In 2002, a major report predicted an Aids catastrophe in India. The country would have 20-25m Aids cases by 2010. People were being infected at the rate of about 1,000 a day. Aids orphans numbered 2 million. This scourge would ravage families, society, and the economy. India was going to be the Aids capital of the world.
But 2010 came and went. India averted an Aids epidemic. That victory – India’s biggest public health achievement – has remained uncelebrated. But a new book by one of the major HIV campaigners of that time finally honours the people he says were crucial in guiding India away from its seemingly inescapable destiny: the country’s sex workers.
Ashok Alexander spent a decade at the helm of the Bill & Melinda Gates Foundation’s campaign against HIV. In his book, A Stranger Truth: Lessons in Love, Leadership and Courage from India’s Sex Workers, he says the miracle would never have happened without the cooperation of sex workers.
Alexander, 64, was born into India’s elite. His father, PC Alexander, was principal secretary to Indira Gandhi. In leaving his career as senior director in the India office of McKinsey & Company to join the campaign to stop the spread of HIV, Alexander swapped a life of plush boardrooms and fine dining with CEOs for sitting on mud floors with sex workers, gay and transgender people and intravenous drug users. In short, a world of which he had little knowledge.
His account begins with his first day in the field, walking through a park in Vizag, in south India, in pitch darkness. As they navigated around couples having sex on the grass or behind the bushes, a local NGO worker urged: “Please don’t step on the people having sex.”
This was where sex work took place in India – in parks, at bus stops, on street corners. The fact that brothels accounted for only 7% of sex work presented a fundamental difficulty for the success of Avahan, as the foundation’s programme was called. How do you contain an epidemic in a setting where women are not clustered in one place, but dispersed and on the move? Where sex workers on the highways would get picked up by truckers then, when finished, cross the road to return on another truck?
Inevitably, a lot of data crunching and analysis had to happen – about which sex workers worked where, for how long, at what risk, and with how many customers – and this was entrusted to impoverished sex workers. They could have refused, but took on the task.
Tackling fatalism, an aspect of the national psyche, was harder. This quality can be seen every day on India’s roads, where drivers burst on to highways in the path of oncoming traffic without looking right or left. As one trucker told Alexander: “HIV might kill us in 10 years but this truck might kill us the next minute.”
Add the poverty, helplessness and lack of choice facing sex workers to this inherent fatalism, and the risk of catching the virus from unprotected sex seems remote and hypothetical compared with the brutal reality of survival. “You are telling me that if I get HIV I will die in 10 years’ time. But sir, 10 years is a lifetime for me. I have other, more serious things to worry about now,” said Theny, 25, a street-based sex worker.
Simple things often worked beautifully. At the outset, Alexander had no idea that a safe place to sit for a few hours, away from the violence of boyfriends, pimps, and police, could be so important. Avahan opened drop-in centres where, from 1-4 pm, they could unwind, have a hot shower and rest on a mattress on the floor. There was also the chance to be checked for sexually transmitted infection by a doctor without fear of being identified and stigmatised. For Avahan, the centres were a way of collecting the women in one place to be able to give them the information, support and condoms they needed.
As a former management consultant who has guided corporate executives on leadership qualities, Alexander couldn’t help but notice that the women – who gradually became his friends and colleagues – had these skills in abundance. In fact, he places sex workers a notch above business leaders on account of the sheer range of their skills. They are excellent judges of character and tough negotiators. Every day, they courageously battle emotional, financial and health crises while simultaneously keeping violence at bay.
Avahan scaled up with striking speed. It had a presence in 550 towns in just two years; within three, it had become the world’s largest privately sponsored HIV prevention programme.
But before scaling up, Alexander had to figure out the solutions. That required understanding sex workers’ lives and why they took the risks they did. Helpful here was the willingness of sex workers to mobilise as a community. The women knew what was best for them. All Alexander had to do, as he says, was tap into “the strength inherent in even the most marginalised of people if they are enabled to come together in a common cause”.
At the height of Avahan’s activities, Alexander and his teams were providing HIV prevention services to more than 270,000 sex workers, working in 672 towns, and distributing over 13m condoms a month. The programme, which cost $375m (£297m), is credited with an important role in the subsequent decline in India’s HIV status. Today, 2.1 million Indians are living with HIV. The prevalence of HIV is 0.22%, lower than that of the US.
The reason India’s sex workers never been praised for their contribution to this achievement, says Alexander, is that this was a success story no one wanted to author: “Their selfless contribution will never be recognised because of the stigma that still surrounds this disease.”
A Stranger Truth by Ashok Alexander is published by Juggernaut