High-risk sex among mobile female sex workers in the context of jatras (religious festivals) in Karnataka,India

INTRODUCTION

India ranks third in the world and first in Asia in terms of the absolute number of people living with HIV/AIDS (PLHAs), with about 2.5 million people estimated to be HIV positive. ¹ The HIV epidemic is concentrated in six states: Manipur, Nagaland, Tamil Nadu, Andhra Pradesh, Karnataka and Maharashtra. Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka states contribute 63% of all PLHAs in India. The epidemic is largely driven by heterosexual transmission, and research has shown that a substantial proportion of this transmission involves sexual networks that include female sex workers (FSWs). ² Sentinel data among FSWs indicate an HIV prevalence of 5.4% in India ³ and 16.3% in several districts in Karnataka state. ⁴

In an effort to respond to the HIV epidemic in India, substantial efforts have been made over the last few years towards offering FSWs access to information about sexually transmitted infections (STIs) and HIV, and access to condoms, medical clinics and other medical services. However, FSWs who tend to move geographically for sex work have been particularly difficult to cover by programmes. FSWs on the move are more difficult to contact, follow up, treat and empower. In this paper, we discuss FSWs' movement to jatras as a special case of mobility.

Karnataka has a number of jatras each year, in which thousands of people assemble for a short duration of time at a specific location. Jatras (yatra means procession or journey in Sanskrit) are gatherings of people on the occasion of religious festivals. In time, they have become sociocultural events, providing opportunities for entertainment and leisure activities, especially for people from rural areas. Jatras also represent a venue for women to practice sex work, and for men to seek their sexual services, in a context where the social controls regarding such behaviours which may exist at the places of origin are lacking. However, very little is known about the practice of sex work at jatras. This study represents an attempt to understand the HIV risk associated with sex work at jatras in Karnataka, and brings attention to the need for HIV prevention programmes to target FSWs and men visiting jatras.

BACKGROUND

Jatras are religious festivals taking various forms, depending upon their origin and the local culture and customs. Jatras are celebrated throughout India at different times of the year and have varying durations. While some well-known jatras can attract tens of thousands people or more, including many from far away, local jatras are usually attended mainly by people from the surrounding areas (especially rural areas). The predominant nature of jatras is religious. Irrespective of the religious, caste or community group which organizes the festival, people from all communities from neighbouring villages attend jatras as a mark of support for the organizing community, and in the interest of social harmony and cohesiveness. ⁵ For example, it is not uncommon for a large number of Hindus to attend jatras organized by Muslims and vice versa.

Perhaps because of the heterogeneity of the people who attend these festivals, the religious activities vary from jatra to jatra, even when they take place in the same region. ⁶ For instance, in some jatras people appear to be possessed by the deity of the festival, demonstrated by walking barefoot on burning coals, placing long rods through piercings, pulling heavy objects attached to their hair, etc. In other jatras, thousands of sheep and goats may be offered as animal sacrifices followed by a celebrating feast. Similarly, in some jatras, a bottle of country liquor may be offered to the deity, after which the participants in the jatra drink together. On these occasions, people are free to communicate across the boundaries of social hierarchy without worrying about offending those of higher status. True emotions and feelings are revealed and the psychological distance among people dramatically narrows. ⁷

Most local jatras also organize sociocultural activities. These include folk music and dance, devotional singing, and special competitions for children and women, such as painting, drawing, classical dance and music. Jatras are also a venue for sports with the most popular ones being wrestling, weight lifting, three-legged races and eating competitions. ⁸ The most common activities in almost all jatras are dramas, plays, circuses, tamasha theatres (female dancing), and mobile cinema theatres showing a variety of movies from religious to pornographic. Young men are attracted to jatras mainly because of dramas, songs and dances, which, at times, are lewd. Most of these activities take place late in the evening or at night. As there is often a shortage of power, they are often conducted using independent electric generators, and there are hardly any street lights. This provides a conducive environment for sexual activities, both commercial and casual. ⁹ There is also a multitude of gambling activities. Temporary stalls sell food, liquor, tobacco, etc.

