4.1 Backdrop

UNAIDS defines sex work as selling sexual services [1]. Sex workers involved in sexual relations with multiple partners are a key group of women who need access to comprehensive sexual health services, including HIV prevention, treatment, and care [2]. There are a broad range of sex workers in various locations including those who are street-based and brothel-based, those who work as escorts, and those who work from their own homes. Some women exchange sex for cash or goods but do not see themselves as sex workers [3,4,5]. Migrant sex workers are particularly at high risk of HIV [6]. Globally, female sex workers are 13.5% more likely to be living with HIV than other women of reproductive age [7]. In Asia, female sex workers are almost 30% more likely to be living with HIV than other women. Unprotected sex with multiple partners puts sex workers at high risk of HIV [8]. In India, targeted HIV interventions for female sex workers are found to be highly cost-effective [9]. However, interventions must be adapted to meet the needs of sex workers in different settings.

To address structural barriers and ensure human rights, WHO supports countries to implement a comprehensive package of HIV and health services for sex workers through community-led approaches [7]. Programs that enhance sex workers’ ability to use condoms are also vitally important [2, 10]. Health interventions for prevention of sexual transmission of HIV and other STIs among sex workers include condom programming, harm reduction interventions for those who inject drugs, behavioral interventions, HIV testing and counseling, HIV treatment and care, pre-exposure prophylaxis (PrEP), prevention and management of viral hepatitis, tuberculosis, mental health conditions, and sexual and reproductive health problems.

Lack of safe and supportive working conditions and violation of human rights render sex workers vulnerable to HIV infection through actions such as confiscating condoms, using condoms as evidence against sex workers and violence against sex workers. Female sex workers have difficulty in accessing health services in many parts of the world due to criminalization of sex work. Because of criminalization, sex workers are less able to negotiate condom use and are subjected to violence by clients [11]. Globally, decriminalization of sex work could lead to a 46% reduction in new HIV infections in sex workers and eliminating sexual violence against sex workers could lead to a 20% reduction in new HIV infections [12].

Sex workers have basic human rights to prevention, care, and treatment [13]. Most interventions currently focus on prevention and condom use. Sex workers should also have equitable access to antiretroviral therapy. In many countries, such as India, no published data are available on the number of sex workers receiving antiretroviral therapy [14]. As a vulnerable population, it is very critical for sex workers with HIV to have access to treatment [15]. There is, however, an increase in the number of sex workers accessing antiretroviral therapy with the help of peer educators, as well as trained, non-judgmental providers [14].

Legal frameworks are needed to protect human rights. There should be mandatory measures by governments such as compulsory HIV testing of sex workers. Interventions that improve HIV knowledge and protective behaviors, particularly condom use, as well as those that respect human rights are the key to successfully preventing HIV among female sex workers.

In addition to legal reform, programs that take an empowerment approach, such as the Sonagachi Project and Sagram in India, have shown to create better working conditions and have been most effective in reducing HIV acquisition by female sex workers [16, 17]. Female sex workers themselves have led some of the most effective, evidence-based responses [18]. Empowering female sex workers with the means to protect themselves has worked effectively for HIV prevention.

4.2 Research on Female Sex Workers

Research was undertaken to study the values, preferences, and practices with regard to self-care for sexual and reproductive health and rights (SRHR) and HIV prevention and treatment in female sex workers. The objectives were to obtain an understanding of their views about self-care practices; how they obtained information on self-care interventions; what were their motivations to use them; what barriers they faced while using them; and what they did if self-care practices failed.

Research was undertaken in Delhi and Tamil Nadu. A qualitative study design was employed. In-depth interviews (IDIs), focus group discussions (FGDs), key informant interviews (KIIs), and a workshop were conducted with female sex workers. Qualitative research methods allowed greater spontaneity and interaction with participants. They provided an opportunity to the participants to respond elaborately and in greater detail. The interviews were conducted using interview guides. The interviews were approximately 90–120 minutes in length. The interviews were recorded, and the recordings were transcribed and checked for accuracy. Two IDIs, two KIIs, and one FGD (8–10 participants) were conducted in Delhi. One workshop was conducted in Tamil Nadu with 15 female sex workers who were HIV positive to understand their general health problems, sexual health and HIV issues, and how they accessed information on SRH products and services on social media and other platforms.

