Lozada R, Staines-Orozco HS, Abramovitz D, Semple S, et al. Condom use among female sex workers and their non-commercial partners: effects of a sexual risk intervention in two Mexican cities. Int J STD AIDS. 2012;23(4):229–34.CrossRefGoogle Scholar
  37. 37.
    Piot P. Setting new standards for targeted HIV prevention: the Avahan initiative in India. Sex Transm Infect. 2010;86(1):i1–2.CrossRefGoogle Scholar
  38. 38.
    Kempadoo K, Saghera J, Pattanaik B. Trafficking and prostitution reconsidered: new perspectives on migration, sex work, and human rights. London: Routledge; 2015.Google Scholar
  39. 39.
    Evans C, Lambert H. Health-seeking strategies and sexual health among female sex workers in urban India: implications for research and service provision. Soc Sci Med. 1997;44(12):1791–803.CrossRefGoogle Scholar
  40. 40.
    Sarkar K, Bal B, Mukherjee R, Niyogi SK, Saha MK, Bhattacharya SK. Epidemiology of HIV infection among brothel-based sex workers in Kolkata, India. J Health Popul Nutr. 2005;23(3):231–5.PubMedGoogle Scholar
  41. 41.
    Bharat S, Mahapatra B, Roy S, Saggurti N. Are female sex workers able to negotiate condom use with male clients? The case of mobile FSWs in four high HIV prevalence states of India. Plos ONE. 2013;8(6):e68043.CrossRefGoogle Scholar
  42. 42.
    Parikh SA. The political economy of marriage and HIV: the ABC approach, “safe” infidelity, and managing moral risk in Uganda. Am J Public Health. 2007;97(7):1198–208.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Psychiatry & Biobehavioral Sciences, Semel InstituteUniversity of California, Los AngelesLos AngelesUSA
  2. 2.Public Health Foundation of India (PHFI)GurgaonIndia
  3. 3.Sonagachi Research & Training InstituteDurbar Mahila Samanwaya CommitteeKolkataIndia
  4. 4.Durbar Mahila Samanwaya CommitteeKolkataIndia
  5. 5.School of Social Policy & PracticeUniversity of PennsylvaniaPhiladelphiaUSA
  6. 6.University of California Global Health Institute’s Center of Expertise in Women’s Health, Gender, and EmpowermentSan FranciscoUSA

Personalised recommendations