Depending upon the presiding deity of a jatra, the ritual and customs encourage the dominance of a particular gender. For example, there is a well-known jatra in northern Karnataka called Yellamma (namesake goddess of the fair) in Saundatti of Belgaum district. At this jatra, young girls are initiated through rituals as Devadasis, who take on a permanent ‘unmarried’ status, and engage in forms of entertainment for men that include sexual services. ¹⁰ This jatra is attended not only by those who are being initiated, but also by older Devadasis. Since it is well known that sex work takes place at the Yellamma jatra, many men go there from distant places to receive sexual services.

In addition to having sociocultural and religious purposes, jatras also serve economic purposes. For rural people, especially farmers and agricultural labourers, they are often a venue for cattle transactions. If a jatra is celebrated for a week or more, usually the first two to three days are dominated by religious rituals and the remaining days may be spent with cattle transactions. During the animal transactions, most children, female family members and elderly people go back to their places of residence. Only the adult men, especially those involved in buying and selling cattle, are left behind. During this time, as per our observation, the concentration of FSWs around the cattle fair area tends to increase.

The timing of jatras is also important for village people. Jatras usually take place following harvesting and other occasions worth celebrating. People feel the need to eliminate their boredom and tiredness by participating in these jatras. By the same token, within the confinement of time and space, the boundaries separating people in their day-to-day lives are blurred, which allows the participants to reveal feelings of oppression, and to heal these feelings by being part of the ‘chaos’ of the jatras. ¹¹

DATA AND METHODS

We employed data from a survey conducted among mobile urban FSWs from five districts of Karnataka state in order to assess the extent of their mobility and the associated HIV risk. The survey collected information on the places where mobile FSWs worked within the two years prior to the survey. In addition, participants were asked about their mobility to jatras and the extent of their sex work practice on these occasions. The analysis focused on: (1) the patterns of jatra mobility; (2) the sociodemographic profile of jatra attendees compared with non-jatra attendees; and (3) the sexual behaviour and HIV risk of jatra attendees at their regular places of residence.

The survey was conducted in 2007 in the districts of Bangalore Urban, Dakshin Kannada, Bellary, Dharwad and Gulbarga, after characterizing the study areas. This included identification of sex work sites and estimation of the number of FSWs. These lists of ‘hot spots’ were used to prepare a list of primary sampling units (PSUs), with each PSU covering an estimated 500 FSWs. A total of 45 PSUs were formed, of which 30 PSUs were selected randomly to constitute the sampling frame for the survey. The sampling procedures involved two-stage systematic sampling in brothel-based areas, and time-location sampling in non-brothel-based areas. The study was confined to FSWs 18 years and above who consented to participate, had been in sex work for at least one year, and who fulfilled our definition of mobility, i.e. who had visited two or more places for the purpose of sex work in the past two years, one being outside the district. Power calculations based on 30% non-consistent condom use among FSWs indicated a sample of 200 mobile sex workers interviews was sufficient for determining non-consistent condom use and associated risk factors, including degree of mobility. Assuming that half of the randomly selected FSWs are mobile in each district, we targeted for the survey between 300 and 400 FSWs. A total of 2406 sex workers were screened in the survey, of which 1499 were eligible satisfying the inclusion criteria described above. Thus, 62% of all the FSWs interviewed were mobile in Karnataka by our definition. However, only a third of these 1499 mobile FSWs attended jatras. Ethical approvals from the University of Manitoba, Canada, and the Population Council of India, were obtained.

Data were analysed using SPSS 15.0. In the bivariate analysis, chi-square tests of significance were conducted for categorical dependent variables and analysis of variance for interval dependent variables. Multivariate analyses consisted of multinomial logit regression predicting jatra-related mobility status, and logistic regression predicting non-condom use at last sex with an occasional client.

RESULTS

Table 1 presents data on the pattern of jatra-related mobility. Almost one-third of FSWs visited jatras in the year prior to the survey. FSWs went to jatras on average every 3.5 months. Jatra mobility was generally not mediated by other people such as pimps, brokers and agents, as most FSWs went to jatras either by themselves (37%) or with other FSWs, friends or family members (59%). Almost two-thirds of FSWs went to jatras in groups of 2–3 people. About 63% of FSWs reported doing sex work at jatras, and of those who did, the large majority reported servicing men coming from other places for the duration of the jatra (94%). Only 13% of the women reported using condoms consistently when they sold sex during the last jatra.