For the key informant interviews, participants were selected on the basis of their experience. They were peer educators working with NGOs. For in-depth interviews, outreach workers with 4–5 years of experience were selected. Focus group discussions included peer educators, outreach workers, and other young female sex workers. During the workshop, participants were asked to depict their sexual practices in art form for which they were provided with colors and canvas.

Triangulation of data generated by KIIs, IDIs, FGDs, and the workshop made it possible to obtain reliable information on complex issues. Ethical approval for undertaking the study was granted by the Ethical Review Board of the Humsafar Trust. Before initiating the study, participants were given consent forms which described the study. Consent of all participants was taken in writing and orally. Confidentiality of all participants was assured.

4.2.1 Research Findings

The findings include a discussion of the feelings and behaviors of female sex workers; self-care interventions for SRHR; information sources for SRHR; risks and barriers faced by the community; and motivations for self-care.

4.2.2 Involvement in Sex Work

Study participants including sex workers, peer educators, healthcare providers, and counselors indicated that social exclusion due to poverty, low income, unemployment, lack of education, little or no social support from the family, and adverse living conditions dragged women into sex work.

Because they were not qualified to get well-paid jobs and were harassed by their employers at their workplace, women engaged in sex work. They disliked their work and found that sex work was their best or only option to make a living. Some were agnostic about sex work but found that it offered flexibility and good pay.

The conditions of our workplace were harassing, there was no flexibility in working hours, and sex work offers us a better pay off.

Generally, migrants from poor regions who were unable to find work to meet their basic needs ended up in the sex work industry.

In order to earn our livelihood, we prefer to get involved in sex work; this is the easiest way for us.

Sex workers, like most workers, had diverse feelings about their work.

We enjoy our work and find it rewarding and fun which is not so with other work.

4.2.3 Self-care Interventions for Health and Family Planning

The study showed that for common conditions, such as fever and flu, sex workers first tried homemade, herbal remedies. If they did not work, or they still needed help, then they visited the pharmacy (preferably the one that they accessed regularly). If they still needed help, they visited a health clinic. For HIV and sexually transmitted infections (STIs), they usually visited a health provider at a non-governmental organization (NGO) usually one that they regularly associated with. Only when absolutely necessary, they visited health centers, mostly government-run health centers.

We visit clinics in severe conditions only, else we prefer home-made remedies.

Female sex workers preferred to use condoms as they could get them free of cost from NGOs or their clients brought them. The use of creams and gels among female sex workers was rare as the NGOs did not provide these and they had to purchase these products from medical stores.

We only use condoms as contraceptives. Creams and gels are difficult for us to buy.

The study indicates that consistent use of condoms was difficult with partners who refused to use condoms and promised to pay more instead. Sometimes, for fear of losing their clients, they did not insist on using condoms.

We easily get ready for sexual encounters without protection to retain our clients.

Female sex workers faced the risk of unwanted pregnancy and sexually transmitted diseases (Fig. 4.1). They had unmet needs for contraceptives and required more comprehensive interventions for sexually and reproductive health (SRH).

As we agree to have sex without condoms; we face the risk of pregnancy and have to get aborted.

Fig. 4.1
figure 1

Female sex workers access condoms painting by Ashu (Bips)

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Female sex workers were informed about modern contraceptives by the peer educators of the NGOs but had limited access to them. The study shows that because of lack of social support, limited resources, fear of violence from the clients, poverty, and unemployment, female sex workers compromised their own health and well-being.

