Gangopadhyay DN, Chanda M, Sarkar K, Niyogi SK, Chakraborty S, Saha MK, et al. Evaluation
of sexually transmitted diseases/human immunodeficiency virus intervention programs for sex
workers in Calcutta, India. Sex Transm Dis. 2005 Nov; 32 (11): 680-684.
OBJECTIVE: To compare the differences in STD prevalence, knowledge, attitudes and practices,
health seeking behavior and demographic characteristics between 2 groups of female sex
workers (FSWs) in and around Calcutta: those in the Sonagachi Project and those receiving only
the National AIDS Control Organization (NACO) intervention.
STUDY DESIGN: Cross-sectional survey and STD evaluation of FSWs. Comparisons were made
with historical cross-sectional STD data collected from FSWs in 1992 at the beginning of the
Sonagachi project.
SETTING: Sonagachi district (the largest red light area) of Calcutta, India, and brothel areas on
the outskirts of the city.
PARTICIPANTS: Brothel-based FSWs >/=18 yrs of age from the Sonagachi district were
randomly selected (n = 173). All adult brothel-based sex workers from the outskirts of Calcutta in
areas only receiving the NACO intervention were asked to participate (n = 169). Data from 1992
had been collected from 418 FSWs in the Sonagachi Project area.
INTERVENTION: The Sonagachi Project was established in 1992 and targets nearly all brothelbased sex workers within Calcutta. Its focus is on organizing sex workers so they can demand
their social, political and economic rights from clients and powerbrokers controlling the sex trade.
The project employs FSWs as outreach workers, promotes condom use, and provides general
health services, STD treatment, and information about STD/HIV prevention. The NACO program
is instituted through local NGOs and provides the same general health and prevention services,
but does not include any organized empowerment effort.
PRIMARY OUTCOMES: FSWs completed an interviewer-administered questionnaire to evaluate
knowledge, attitudes, health-seeking behavior and sexual risk behavior. All women were clinically
examined for STDs, and evaluated with RPR, TPHA, cervical and vaginal smears, and urine PCR
testing for gonorrhea (GC) and Chlamydia (CT).
RESULTS: The response rate for Sonagachi FSWs was 87% compared to 65% among the
NACO-only FSWs. There were demographic and risk behavior differences between the 2 groups.
The Sonagachi women were significantly younger (mean age 27 yrs vs. 32 yrs), more likely to be
literate (20% vs 11%), unmarried (44% vs 30%), have >/=3 clients/day (50% vs 22%), to have
been working < 5 years (66% vs 33%). The overall prevalence of STDs in the two groups was
similar: 57% among the Sonagachi women and 53% in the NACO-only group, although
Sonagachi sex workers had a higher prevalence of CT (12% vs 4%) and a lower prevalence of
syphilis (16% vs 28%) and candidiasis (15% vs 25%). The frequency of unprotected sex was
similar in the two groups – about half of FSWs surveyed would agree to sex without a condom if
pressured or offered more money. Significant differences between the two groups were found in
health-seeking and other behaviors: A higher proportion of Sonagachi sex workers had been
tested for HIV (60% vs 27%), had regular STD check-ups, performed sex work only within a
brothel, and preferred government clinics for STD treatment. Comparison of data from Sonagachi
FSWs in 2003 to that collected in 1992 showed a significant decline in the prevalence of syphilis,
vaginal discharge, candidiasis, and trichomoniasis; women were also more likely to use condoms
regularly.
CONCLUSIONS: The current study found the prevalence of all STDs among sex workers in
Calcutta was the same in both the Sonagachi and NACO-only areas but was much lower than
that observed in 1992. Thus, both the Sonagachi intervention and the West Bengal NACO
intervention appear to have been successful. The Sonagachi intervention, however, appears to
have the additional benefit of significantly improving the treatment-seeking behaviors and
optimistic attitude of sex workers.
QUALITY RATING: This study was of adequate quality. The authors described the selection
scheme, performed a sample size calculation and discussed attrition. The quality of this study
was limited by the following: this was an observational study; participants in the Sonagachi
sample were not similar to those in the NACO-only group; response rates in the two groups were
different. There was minimal description of the NACO-based programs. The authors used
“propensity” scoring to adjust for demographic and response rate differences between the groups
in the analysis of STDs, but this technique and its utility could have been more clearly evaluated.
Overall, the sample size for both groups was small, and the authors had difficulty in finding a good
comparison group, because of the overall reach of the Sonagachi program. The comparison of
data from 1992 and 2003 only included data collected from the Sonagachi area, and may not be
representative of NACO-only FSWs. The validity of the comparison between the samples
collected 11 years apart is difficult to determine from the brief description given of the 1992 study
methods and comparability of the samples. Infection with HSV2 and HBV were not tested, and
are likely to be prevalent among FSWs.
IN CONTEXT (Reviewer comments): Despite the empowerment component of the Sonagachi
project, there were no significant differences in STDs or condom use with those who were only
exposed to NACO-funded NGO programs. These results are somewhat surprising, as the
Sonagachi project has been considered an optimal model for how FSWs could be organized to
improve their living and working conditions, and it appears that NACO/NGO programs could be
working just as well. It was also surprising that nearly 50% of women in the Sonagachi project
were willing to not use a condom if pressured. Thus, despite “empowerment,” women remain
highly vulnerable and many do not even test for HIV. However, it may be that the Sonagachi
project improves the lives of these women in ways that are not described here, such as
enhancing overall quality of life, self-esteem, and sense of community.
PROGRAMMATIC IMPLICATIONS: This study may indicate that efforts to replicate the
Sonagachi project may not be necessary if prevention programs that provide STD care, condom
promotion, and peer outreach are in place.