Journal of Food Security
ISSN (Print): 2372-0115 ISSN (Online): 2372-0107 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
Journal of Food Security. 2016, 4(5), 104-111
DOI: 10.12691/jfs-4-5-1
Open AccessArticle

Food Insufficiency, Violence and HIV Risk Behaviors among Female Sex Workers in India

Sangram Kishor Patel1, , Madhusudana Battala1 and Rajatashuvra Adhikary1

1HIV and AIDS Program, Population Council, 142, Golf Links, New Delhi, India

Pub. Date: September 08, 2016

Cite this paper:
Sangram Kishor Patel, Madhusudana Battala and Rajatashuvra Adhikary. Food Insufficiency, Violence and HIV Risk Behaviors among Female Sex Workers in India. Journal of Food Security. 2016; 4(5):104-111. doi: 10.12691/jfs-4-5-1


Background: Food insufficiency is one of the important contributing factors among female sex workers (FSWs) to engage in risky sexual behaviors and cause of HIV infection in developing countries. Studies exploring linkages between food insufficiency and HIV risk behaviors among FSWs are limited despite having potential program and policy implications. This study attempts to assess the food insufficiency among FSWs and examine its relationship with HIV risk behaviors and violence in India. Materials and Methods: Data were drawn from the Avahan-III baseline evaluation survey- 2015, conducted among FSWs (n=4098) using a three-stage cluster sampling approach in four states of India. Multivariate logistic regression (with adjusted odds ratios (AOR) and their 95% confidence intervals (CI)), bivariate analysis and frequency were used to assess the relationships between food insufficiency, HIV risk behaviors and violence. Results: Nearly one-fifth of FSWs (17%) reported of facing food insufficiency in past 6 months. More than 35% of FSWs had entertained more clients to cope with the situation of food insufficiency followed by defaulted on loans (24%), borrowed money from informal sources (20%) and had sex without condoms (7%). The likelihood of consistent condom use with non-regular (67% vs. 77%; AOR: 0.6; 95% CI: 0.4-0.9) and regular partner (22% vs. 51%; AOR: 0.3; 95% CI: 0.2-0.4) were significantly lower among FSWs who reported food insufficiency than among those who did not. The likelihood of consistent condom use with occasional (90% vs. 95%; AOR: 0.5; 95% CI: 0.4-0.7) and regular clients (88% vs. 91%; AOR: 0.8; 95% CI: 0.6-0.9) were significantly lower among FSWs who reported food insufficiency compared to those who did not. FSWs who reported food insufficiency were also significantly more likely to report STI symptoms (28% vs. 13%; AOR: 2.7) and any violence (16% vs. 9%; AOR: 2.1) than their counterparts. Conclusions: The findings of the study highlight that FSW’s food insufficiency is significantly associated with HIV risk behaviors and violence. This study underscores the need for community-led interventions focusing on food insufficiency and economic strengthening activities to reduce HIV vulnerability among FSWs. However, further evidence-based research and advocacies on food insufficiency is required to ensure that HIV prevention programs are appropriately addressed.