4.2.4 Information Sources

Data on sex workers in different places revealed that it was important for women who trade sex for money, to have knowledge about HIV prevention and sexual and reproductive health. Female sex workers got information through social media, mass media, and their interpersonal contacts, i.e., peer educators and outreach workers. Through television and radio, they got information related to condom use for safe sex. The study findings suggest that women who were involved in sex work generally got information from NGOs and outreach workers. NGO workers undertook behavior change communication programs to make them more aware about sexual and reproductive health. NGOs conducted condom demonstrations and also provided information on hygienic practices that female sex workers should follow.

Female sex workers generally obtained products such as antibiotics, condoms, creams, and gels from NGOs who also provided regular checkups for detection of syphilis and HIV testing. Thus, NGOs provided female sex workers services and also informed them about safe and protected sex.

I use condoms. NGO told me to use these. They taught me how to use a condom when I joined there. When I first went there, they asked me to take an HIV test and I refused, but they made me understand that this was for my own benefit.

4.2.5 Risks and Barriers Faced by the Community

Women traded sex for money because they faced poverty issues. They lacked support from their families. When they had children, they had to bring them up alone.

We are all alone to look after our children and our families. Our parents do not support us. Our husbands also rely on us for their extravagant lifestyles. They indulge in debauchery. We have no option except to trade sex for our livelihood. Some of us are forcefully thrown into the sex trade by our husbands.

The study shows that because female sex workers were stigmatized by the health system, they were afraid to visit doctors. When they had a problem, they preferred to take medicines from the pharmacies. However, if they were unable to explain their problems related to sexual health to the pharmacist, they could take the wrong medicine which resulted in harmful effects.

We have a fear of breach of confidentiality, and so we avoid visiting the healthcare facilities.

4.2.6 Mental Health Problems Faced by the Community

Women in sex work traded sex for money; their sexual encounters generally involved sex without any emotional attachment. The study reveals that these women faced mental health problems and were ill-treated and abused by the community, police, and others (Fig. 4.2).

We are sexually abused by the police and other men around us. They do not pay us after sexual intercourse and sometimes they bring 4–5 men with them to abuse us.

Fig. 4.2
figure 2

Female sex workers seek protection painting by Ashu (Bips)

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They faced stigma in society which resulted in mental depression and isolation. They actively chose sex work because they found more perks in sex work than in other jobs.

If we have to get abused anyway, we might as well earn through sex work.

4.2.7 Violence Faced by the Community

The study shows that female sex workers experienced physical, psychological as well as sexual violence by the community. They were forced to have sex with men in their own families. They were threatened and abused by their family. They were also beaten up by the older members of their families.

We are humiliated and threatened by our families and fear the loss of custody of our children.

They were abused sexually and were denied their basic rights. They were forced to consume alcohol and drugs and were sometimes arrested by the police for carrying condoms. Female sex workers also faced verbal abuse because customers and other community members saw them as undesirable women in the society.

People call us ‘whore’ and bully us.

4.2.8 Motivation for Self-care

The study shows that when female sex workers were not aware about HIV and other sexually transmitted diseases, they frequently had sex without protection. At times, their clients forced them to have sex without protection by bribing them with extra money. Through their association with NGOs, they become more informed about sexual and reproductive health. Consequently, they refused to have sex without protection even if they were offered more money. With increasing awareness through different programs, female sex workers become more concerned about their sexual and reproductive health. They got motivated to use self-care through workshops organized by NGOs to enhance their awareness of the importance of following self-care practices.

4.2.9 A Female Sex Worker with AIDS: Personal Narrative on Self-care

Documented By: Philo Magadalene A.

Women driven to sex work face intersectional oppression encountering the very realities that they seek to overcome. As they struggle to confront, cope with, and survive these conditions, it is only normal that self-care tends to take a backseat.

This is the story of an HIV-positive widow who turned to sex work out of sheer desperation to feed the family, and whose self-care practices were purely driven by the motive that she, being the only breadwinner of the family, could not let her children be orphaned.

