Preface for At Risk

Preface

When I tell people this book is about AIDS¹ politics in India, they are often surprised. “Is AIDS still a problem?” they ask. “Is there AIDS in India?” In the US, when AIDS is not a relic of an (assumed white) queer past,² it’s usually the specter of Africa, not India, that animates the popular imaginary. But the scenario looked different in the mid-2000s, when I first began to learn about AIDS. In 2005, UNAIDS, a joint venture on HIV by eleven United Nations system organizations, estimated that India had the largest AIDS epidemic in the world, with 5.7 million people living with AIDS.³ Warnings that India’s AIDS epidemic would follow the path of sub-Saharan Africa’s made global headlines. North American experts predicted that India was on the brink of an explosive crisis and warned that its government, and what they considered a sexually conservative society, were woefully unprepared to stop it. In the next decade, massive resources would be mobilized for the Indian AIDS response.

Around that time, in the summer of 2004, I was an intern with a reproductive health research organization in Durban, South Africa. I had just turned twenty, and I was endlessly curious. It had been ten years since the end of apartheid, and conversations about race, politics, and inequality surrounded me. I had gone to Durban hoping to learn about women’s health in the context of a devastating AIDS epidemic. South Africa had (and has)⁴ one of the worst AIDS epidemics in the world. Some 5.3 million South Africans were living with HIV in 2004. In KwaZulu-Natal, 37.5% of pregnant women were estimated to be HIV-positive.⁵ That summer, I read an article about how the city of Durban had begun to recycle its graves.⁶

As I spent time in Durban, I began to understand the social and political drivers of South Africa’s AIDS crisis. I learned about the history of racist population control programs that prioritized reducing Black women’s birth rates over their sexual wellness.⁷ I learned about the apartheid migrant labor system that created the conditions for AIDS, and the neoliberal patterns of labor exploitation that intensified its effects.⁸ I learned about gendered economic precarity and its implications for sexual relationships, power, and control.⁹ I saw that AIDS was a symptom of globalization, an index of inequality and marginalization that cut to the heart of the thorny links between race, gender, sexuality, and capitalism.¹⁰ It was that summer that made me a sociologist. I wondered if India’s imminent crisis would play out the same way.

Eight years later, when I returned to South Africa, I was beginning a project on AIDS, and I got back in touch with my mentor from 2004. I was surprised to learn that India now featured much more prominently in her work, and in a very different way. No longer an example of a lackluster reaction to an unacknowledged growing threat, India’s AIDS response had become a model one. AIDS researchers in South Africa were now collaborating with AIDS researchers in India to develop new strategies for HIV prevention. The organization I had interned with was collaborating with a group in Karnataka, a state in South India, to learn about HIV prevention interventions with sex workers. The coincidence was unexpected. What could South Africa, I wondered, have to learn from India about AIDS? Wasn’t India’s AIDS epidemic, in which HIV prevalence reached barely one half of 1%, dramatically different from South Africa’s? Yet experts from India were helping to develop new approaches for HIV prevention in collaboration with South African experts. The South African minister of health, Aaron Motsoaledi, had visited India to learn about the Gates Foundation’s Avahan program. A sex worker activist I interviewed said of the visit, “That was the first time he met a sex worker. And we thought, you can meet a South African sex worker right here! You never asked us!”

From the vantage point of South Africa, India’s position on the global AIDS map had changed considerably. Over the short span of less than a decade, global AIDS experts had gone from seeing India’s epidemic as a looming catastrophe to an impressive example of prevention that could provide models for the rest of the world. In particular, India was often cited, in global AIDS circles, for its targeted HIV prevention programs with sex workers, sexual minorities, and transgender people.¹¹ These prevention programs, which South Africa’s health minister had gone to learn about, emphasized working with communities considered most at risk of HIV. Indian HIV prevention efforts, these visits suggested, had been a success. The crisis had been averted. But how had India gone from a country where conversations about sex were taboo to a place where sex workers met foreign diplomats? To what extent did the accounts of globe-trotting experts reflect the realities of the AIDS response? And what had the effects of HIV prevention programs been on those at its heart, those targeted as high risk? In short, how had crisis reshaped Indian sexual politics?