food insufficiency food insecurity consistent condom use violence HIV risk India

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  FAO, IFAD and WFP. The state of food insecurity in the World 2015. Meeting the 2015 international hunger targets: taking stock of uneven progress. Rome, FAO. 2015.
[2]  Laraia B, Siega-Riz A, Gunderson C, Dole N. Psychosocial factors and socioeconomic indicators are associated with household food insecurity among pregnant women. Journal of Nutrition 2006; 136(1):177-182.
[3]  Foley W, Ward P, Carter P, Coveney J, Tsourtos G, Taylor A. An ecological analysis of factors associated with food insecurity in South Australia, 2002-7. Public Health Nutrition 2010; 13(2): 215-221.
[4]  Mohammadzadeh A, Dorosty A, Eshraghian M. Household food security status and associate factors among high-school students in Esfahan, Iran. Public Health Nutrition 2010; 13(10):1609-1613.
[5]  Kadiyala S, Gillespie S. Rethinking food aid to fight AIDS. Washington, DC: International Food Policy Research Institute; 2003.
[6]  Fenton L. Preventing HIV/AIDS through poverty reduction: the only sustainable solution. Lancet 2005; 364(9440):1186-1187.
[7]  Gillespie, S., Kadiyala, S. HIV/AIDS and food and nutrition security: from evidence to action. Washington, DC: International Food Policy Research Institute; 2005.
[8]  Weiser S, Leiter K, Bangsberg D, Butler L, Pery-de Korte F, Phaladze N, Heisler M. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Medicine 2007; 4:1589-1597.
[9]  Ngo AD, McCurdy SA, Ross MW, Markham C, Ratliff EA, Pham HT. The lives of female sex workers in Vietnam: Findings from a qualitative study. Culture Health and Sexuality 2007; 9(6): 555-570.
[10]  Fitzgerald-Husek A, Martiniuk AL, Hinchcliff R, Aochamus CE, Lee RB. I do what I have to do to survive: an investigation into the perceptions, experiences and economic considerations of women engaged in sex work in Northern Namibia. BMC Womens Health 2011; 11: 35.
[11]  Gillespie S, Kadiyala S, Greener R. Is poverty or wealth driving HIV transmission? AIDS 2007; 21(Suppl 7):S5-S16.
[12]  Dunkle KL, Jewkes RK, Brown HC, et al. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Social Science and Medicine 2004; 59:1581-1592.
[13]  Oyefara JL. Food insecurity, HIV/AIDS pandemic and sexual behaviour of female commercial sex workers in Lagos metropolis, Nigeria. Journal of Social Aspects of HIV/AIDS 2007; 4(2): 626-635.
[14]  WHO. Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation. Geneva: World Health Organization; 2003.
[15]  Tsai AC, Weiser SD. Population-based study of food insecurity and HIV transmission risk behaviors and symptoms of sexually transmitted infections among linked couples in Nepal. AIDS and Behavior 2014; 18 (11):2187-97.
[16]  Vogenthaler NS, Kushel MB, Hadley C, Frongillo EA, Jr., Riley ED, Bangsberg DR, et al. Food insecurity and risky sexual behaviors among homeless and marginally housed HIV-infected individuals in San Francisco. AIDS and Behavior 2013; 17 (5):1688-93.
[17]  Eaton LA, Cain DN, Pitpitan EV, Carey KB, Carey MP, Mehlomakulu V, et al. Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships. The Journal of Primary Prevention 2014; 35 (4):255-65.
[18]  Raiford JL, Herbst JH, Carry M, Browne FA, Doherty I, Wechsberg WM. Low prospects and high risk: structural determinants of health associated with sexual risk among young African American women residing in resource-poor communities in the south. American Journal of Community Psychology 2014; 54(3-4):243-50.
[19]  Kerrigan DL, Fonner VA, Stromdahl S, Kennedy CE. Community empowerment among female sex workers is an effective HIV prevention intervention: A systematic review of the peer-reviewed evidence from low- and middle-income countries. AIDS and Behavior 2013; 17(6): 1926-1940.
[20]  Tsai AC, Leiter K, Heisler M, Iacopino V, Wolfe W, Shannon K, et al. Prevalence and correlates of forced sex perpetration and victimization in Botswana and Swaziland. American Journal of Public Health 2011; 101 (6):1068-74.
[21]  Tsai AC, Hung KJ, Weiser SD. Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil. PLoS Medicine 2012; 9 (4):e1001203.
[22]  Reed E, Gupta J, Biradavolu M, Devireddy V, Blankenship KM. The context of economic insecurity and its relation to violence and risk factors for HIV among female sex workers in Andhra Pradesh, India. Public Health Reports 2010; 125 Suppl. 4: 81-89.
[23]  Saggurti N, Jain AK, Sebastian MP, Singh R, Modugu HR, Halli SS, Verma RK. Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India. AIDS and Behavior 2012; 16:952-959.