Vijaya along with her one-year-old daughter was diagnosed with HIV in the year 1998. Having received the infection from her alcoholic husband who had an illegitimate affair, Vijaya did not know that he had been infected until then. She shuddered when the nurse said, “You have AIDS. You will die in four years. You already have two daughters with you. Get them married soon.” AIDS had been the go-to word as nobody used the term “HIV” then. Having been abandoned by her second husband and left alone to fend for the family of four children, she sunk further into poverty with heightened vulnerabilities. Her health conditions did not allow her to be a domestic helper anymore. She realized, “How will people in the houses accept me for work if I keep scratching myself?” Sex work appeared to be the only plausible option.

Vijaya’s knowledge about sexual and reproductive health was limited before she entered sex work. But she knew well enough to visit the medical health facility when she needed anything. That was how she aborted her fourth child who was conceived soon after the delivery of the younger child. When she conceived again for the last time, she resorted to unsafe abortion through hearsay remedies like papaya, sesame, and palm sugar, but had to reach out to the government hospital after three months when nothing worked. By then, it was too late for safe abortion. She pleasantly recalls, “I was told, ‘Be it a boy or a girl, give birth and raise the child.’ Now that is the daughter who is feeding me.” Vijaya underwent family planning surgery 14 days after her fourth child was born.

Vijaya’s first experience with sex work was at a prostitution home she used to visit. Since her knowledge about condoms and safe sex practices came only from interaction with non-governmental organizations (NGOs), one can believe that before this relationship with NGOs, she was involved in high-risk sexual behaviors during her time in the prostitution home. In addition to health vulnerabilities, she also put herself at social risk. She remembers a time when her landlord visited the prostitution home as a client and she had to request someone else to attend to him because she “didn’t want him knocking at my door in the middle of the night causing problems.” At this point in Vijaya’s life, one sees no instance of positive self-care behavior in terms of sexual and reproductive health.

Realizing the dangers that come with visiting a prostitution home, Vijaya decided to stop going there and began attending to clients in their own homes or in her home. As she went to the District Collectorate every morning in search of customers, she got introduced to NGOs like Teddy, Russ Foundation, and Thaai Vizhudhugal who looked out for people like her in that place. A person from an NGO told her, “There are so many NGOs. Just by attending all their meetings, you can get around 600 per month.” In pursuit of an alternate way to earn, Vijaya promptly made use of this opportunity and began attending different NGO meetings in exchange for food and money. Despite this motive, she did end up receiving crucial learnings about self-care that were of much higher value.

Vijaya learned about the importance of condoms and regularly received a sufficient number of these from the NGOs. She says, “There are places in bus stands, where you can place the money and get condoms. I never take from there because I always have what the NGO gives me.” After she learned about the indispensable nature of condoms, she began carrying one in her handbag wrapped in a newspaper always and strictly ensured that the customers used it. Usage of condoms was one continuous self-care routine that she practiced because she believed this: “I don’t want them to face what I am going through by living with HIV.” Even for a self-care routine as simple as the usage of condoms, Vijaya faced several barriers. Many clients, assuming that “Free condoms won’t be good” or that “they will break,” refused to use the condom she offered. Speaking of this difficulty, she admits, “I won’t tell them that I am infected. If they know that, they won’t come to me.”

The condom was not the only contraceptive that the NGOs introduced to Vijaya and her community members. Speaking of an instance when an NGO proposed the use of female condoms and offered them samples, Vijaya says, “I didn’t like it. But some people did, because, with female condoms, they could attend to their clients without any issues even when they were having their periods.”

In addition to the quality information provided by NGOs, Vijaya also acted on the information she received from pharmacies. More often than not, the medicines she took were to ensure that she could continue her work without any hindrance. She made frequent visits to the pharmacy requesting medicines that would postpone her period because she had to “visit the temple.” Her ignorance and lack of knowledge about such health practices led to complications that Vijaya never anticipated. When she turned 40, she began having intense flow lasting for 15–20 days that no amount of medications could control. The government hospital refused to operate on her, and the private facility was too expensive for her to afford. She blames herself for the situation she was in saying, “I didn’t know we were not supposed to take that tablet a lot.” Only after she produced a letter from an influential activist did the government hospital decide to treat her.