This book argues that the response to India’s AIDS crisis transformed, temporarily, the terrain on which sex workers, sexual minorities, and transgender people engaged the state. India’s AIDS response unfolded within a global set of AIDS institutions made up of donors, UN agencies, other governments, research institutions, and international nongovernmental organizations (NGOs). This set of institutions—which together comprise what this book considers a field—placed countries in a hierarchical and temporal relationship to each other. Within this field, India was at risk of becoming what Africa had already become. In response, the Indian state sought to contain the risk among sex workers, sexual minorities, and transgender people. But containment had unexpected effects. This book traces how containing the crisis created hybrid zones and institutions within the state, in which groups defined as at risk developed new solidarities and modes of citizenship. At its heart, this book traces the everyday implications of the global AIDS response. It charts how India’s relationship to the AIDS crisis crystallized tensions about India’s place in the world, and it examines how the Indian state’s response affected the lives of those most targeted for HIV prevention. How did the risk of a global crisis alter the lives of the groups who came to embody and represent risk?

Lata¹² illustrates one such trajectory. I was just beginning my fieldwork when I met her. As we sat on a bench at a Kolkata conference center, grateful for a little bit of shade, she told me about her organizing work. Lata looked younger than forty, though there were wrinkles around her eyes, as though she’d been squinting into the sun. A year later, I finally asked if I could interview her with a recorder. Lata was born into a family she classified as scheduled caste (SC) or Dalit.¹³ She had been married at fourteen, she told me, sitting on a small cot in her friend’s house. The family had refused to introduce her to the intended groom until the day of the wedding. When she finally saw the groom, Lata said, she cried. “Was I really weighing my family down so much? If they’d given me work to do, I’d have done it.”

“Their culture was great!” she told me sarcastically of her new in-laws. “You always had to be wearing this wide a kunkuma [bright red powder] on your forehead, bangles up to here,” (she pointed to her elbow) “and the pallu [the loose end of the sari] shouldn’t slip; you had to pull it together and pin it. Just look at the tradition in their house! But if you looked inside, it was all rotten!” Any time her father-in law washed his hands, he’d wipe his hands on your sari, she said. When you leaned over to serve his food, his eyes would linger. One night, when everyone else was out of town, he had come into her room and demanded to have sex with her. “I’ve paid the money and I’ve gotten you married,” he said. “You can’t say no to any of the eight of us [men living in the house.]” Lata said she didn’t know where the anger and strength came from, but she fought him until he gave up and left. When she told her husband about it, he said if the land belonged to the family, it didn’t matter who planted the seeds. Once, while the rest of the family was out of town, her brother-in-law attempted to rape her and, as she fought back against him, she fell into a gutter outside her house. She was seven months pregnant and soon miscarried.

A few years later, after finally leaving her in-laws, beginning a second relationship that ended abruptly, and enduring months of physical and emotional abuse from her own family, Lata found her life at a turning point. Now with two children, one only fifteen days old, Lata began to work at a brick factory. She lived in the factory quarters with her children. There, a friend introduced her to her first clients. “I thought, how long can I take care of the kids with twenty rupees? They give five kilograms of rice and oil. How long can I do this for my kids?” She first worked for an acquaintance, who took nearly half of her earnings as commission, until a client gave her enough money to pay the deposit on her own apartment. Eventually she made enough money to put her children through school. It was an uneven path, but she made a life for them. “This occupation (vṛtti) is what filled my hands,” she said. Her voice hinted at pride and a twinge of redemption as she described holding an elaborate wedding for her daughter in her family’s village. She had invited all her family members to the wedding, the same ones who had once chased her out of her village with a three-year-old daughter and an infant, calling her a whore (sūḷe). “For all the pain they gave me,” she said, “I wanted to give them something back.”