Table 2 illustrates the variation in a number of sociodemographic and sex work-related parameters, as well as HIV risk/vulnerability and programme exposure variables, by jatra-related mobility status. We distinguished between three groups of mobile FSWs: (1) those who did not go to jatras in the year prior to the survey; (2) those who went to jatras and did not do sex work; and (3) those who went to jatras and did sex work. We mainly compared the first and third groups of FSWs, as FSWs who reported going to jatras but not doing sex work may have felt uncomfortable admitting practising sex work at jatras, so this may have been under-reported.

Table 2 suggests that women who do sex work at jatras had a different sociodemographic profile compared with non-jatra-attendees, as they were older (mean age 27.5 versus 26.9 years), less educated (3.5 versus 4.2 years), slightly over-represented among the Hindus (86% versus 77%), and were less likely to be unmarried (18% versus 29%). Jatra-attendees started sex work at slightly younger ages (23 versus 24 years) and had been in sex work for a longer period of time (4.3 versus 3.1 years). Both groups reported about the same number of clients per week (14.2 and 14.5), but jatra-attendees earned significantly less money from sex work (Rupees 2439 per week, approximately US$51) compared with their counterparts (Rupees 3922 per week, approximately US$82). Hence, it is not surprising that only 48% of jatra-attendees indicated sex work as their only source of income, compared with non-jatra-attendees (71%). Women practising sex work in brothels, lodges or on highways were under-represented among jatra-attendees, and those working from homes or public places were over-represented.

In addition to jatra-attendees practising unsafe sex when doing sex work at jatras (only 13% use condoms consistently), they also reported lower condom use at last sex with an occasional client at their regular place of residence compared with non-jatra-attendees (33% versus 53%). Jatra-attendees reported higher percentages of alcohol consumption (67% versus 59%) and of clients under the influence of alcohol (96% versus 89%). The riskier sexual behaviour of jatra-attendees was in contrast with their reporting higher membership in non-governmental organizations or community collectives compared with non-jatra-attendees.

Table 3 presents the results of multinomial logit regression predicting jatra-related mobility status (defined as indicated above). Compared with non-jatra-attendees (the reference category), women who went to jatras tended to be from districts other than Bangalore, of Hindu religion, to have been in sex work for a longer period of time, to have done other work in addition to sex work, and to practice sex work in public places, their own homes or on highways.

Table 4 presents the results of logistic regression predicting non-condom use at last sex with occasional clients at the regular place of residence. Jatra-related mobility was a significant predictor of non-condom use, even after controlling for sociodemographic, sex work-related, HIV vulnerability and programme exposure variables. Compared with non-jatra-attendees, women who practiced sex work at jatras were almost twice as likely to report lack of condom use at last sex with an occasional client.

DISCUSSION

This paper represents a first attempt to describe the practice of sex work at jatras and shows that jatra-attending FSWs have risky sexual behaviours, as indicated by their extremely low use of condoms. Close to one-third of the FSWs surveyed had practiced sex work at jatras in the previous year, and only one-third of jatra attendees used condoms during sex with their most recent occasional client while practicing sex work at the usual places of residence. At the same time, only 13% of them used condoms consistently while practicing sex work at jatras. This difference in sexual behaviour indicates that jatras represent a particularly risky environment for sex workers. Anecdotal evidence suggests that this may be the result of a combination of factors. First, one cannot usually buy or be given condoms at jatras, as there are no shops or programmes established at these places where condoms can be obtained. Because some women may not practice sex work on a full-time basis in their villages of origin, they may not bring their own condoms with them. Second, women who have condoms may find it difficult to use them, as many of the men are from rural areas and may not be accustomed to condoms, or willing to use them. Third, even if men are willing to use condoms and condoms are available, the darkness and/or the lack of privacy and time might often make it difficult to use condoms correctly. Fourth, the issue of condom use may be complicated by the fact that drinking is a widespread practice at jatras and sometimes even part of the jatra rituals. If both the woman and the client are under the influence of alcohol, it is unlikely that they will use condoms. Finally, because most clients are from rural areas, FSWs may perceive the men who come to jatras as being less risky. These may be some of the reasons why jatra-attending FSWs tend not to use condoms, even if they are over-represented in FSW collectives.