Vijaya’s dependence on the pharmacy was not restricted to period delay medicines alone. She dealt with the frequent STIs by approaching the pharmacy and buying tablets for amounts as little as 15 rupees. At times when that did not work, she visited the government hospital receiving a prescription for 15 days which she would reuse the next time she had the same infection. Vijaya’s reliance on medicines dispensed in the pharmacy may be seen as a form of a self-care routine, but it also points to her high-risk behavior. Through pharmacies, she had open access to an excess amount of medicines like Brufen and Paracetamol that she had little knowledge about. She says, “For a long time, I had thought I could take as much Paracetamol as I wanted because it won’t affect my body.”

One can understand that the self-care that Vijaya believed in practicing to manage her health issues was partly driven by faulty assumptions and myths. Having been sensitized by the NGOs about the importance of condoms, she moved with the belief that condoms are enough to protect oneself and maintain good sexual and reproductive health. Once, when the doctors strictly insisted that she limits the number of clients and avoids excessive use of tablets to deal with the recurring sores in her vagina, she argued that “the customers are using condoms anyway.” She only realized she was wrong when they told her, “this has nothing to do with that.”

Given her illiteracy and poverty, the only sources she could count on for health-related information were NGOs, pharmacies, and government health facilities. Vijaya’s account of doctors in the government hospital reveals that she received constant lectures from them advising her to “exercise self-control,” “go for construction labor,” and not “make your child an orphan,” It sometimes even went to the extent of making her cry. The doctors insisted that she should come to the hospital for any ailment instead of visiting the pharmacy. But, interestingly, one notices that the support Vijaya received in terms of knowledge and information was much better from the pharmacy. For example, when Vijaya wanted to know about a particular injection she received in the hospital, the doctor had said, “Even if I tell you, are you going to understand?” But whenever she asked from the pharmacy what a particular tablet was for, they said, “It’s for pain. Don’t take it too much. If you take too much, it’ll affect your kidney.” Or when she asked for “three strips of painkillers,” they advised her to “take one, as and when it was really necessary.” Although it is not appropriate for a pharmacist to take over the duty of the doctor, when it came to informing and sensitizing the patient, in Vijaya’s case, it was the pharmacy that usually provided her the support she needed.

NGOs were Vijaya’s monumental support system attempting to address her intersectional vulnerabilities. They played a critical role in ensuring that condom usage and other positive health behaviors become a part of Vijaya’s self-care routine and that she understood the importance of her medications for HIV. She notes, “They tell me that even if I had nothing to eat, I must at least have a biscuit and tea and take my medications, and at no cost, should I stop my medication.” Aside from sensitizing people, NGOs also provided emotional support whenever Vijaya needed it. It was a space she could impulsively reach out to anytime she needed anything.

Vijaya’s strong dependence on NGOs can be explained by the fact that she lacked social support elsewhere. With her parents and even some of her children not knowing about her HIV status and sex work, Vijaya did not have anybody to confide things. She was not closely involved with her peers preferring to keep her affairs to herself. Her discretion stemmed from many obvious reasons. Vijaya was especially wary of her neighbors finding out about her situation and creating problems. She says, “They used to ask, ‘Why do you always go to the government hospital and get medicines? What medicine is that? What is it for?’… If I had told them the truth, they wouldn’t have let me stay.” Many years back, when the school her daughter studied in discovered the child’s positive status, they made her sit outside in the rain during examinations because she had gotten sick. Vijaya fought with the teachers and removed her from that school the same day.