Lata’s first contact with a sex worker organization came more than a decade after she first began doing sex work. In 2002, she met a field supervisor from an HIV prevention NGO. The NGO was one of a growing number of HIV prevention NGOs in the state of Karnataka: between 2000 and 2004, the number of targeted interventions with at-risk groups run by NGOs more than doubled to thirty,¹⁴ as part of a nationwide effort at HIV prevention, with a particular focus on states with high HIV prevalence.¹⁵ Starting in 2003, Karnataka became a focus state for the Gates Foundation’s US$338-million AIDS program in India, the Avahan initiative. At the time, public health surveillance indicated that 14.4% of women in sex work in Karnataka were HIV positive, and the percentage would jump to 21.6% the following year.¹⁶ In Lata’s district in 2004, HIV prevalence among all pregnant women was estimated at 2.5%.¹⁷ Lata herself had not heard of AIDS, but from the NGO, she learned about STIs and HIV.¹⁸ She became a peer educator who kept in contact with sex workers, provided them with condoms, and brought them to clinics to get them tested. Lata became well versed in the language of HIV prevention—meetings, trainings, field visits, peer educators, mapping—and began to monitor regularly the sexual behavior of sex workers she contacted. She filled out forms every week documenting the sexual activities of her regular contacts, keeping track of how many partners they had had, how many times they had had protected sex, and how many condoms she had given them. Through detailed documentation, Lata learned to categorize her contacts as FSW (female sex worker) or MSM (men who have sex with men), and describe FSWs as home-based, street-based, or brothel-based. The stacks of forms on which Lata documented her peers’ sexual acts, clients, health status, and condom use would be aggregated weekly and monthly across her zone, city, and state, to form an intricate picture of sexual practice as Karnataka fought off the epidemic.

HIV prevention was Lata’s first step into organizations and activism. In 2006, she took a second step: she decided to move to a newly forming activist organization. At a time when HIV prevention programs for sex workers in Karnataka were growing rapidly, the Karnataka Sex Workers’ Union was one of the only sex worker organizations in Bangalore not implementing a state-level HIV prevention program. Instead, it focused on legal recognition and workers’ rights for sex workers. It was the NGO that brought change to her life, Lata said, but it was the Union that taught her she was no less than anyone else, that if she was unified with others, she could achieve something. She began to speak more openly about her life as a sex worker in meetings. As a Union leader, she traveled around the state and around India and marched in protests against police abuse. She helped Union members obtain ration cards, voter identity cards, and loans and leave abusive partners. She participated in protests of coercive AIDS policies and police violence against sex workers, working-class sexual minorities, and transgender people. She built friendships with kothis¹⁹ and transgender women who organized alongside her.

Lata’s activism was one part of the evolution of large-scale social movements focused on sexuality all around India. In 2009, in response to a 2001 writ petition filed by the Naz Foundation, an NGO working on HIV prevention and treatment, the Delhi High Court declared Section 377 of the Indian Penal Code, which criminalized “carnal intercourse against the order of nature,” unconstitutional. The case mobilized arguments about the barriers Section 377 posed to HIV prevention, and the National AIDS Control Organization (NACO) filed an affidavit in support of the petition. In 2006, when the Ministry of Women and Child Development introduced a bill in Parliament that proposed amendments to the Immoral Traffic Prevention Act (ITPA), including making paying for sex a punishable crime as a way of curbing sex trafficking, sex worker groups like Lata’s across the country protested, with support from NACO, and the bill eventually lapsed in 2009. Lata herself traveled to Delhi to protest the bill. These were national-level shifts, but there were local ones too. In Karnataka in 2005, the director general and inspector general of police issued a circular instructing police officers not to arrest sex workers under ITPA, as a way of reducing the “harassment of the women sex workers.” Perhaps most significant were shifts in everyday practices of policing sex work. Lata and other sex worker activists argued case after case in local police stations in which sex workers had been unlawfully detained or assaulted by police. These struggles were about much more than HIV, but they coincided with, and were partly catalyzed by, the epidemic response.