Women who practice sex work at jatras have a certain sociodemographic profile, which suggests that they represent a select group of sex workers. Compared with non-jatra attendees, women who go to jatras tend to be from northern Karnataka, of Hindu religion, to have practiced sex work for a longer period of time, to do other work in addition to sex work, and usually practice sex work in public places, their own homes or along highways. At least in Karnataka, street- and home-based FSWs generally experience lower levels of risk compared with women working in more organized settings (e.g. brothels), in terms of the number of clients they entertain. ¹² However, their sex work practice at jatras represents an additional risk that needs to be taken into account, as on these occasions the women have many clients (anecdotal evidence suggests between 10 and 20 clients per day, where a jatra lasts between 3 and 8 days), and most of the times they tend to engage in unprotected sex.

The finding that jatra attendees represent a select group of sex workers is supported by the fact that, in comparison to women who do not visit jatras, they reported lower condom use even at their usual places of residence. Jatra-related mobility was a significant predictor of non-condom use with occasional clients at the place of origin, even after controlling for sociodemographic, sex work-related, HIV vulnerability and programme exposure variables. In other words, in addition to the vulnerabilities specific to the environment of the sex work practice at jatras, the women themselves seem to be more prone to engaging in risky sexual behaviour. By comparison, condom use among Karnataka FSWs overall is reported to be very high (over 80%), and HIV and STI prevalences among them have been decreasing. ¹³

A number of limitations of this study need to be taken into account. The data come from a survey conducted among mobile FSWs whose focus was not on jatra mobility. Hence, limited information was collected regarding the HIV risk associated with this type of movement. Moreover, the study was conducted in urban areas and not at jatra places themselves. Anecdotal evidence suggests that jatra mobility, especially in the context of local small jatras, is largely a rural phenomenon, which makes the representativeness of the quantitative survey limited from the point of view of jatra mobility. Given that the survey was focused on mobility of FSWs in general and not specifically on jatra mobility and associated HIV risk, caution is advised in interpreting the findings.

Future studies should try to better understand the mobility pattern of women who practice sex work at jatras. Data on the jatras that FSWs visit would allow us to understand the networks of jatras, because women from a certain area might tend to visit the same jatras, and this would have implications for the sexual networks in the area and for HIV transmission dynamics. In addition, it is important to understand the intersection of jatra mobility with other types of movement (i.e. short-term mobility from villages to small nearby towns, long-term migration from villages to large cities), so that effective HIV preventive interventions can be planned.

Future research could also assess the different types of clients at jatras. While some men from rural areas only visit FSWs at jatras, others do so both at jatras and in their villages of origin, while still others may visit FSWs at jatras and in nearby small towns. Understanding the size of each of these groups and their sexual behaviour at each of the places where they visit FSWs would provide us with a clearer picture of the role of the clients of FSWs at jatras, and how they contribute to sexual networks. This has implications for HIV transmission in India, especially in rural areas. It is possible that most men who visit FSWs at jatras only do so on these occasions (i.e. do not visit FSWs in any other places), which means that the clients of FSWs at jatras may be a select subgroup of the FSW client population.

The findings of this study clearly suggest that from a programmatic perspective, condom availability and accessibility should be a priority at jatras, and HIV prevention programmes should make efforts to introduce outreach activities and offer services for sex workers and their clients at jatras. Many of the women who practice sex work at jatras may not do sex work at their places of origin, and may be particularly concerned with keeping their activities and identities confidential. This represents a great challenge for HIV prevention programmes among sex workers. Outreach strategies may need to be developed for reaching FSWs and their clients at jatra places. Most jatra-attending FSWs practice sex work in their places of origin in public places or their own homes, which are generally less easily identifiable than lodge-based or brothel-based FSWs. Hence, intervention activities at jatras might indirectly present an opportunity to reach FSWs who are more difficult to reach at their places of origin.

In summary, this paper represents a first attempt to understand the HIV risk associated with sex work at jatras and draws attention to the need for HIV prevention programmes to target sex workers and men visiting jatras.