Besides these social struggles, the financial burdens she had to wade through to make ends meet only enhanced her vulnerability. A customer of hers intermittently lived with her offering to support the family, but it was not enough for her to quit her work. She borrowed from neighbors and local rowdies owing them a large amount of money that grew with cumulative interests daily. There were times when she had to lock the door from the outside and stay inside with her children or vacate the house abandoning everything in the wee hours of the morning.

Having quit sex work for three years now, she currently lives in a government-sanctioned house, having neighbors who have lived through similar experiences like her.

Speaking of self-care, Vijaya says, “Self-care to me is, taking good care of my own body—not attending to more customers than my body can handle and immediately visiting the doctor at the hospital if I have any ailments. If it is just a headache or fever, I’ll be all right by just tablets, but if I have any other problems I will cancel everything I have to do and run to the hospital first thing in the morning. One must take care of oneself in such a way that one doesn’t have any ailments.”

Like all breadwinners of a family, her motive for self-care stems from the need to be alive and active for the sake of providing for her children.

4.3 Discussion

Recent estimates suggest there are approximately 8,68,000 women in India who are currently engaged in sex work [19]. Sex work is closely linked to caste discrimination, poverty, and gender inequality that is pervasive in India, with practices of underage marriage and dedication of young girls into sex work as part of religious traditions including the “devadasi” system in northern parts of Karnataka [20]. Although the devadasi system was made illegal in 1988, it is still one of the most common forms of traditional sex work in north Karnataka [21]. More than 90% of female sex workers in northern Karnataka come from devadasi families and represent the most marginalized “Scheduled” Castes or tribes [20].

Female sex workers have been historically blamed for the spread of STIs. In recent years, they have been held responsible for the spread of HIV [22,23,24,25]. Programs have targeted female sex workers for HIV/STI prevention [22]. While this has benefitted them, it has unfortunately increased stigma and discrimination for female sex workers as they have been labeled as “vectors of disease” [26].

Female sex workers face multiple, complex, and interdependent health problems. One example is violence which is widespread originating from a range of perpetrators including intimate partners, police, pimps, and paying partners [27, 28]. There is a growing body of evidence to show that exposure to violence among female sex workers is associated with many adverse health outcomes including: increased prevalence of HIV and sexually transmitted infections; poor emotional health; increased alcohol or drug misuse; and reduced access to STI/HIV clinics [29,30,31,32].

The mechanisms through which violence adversely affects women’s health are complex and bidirectional. Violence may increase the risk of HIV/STI transmission directly through forced unprotected sex. Evidence suggests that coerced sex is rarely protected and can result in injuries that increase the risk of transmission of STIs and HIV [33,34,35]. Exposure to violence can also lead to depression and low self-esteem, which in turn may lead to alcohol or drug use and reduced ability to negotiate condom use. This, in turn, can compound low self-esteem and emotional health problems [36]. Additionally, broader gender inequalities that are key determinants of both STI/HIV transmission and violence among female sex workers often play an important role in reproducing gender inequalities leading to higher risk of HIV/STI transmission [37, 38]. Gender inequalities that give men power over women increase the risk of violence against women, by reducing their ability to negotiate safe and consensual sex, and hindering women’s recourse to justice and help [39]. Research shows that men who are violent are more likely to have multiple concurrent partners, use condoms less frequently, have unprotected anal sex, and report substance use [40]. All these factors have been linked to increased risk of HIV/STI transmission among female sex workers [41, 42].

A significant intervention project, the Sonagachi Project (Durbar) in Kolkata, West Bengal, serves over 65,000 female sex workers annually [26, 43, 44]. The strategy employed by the Durbar project for female sex workers and their partners is to ensure consistent condom use (CCU) in every sexual encounter. A study conducted in Kolkata showed that nearly half of the female sex workers reported symptoms of STIs that required treatment in the previous 12 months [43]. It also showed that 92% of female sex workers used condoms for the prevention of pregnancy [45]. In this project, female sex workers are empowered to use condoms in every sexual encounter. Condom use is prioritized in this community because other strategies for decreasing infection such as reducing the number of sexual partners are not feasible given female sex workers’ financial needs.