By the time I met her, Lata was completely different from the young girl married into an abusive family at the age of fourteen. Years later, she bumped into her former husband one day on the way to visit her daughter. “He had forgotten me,” she said. “I said . . . you forgot me already? He said I forgot you. Have you seen your wife? I asked. He said she left, why do you ask? I said my God, I’ll throw my sandal at you! He said I don’t even know you; why are you yelling at me?” Lata collapsed into laughter. “I don’t know where he went after that!”

India’s predicted AIDS crisis never fully materialized on the scale that had been predicted. And yet massive amounts of money were spent to prevent it. Through the efforts of women like Lata, by 2011, the Karnataka government said over seventy-eight thousand sex workers had been reached with HIV prevention programs.²⁰ The UNAIDS 2010 Global Report noted that “the Indian state of Karnataka has shown evidence that intensive HIV prevention efforts among female sex workers can be highly effective.”²¹ An article in The Lancet found that the Gates Foundation’s program, out of its six focus states, was most effective in Karnataka, where it was associated with a 12.7% decline in HIV prevalence.²³ Karnataka’s efforts were part of India’s global success. One NACO official told me:

UNAIDS . . . look[s] completely to India as a success story. Even on the world stage. If they want to show success, India is one of the countries they always show. We are achieving MDG 6,²³ halting and reversing the epidemic, which means you have to reduce new infections by 50%. India already reduced [new infections] by 56%. In 2015 when we go to the world stage, India will be in the list of countries which have achieved MDG 6. Not many have done it. It’s a great example, a silver lining in the dark cloud we have in this country, when we have so many failures, at least something we can show as a success. And they also understand [that], in a country like India, it’s difficult to make anything succeed.

This pride in India’s success points to how the AIDS crisis was fundamentally tied to ideas about the kind of nation-state India was and could be. In the response to a crisis, states are compared to each other. They become exemplary of certain dynamics, problems, or solutions in a global field, based on, in the case of AIDS, the size of their epidemics, the populations most affected, and the success of their response efforts. The AIDS epidemics in India and sub-Saharan Africa, as my own entry into this book indicates, were defined, understood, and managed in relation to each other. Even though India’s predicted AIDS crisis never fully arrived, it carried with it new engagements with global institutions, a new way of thinking about how the Indian state managed sexuality, and new openings for social movements to navigate.

Several months after our interview, Lata left behind activism. Two years later, when I called to tell her I was in town, she told me she had opened a bangle stall. Apart from the fact that Lata’s shop was often visited by sex workers who worked in the bus stand and its surrounding area, no one would know from a casual conversation that Lata had spent eight years working in HIV prevention programs, that she had traveled to Kolkata and Delhi to protest the criminalization of sex work. “They came and did something and then they left,” she told me. “We still have to be here. They brought us out into the open and then they left us.” The AIDS response had temporarily placed Lata at the center of an impending crisis. It had made sex work the defining feature of her winding path through various forms of sexual exchange and violence. Lata had once organized protests on the steps of Town Hall, held meetings with government officials, and given statements to the newspapers. She now lived in the purported aftermath of the crisis. The donors had gone home, the state had moved on, and she was still here. She had returned to the tangle of commerce, intimacy, and survival that had always shaped her life.

When I last visited Lata, in 2019, she was running a flower stall. Every morning she would quickly tie flowers together into elaborate garlands for sale. She was in touch with many friends who did sex work. Though she was no longer involved in HIV prevention work or activism, her friends from her activist and NGO days would visit her with news and gossip every once in a while. By then, Lata was clear she did not want any part in activism. As I sipped juice in a corner of her stall, we talked in code about the work she had done before and the people she had worked with, a time she still vividly remembered. “They brought us out into the open,” she said again, when we began talking about the AIDS response. “That time was different. Now, here, in this situation, for this life, I can’t be open like I was then.” Lata, like many I discuss in this book, was not HIV-positive. But HIV, as the basis for funding, organizational resources, and political access, had temporarily transformed her life.

