HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women

A study by Harvard School of Public Health (HSPH) researchers of girls and women who were sex-trafficked from Nepal to India and then repatriated has found that 38 percent were HIV positive.

The infection rate exceeded 60 percent among girls forced into prostitution prior to age 15 years. One in seven of the study's participants had been trafficked into sexual servitude prior to this young age.

Approximately 600,000 to 800,000 people are trafficked across the globe every year, and 80 percent of these individuals are estimated to be women and girls, according to the U.S. Department of State. The State Department further reports that the majority of transnational victims are females trafficked into commercial sexual exploitation. An estimated 150,000 women and girls are trafficked annually within and across South Asia, with the majority destined for major Indian cities, according to a report by the Congressional Research Service.

“The high rates of HIV we have documented support concerns that sex trafficking may be a significant factor in both maintaining the HIV epidemic in India and in the expansion of this epidemic to its lower-prevalence neighbors,” said Jay Silverman, Associate Professor of Society, Human Development, and Health at HSPH.

India has the third largest HIV/AIDS population in the world, with approximately 2.5 million infected individuals, according to the country's National AIDS Control Organization, supported by UNAIDS and the World Health Organization. Neighboring Nepal has far lower but increasing numbers of HIV/AIDS cases. Trafficking of Nepalese women and girls to India has been cited by the World Bank as a risk factor for HIV transmission in the region.

Silverman is the lead author of the study published in the August 1, 2007, issue of the Journal of the American Medical Association ( JAMA ). He led a research team in reviewing the medical documentation and case records of 287 girls and women who had been sex-trafficked from Nepal to India between the years 1997 and 2005. All had been repatriated back to Nepal and had received rehabilitative services from Maiti Nepal, a non-governmental organization that works to assist trafficking victims. The word “Maiti” means “mother's home” in Nepali.

The researchers found that among the 287 girls and women, 38 percent tested positive for HIV. Among those with complete documentation of trafficking experiences (225 girls and women), the median age at time of trafficking was 17 years, with 33 girls (14.7 percent) trafficked prior to age 15 years. Compared to those trafficked at 18 years or older, girls trafficked prior to age 15 years had an increased risk for HIV, with 60.6 percent infected among this youngest age group. Risk was also associated with being trafficked specifically to Mumbai, India, and with longer durations in brothels.

“HIV infection has been seen as perhaps the most critical health consequence of sex trafficking, but sex-trafficked girls and women are rarely studied — leaving the prevalence of HIV and other health issues among this highly vulnerable population little understood,” said Silverman. “This study sheds new light on infection rates among a sex-trafficked population and exposes both the tragic existence of the youngest victims and the dire health consequences of this crime.”

Silverman and his team suggest several likely explanations for the observed high risk for HIV infection among the youngest trafficked girls. Previous research on male brothel clients in India suggests that these men prefer very young girls, often presented as virgins, due to fear of HIV and other infection, as well as to the widespread myth that sex with a virgin will cure such illnesses. As a result of client demand and of the relatively high profits earned from prostituting these very young girls, brothel owners take steps to keep them in captivity for longer periods of time. The HSPH team found that girls trafficked under age 15 were more likely than older girls to be held in brothels for a year or longer, and that the risk of HIV infection increased by two percent for every additional month of brothel detention.

“Historically, there has been little recognition of these young girls in brothels because they are typically hidden from both legal authorities and those working to help and study prostituted women,” said co-author and former HSPH doctoral student Jhumka Gupta.

Added co-author and HSPH doctoral student Michele Decker, “Now, we are learning that these youngest girls not only exist, but are actually the most vulnerable to HIV, highlighting the need for improved prevention of trafficking and greater efforts to identify and rescue sex-trafficked girls.”

Silverman and his team suggest that the prevention of sex trafficking and the intervention into the practice should be seen as a critical aspect of preventing both the spread of HIV/AIDS and reducing a widespread and violent human rights violation.

The authors assert that few resources have been devoted to the prevention of sex trafficking, particularly in relation to the large estimated numbers of affected individuals and to the public health consequences. In particular, the authors specify that approaches oriented to male clientele that reduce the demand for sex from young prostituted girls must be emphasized.

“Just as in other areas of HIV prevention, we can no longer afford to ignore the behavior of men and boys,” said Silverman. “Addressing the widely accepted male demand for commercial sex is critical to ending this modern day form of female slavery.”

The study was supported by grants to J. Silverman and B. Willis from the Office of Trafficking in Persons, U.S. Department of State; J. Silverman and A. Raj from the Harvard University Center for AIDS Research; A. Raj from the Center for International Health at the Boston University School of Public Health; and J. Silverman and J. Gupta from the Harvard University South Asia Initiative.

“HIV Prevalence and Predictors of Infection in Sex-Trafficked Nepalese Girls and Women,” Jay G. Silverman, PhD, Michele R. Decker, MPH, Jhumka Gupta, ScD, MPH, Ayonija Maheshwari, MD, MPH, Brian M. Willis, JD, MPH, Anita Raj, PhD, JAMA , August 1, 2007, vol. 298, no. 5.

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