Female sex workers in Durbar are empowered to demand condom use by their partners. The project promotes community mobilization and condom distribution which are supported by brothel owners and peers [44, 46]. Since risk perception depends on the intimacy gradient, female sex workers may not use condoms with intimate clients and husbands [47, 48]. This may also happen if they are offered more money [49]. Newer methods such as pre-exposure prophylaxis (PrEP) are not as yet widely available to female sex workers and have not shown the same community-level impact as constant condom use [50]. Female sex workers have multiple partners whose risk behaviors outside the brothel are not known [51].

The belief that condoms decrease emotional and sexual intimacy results in condomless sexual encounters which increase the transmission of HIV/STIs [52,53,54]. Programming should, therefore, take cognizance of these factors, and strategies should be tailored to the specific needs of female sex workers and their intimate partners to prevent infection. The Sonagachi Project incorporates multiple interventions at multiple levels by including advocacy, community mobilization, micro-banking, and health services [55,56,57].

Over the years, it has been recognized that HIV prevention requires structural interventions to address the vulnerabilities of sex workers, including legal, physical, social, and economic factors [58,59,60]. UNAIDS guidelines emphasize that human rights-based approaches are the standard for HIV prevention interventions, noting that the most successful interventions occur when “female sex workers are able to assert control over their working environments, negotiate and insist on safer sex” [61]. Community mobilization is an intervention strategy that encourages collectivization to bring about structural change [59]. Community mobilization not only aims to empower marginalized key populations (particularly female sex workers) as a group for vulnerability reduction, but also increasingly allows them to make decisions and shape their own lives, which in turn influences the adoption and maintenance of low-risk behaviors [62,63,64]. Community-led interventions seek to change social and political structures by organizing female sex workers to confront structural barriers at multiple levels, resulting in both individual and collective empowerment [65]. The Sonagachi Project, a community mobilization project with a secondary impact on economic strengthening, is one of the best-known female sex worker interventions. It is cited as an example of a best practice and a designated HIV prevention model by the World Health Organization [43]. Inspired by the Sonagachi Project, Avahan India AIDS Initiative program is also known for its combination approach to HIV prevention that includes facilitating structural change through community mobilization.

Migration for sex work is one of the key socio-demographic drivers of the geographical spread of HIV from high- to low-HIV prevalence areas [66]. Migration is consistently reported as a potential driver of the HIV epidemic and migrants (both male and female) are at increased risk of HIV infection [67,68,69,70,71,72]. “Mobility,” in terms of short-term movements, is also a crucial factor that increases the spread of HIV infection due to the higher incidence of unsafe sex along the routes of migration [73]. In India, most studies related to mobility and migration have focused on employment-related male mobility. Male mobility functions as a potential bridge for the transmission of HIV infection from high- to low-risk populations along the routes of migration [74,75,76,77,78,79].

There is limited evidence in India on the movement/mobility-induced vulnerability of female sex workers [80,81,82,83,84]. The chance of economic improvement is a consistent motivation for movement among migrant communities across the globe, including India [76]. However, in the context of sex work, the reasons for mobility among female sex workers are varied. Recent studies on the mobility of female sex workers in southern India indicate that high interstate and district mobility is motivated by the need to earn more money in order to improve their economic condition and to repay debt [72]. The clandestine nature of sex work is another reason for female sex workers to change their sex work venues frequently. Change of place helps to avoid stigma and maintain secrecy about their work from family members [85].

Thus, female sex workers employ a number of strategies to continue their work despite the stigma associated with it. The example above illustrates how NGOs have organized different interventions including mobilizing and collectivization among others to prevent the transmission of HIV/STIs among sex workers and their clients. There is a clear need to design prevention interventions tailored to the needs of different female sex workers in different settings. The changing dynamics of client solicitation through mobile phones present new challenges for the design of appropriate interventions for mobilizing female sex workers and preventing the transmission of HIV/STIs.