Today, there are an estimated 2.1 million people living with HIV in India.²⁴ As AIDS initiatives fade, they have been increasingly forgotten. But the focus of this book is the political implications of AIDS not on those who are living with the virus but on those who, like Lata, live at risk of it. Being defined as at risk opened up new, contradictory ways for sex workers, sexual minorities, and transgender people to relate to the state. It set off transformations in which activist organizations were formed and sustained, and it meant sex workers like Lata developed new ways of speaking, living, and relating to one another, sometimes leading to new hierarchies and exclusions. Some of these shifts were lasting, and some were far more precarious.

Notes

1. In this book, I follow UNAIDS guidelines in not using the term HIV/AIDS. I refer to AIDS when discussing the global pandemic and to HIV when discussing measures to prevent viral transmission. UNAIDS, Terminology Guidelines, 8.

2. Shahani, “How to Survive.”

3. UNAIDS, 2006 Report on the Global AIDS Epidemic, 374.

4. UNAIDS, “South Africa.” In South Africa today, an estimated 7.5 million people are living with HIV.

5. UNAIDS and WHO, “AIDS Epidemic Update,” 23.

6. Wines, “Durban Journal.”

7. Klugman, “Politics of Contraception”; and Marks, “Epidemic Waiting to Happen?”

8. Lurie et al., “Impact of Migration”; Hunter, Love in the Time of AIDS; and Decoteau, Ancestors and Antiretrovirals.

9. Hunter, “Materiality of Everyday Sex.”

10. Farmer, AIDS and Accusation; Comaroff, “Beyond Bare Life”; and Watkins-Hayes, “Intersectionality and the Sociology of HIV/AIDS.”

11. Bishnupriya Ghosh, in “The Costs of Living,” clarifies that female sex workers were the initial focus of HIV prevention programs in India; men who have sex with men became a focus somewhat later; and IV drug users were considered a less significant population, except in Northeastern India.

12. In this book, I use pseudonyms for everyone except for those it would be impossible to anonymize. For these people, I mostly rely on existing public statements and documents or obtained their consent to identify them by name. While those familiar with the contexts I write about may be able to connect data with specific organizations, I have worked to ensure that it cannot be linked to specific people. Where details seem vague or jumbled, I have rendered them so deliberately, in order to maintain confidentiality to the furthest extent possible.

13. Dalit, meaning oppressed or crushed, is a term used to refer to groups formerly designated untouchable in the Indian caste system. The term Dalit emphasizes the systematic oppression of these groups; the census categorizes them as scheduled caste (SC) or scheduled tribe (ST).

14. PFI et al., HIV/AIDS in Karnataka, 20.

15. High prevalence indicated HIV prevalence higher than 1%.

16. PFI et al., HIV/AIDS in Karnataka, 6.

17. PFI et al., 9.

18. Following UNAIDS guidelines, I use the term sexually transmitted infection (STI). However, when a source uses an older term, such as venereal disease or sexually transmitted disease, I follow the terminology of the source. UNAIDS, Terminology Guidelines, 11.

19. Kothi is a vernacular term for a feminine man or gender-nonconforming person who prefers sex in the receptive role with other men. The term also often carries class connotations; it can refer to a working-class person in contrast to elite, English-speaking gay men. The term has a complex history. See L. Cohen, “Kothi Wars.”

20. KSAPS, Annual Action Plan 2012–2013, 27.

21. Moses et al., “Intensive HIV Prevention”; and UNAIDS, Global Report, 2010, 34.

22. Ng et al., “Assessment of Population-Level Effect,” 1649.

23. The UN’s sixth Millennium Development Goal (MDG), set in 2000 to be met by 2015, committed member countries to “combat HIV/AIDS, malaria, and other diseases,” which included the target of halting and reversing the spread of AIDS and achieving universal access to AIDS treatment.

24. UNAIDS, “India Overview.”