At Risk: Indian Sexual Politics and the Global AIDS Crisis

At Risk

Indian Sexual Politics and the Global AIDS Crisis

GOWRI VIJAYAKUMAR

STANFORD UNIVERSITY PRESS

Stanford, California

STANFORD UNIVERSITY PRESS

Stanford, California

©2021 by the Board of Trustees of the Leland Stanford Junior University.

All rights reserved.

No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or in any information storage or retrieval system without the prior written permission of Stanford University Press.

Printed in the United States of America on acid-free, archival-quality paper

Library of Congress Cataloging-in-Publication Data

Names: Vijayakumar, Gowri, author.

Title: At risk : Indian sexual politics and the global AIDS crisis / Gowri Vijayakumar.

Other titles: Globalization in everyday life.

Description: Stanford, California : Stanford University Press, 2021. | Series: Globalization in everyday life | Includes bibliographical references and index.

Identifiers: LCCN 2020050233 (print) | LCCN 2020050234 (ebook) | ISBN 9781503627529 (cloth) | ISBN 9781503628052 (paperback) | ISBN 9781503628069 (epub)

Subjects: LCSH: AIDS (Disease)—India—Prevention. | AIDS (Disease)—Political aspects—India. | AIDS (Disease)—Government policy—India. | Sex—Political aspects—India. | Sex workers—Political activity—India. | Sexual minorities—Political activity—India.

Classification: LCC RA643.86.I4 V55 2021 (print) | LCC RA643.86.I4 (ebook) | DDC 362.19697/9200954—dc23

LC record available at https://lccn.loc.gov/2020050233

LC ebook record available at https://lccn.loc.gov/2020050234

Cover design: Christian Storm

Cover photograph: Bangalore, India. Kiran Ln, EyeEm | Alamy

Typeset by Kevin Barrett Kane in 10/14.4 Minion Pro

GLOBALIZATION

IN EVERYDAY LIFE

EDITORS

Rhacel Salazar Parreñas

Hung Cam Thai

EDITORIAL BOARD

Héctor Carrillo

Jennifer Cole

Kimberley Kay Hoang

Sanyu A. Mojola

Saskia Sassen

Contents

Preface

1. Introduction

2. India and the Specter of African AIDS

3. From Containment to Incorporation

4. At-Risk Citizens

5. Risky Selves

6. Making It Count

7. India in Africa

8. After AIDS

Acknowledgments

Appendixes

Notes

Bibliography

Index

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.²² 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.

1

INTRODUCTION

Sex is always political. But there are also historical periods in which sexuality is more sharply contested and more overtly politicized. In such periods, the domain of erotic life is, in effect, renegotiated.

Gayle Rubin

AS I BEGAN TO MAKE MY WAY from a sex worker health clinic in Nairobi to the nearby minibus taxi (matatu) stop, a woman in the waiting area asked very politely if she could have a word with me. Grace was small and thin, with a jagged scar across her mouth. Tentatively, but insistently, she told me she was a sex worker and had previously worked at the clinic as an HIV peer educator. Then she had been arrested while doing sex work. When she was finally released from jail, she found herself destitute. She had three children, she said, one only seven months old. She might be dressed well, she pleaded, as though that might have dissuaded me, but she had nothing. Could I find her a spot in the next peer educator training session? She rifled through her handbag until she found a crumpled business card to show me. I was surprised to see the familiar logo of a sex workers’ rights and HIV prevention organization based in Karnataka, India.

How did this business card from Karnataka find its way to a sex worker in Nairobi? Answering this question demands an analysis that moves across scales. It requires an understanding of global institutions: agencies including UNAIDS, UNFPA (United Nations Population Fund, the UN sexual and reproductive health agency), the WHO, and the World Bank and donors like USAID (US Agency for International Development) and the Gates Foundation. These global institutions play a defining role in what this book refers to as a global AIDS field. But understanding Grace’s request also requires an understanding of how nation-states govern sexuality within the global AIDS field and how social movements respond to and transform that process of governance. Ultimately, nongovernmental organizations (NGOs), community-based organizations (CBOs) and activists formed the heart of HIV prevention efforts. They formed the context in which Grace, a sex worker, might associate me, a visiting Indian American, with a possible clinic job.

This approach, the one I take in this book, differs from the way many social scientists have studied AIDS. A range of social scientists has written about AIDS, showing that the social and political drivers of AIDS are often missed in biomedical interventions.¹ In India, extensive public health literature assesses the successes of AIDS programs.² But what I aim to do in this book is place the analytical focus beyond the drivers of the global AIDS crisis and their possible responses, to the political reconfigurations that ensued from it. In this way, this book is in line with scholarship that considers what the AIDS response can tell us about politics.³

Critiques of Indian AIDS programs form a powerful foundation for this book. For decades, scholars and activists have exposed the limits of the response to AIDS in India, arguing that it criminalized and isolated the vulnerable, imposed reified biomedical categories on diverse forms of sexual life, and laid the groundwork for further biomedical intervention.⁴ The response to AIDS was always tied up with global institutions: starting in the 1990s, funds and resources for HIV prevention flooded India from bilateral aid agencies, multilateral institutions, and corporate philanthropists. The response to AIDS in India was a global response; it was driven by global funders, agencies, and researchers with money and influence. This book builds on these critiques by analyzing how global institutions responded to the crisis on the terrain of politics—at the interface of the Indian state and Indian social movements.⁵ By the time it closed its doors, even the famous Gates Foundation program in India was forced to recognize the centrality of the state and social movements in addressing AIDS.⁶

This book argues that the global AIDS crisis temporarily transformed the terrain on which sex workers, sexual minorities, and transgender people⁷ engaged the state, both individually and collectively. The global AIDS crisis created a field that positioned nation-states in relation to each other. Within this field, African countries were in crisis, and India was at risk of one. AIDS experts considered sex workers, sexual minorities, and transgender people to embody the heart of this risk. But these groups were criminalized and stigmatized. To respond, state officials created hybrid institutions within the state that were insulated from the rest of a slow-moving and sexually conservative bureaucracy and intimately linked to global networks of experts and activists. Within these spaces, state officials could engage sexuality in new ways to prevent AIDS—moving from tactics of criminalization and marginalization to tactics of incorporation and inclusion. These institutional openings allowed state officials to contain risk, while creating hybrid sites within which sex workers, sexual minorities, and transgender people could experiment with new ways of articulating sexual identity and develop new strategies for engaging the state.

Social scientists have written about risk as an increasingly powerful organizing logic for politics. As the anticipation of catastrophe, risk creates a global community of threats,⁸ ranging from terrorism to economic collapse. But, as this book shows, risk is defined in relation to race, gender, sexuality, and geopolitics. In the case of AIDS, being marked at risk both built on and reinforced existing relations of hierarchy and exclusion.⁹ In order to contain the risk of becoming like Africa, India had to contain the groups that presented an internal threat to the nation’s morality, its gendered and sexual others.

The AIDS crisis was an opening into the remaking of Indian sexual politics, then, because it cut to the heart of tensions about the kind of nation-state India was and could be. Within the global AIDS field, AIDS epidemics and responses were compared, measured, and developed in relation to each other. For state officials, how India governed AIDS