[24]  Patel SK, Prabhakar P, Jain AK, Saggurti N, Adhikary R. Relationship between community collectivization and financial vulnerability of female sex workers in southern India. PLoS ONE 2016; 11(5): e0156060.
[25]  UNSN. Nutrition and HIV/AIDS. Statement by the Administrative Committee on Coordination, Sub-committee on Nutrition at its 28thsession. United Nations Sub-committee on Nutrition: Nairobi, Kenya; 2001.
[26]  Save the Children. Food security, livelihoods and HIV/AIDS: A Guide to the linkages, measurement and programming implications. Westport, CT: Save the Children; 2004.
[27]  UNFAO. The state of food insecurity in the World: high prices and food security--threats and opportunities. United Nations Food and Agriculture Organization; 2008.
[28]  Keenan DP, Olson C, Hersey JC, et al. Measures of food insecurity/security. Journal of Nutrition Education 2001; 33:S49-S58.
[29]  Bickel G,Nord M,Price C, Hamilton W, Cook J. Guide to measuring household food security (PDF). USDA Food and Nutrition Service. Retrieved 23 April 2016; 2000.
[30]  Hargreaves JR, Morison LA, Chege J, Rutenburg N, Kahindo M, et al. Socioeconomic status and risk of HIV infection in an urban population in Kenya. Tropical Medicine and International Health 2002; 7: 793-802.
[31]  Miller CL, Bangsberg DR, Tuller DM, Senkungu J, Kawuma A, Frongillo EA, et al. Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS and Behavior 2011; 15(7):1512-9.
[32]  Fielding-Miller R, Mnisi Z, Adams D, Baral S, Kennedy C. There is hunger in my community: a qualitative study of food security as a cyclical force in sex work in Swaziland. BMC Public Health 2014; 14:79.
[33]  de Waal A, Whiteside A. New variant famine: AIDS and food crisis in southern Africa. Lancet 2003; 362: 1234-1237.
[34]  Stillwaggon E. HIV transmission in Latin America: Comparison with Africa and policy implications. South African Journal of Economics 2000; 68: 985-1011.
[35]  Ambrus JL Sr., Ambrus JL Jr. Nutrition and infectious diseases in developing countries and problems of acquired immunodeficiency syndrome. Experimental Biology and Medicine 2004; 229: 464-472.
[36]  Kalichman SC, Simbayi LC. Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa. AIDS Care 2004; 16: 681-689.
[37]  Koenig MA, Zablotska I, Lutalo T, Nalugoda F, Wagman J, et al. Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda. International Family Planning Perspectives 2004; 30: 156-163.
[38]  Weiser SD, Leiter K, Heisler M, McFarland W, Percy-de Korte F, et al. A population-based study on alcohol and high-risk sexual behaviors in Botswana. PLoS Medicine 2006; 3: e392.
[39]  UNAIDS, UNAIDS guidance note on HIV and sex work. Geneva, Switzerland: UNAIDS, 2012.
[40]  Kennedy CE, Fonner VA, O’Reilly KR, Sweat MD. A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention. AIDS Care 2014; 26 (6):659-73.
[41]  Sherman SG, Srikrishnan AK, Rivett KA, Liu SH, Solomon S, Celentano DD. Acceptability of a microenterprise intervention among female sex workers in Chennai, India. AIDS and Behavior 2010; 14(3):649-657.
[42]  Pillai P, Bhattacharjee P, Ramesh BM, Isac S. Impact of two vulnerability reduction strategies - collectivisation and participation in savings activities - on HIV risk reduction among female sex workers: Karnataka Health Promotion Trust, Bengaluru, Karnataka, India; 2012.
[43]  Lee H, Pollock G, Lubek I, Niemi S, O’Brien K, Green M, Bashir S, Braun E, Kros S, Huot V, et al. Creating new career pathways to reduce poverty, illiteracy and health risks, while transforming and empowering Cambodian women’s lives. Journal of Health Psychology 2010; 15(7):982-992.
[44]  Odek WO, Busza J, Morris CN, Cleland J, Ngugi EN, Ferguson AG. Effects of micro-enterprise services on HIV risk behaviour among female sex workers in Kenya’s urban slums. AIDS and Behavior 2009; 13(3):449-461.
[45]  Baird SJ, Garfein RS, McIntosh CT, Oezler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet 2012; 379(9823):1320-1329.
[46]  Basu I, Jana S, Rotheram-Borus MJ, Swendeman D, Lee SJ, Newman P, Weiss R. HIV prevention among sex workers in India. Journal of Acquired Immune Deficiency Syndromes 2004; 36(3): 845-852.
[47]  Souverein D, Euser SM, Ramaiah R, Ram P, Gowda N, Gowda CS, et al. Reduction in STIs in an empowerment intervention programme for female sex workers in Bangalore, India: the Pragatiprogramme. Global Health Action 2013; 6: 22943.
[48]  Vejella S, Patel SK, Saggurti N, Prabhakar P. Community collectivization and consistent condom use among female sex workers in southern India: evidence from two rounds of behavioral tracking surveys. AIDS and Behavior 2016; 20(4): 776-87.