Community mobilization, empowerment and HIV prevention among female sex workers in south India

Using Peer Education to Promote Psychosocial and Occupational Health and Empowerment Among Female Sex Workers in Nepal

Female sex workers (FSWs) in Nepal are vulnerable to an array of occupational risks, which may compromise their psychosocial health and ability to engage in protective behaviors. A peer education (PE) intervention designed to empower and promote the psychosocial health of FSWs was pilot tested in Kathmandu, Nepal. FSWs who were exposed to the PE intervention (n = 96) had significantly higher scores on psychosocial health knowledge, perceived self-efficacy and ability to access resources, happiness, and job control compared with those who were not (n = 64). PE may be a promising way to promote psychosocial health and empowerment among FSWs.

HIV prevention programme cascades: insights from HIV programme monitoring for female sex workers in Kenya

INTRODUCTION

HIV prevention cascades have emerged as a programme management and monitoring tool that outlines the sequential steps of an HIV prevention programme. We describe the application of an HIV combination prevention programme cascade framework to monitor and improve HIV prevention interventions for female sex workers (FSWs) in Kenya.

METHODS

Two data sources were analysed: (1) annual programme outcome surveys conducted using a polling booth survey methodology in 2017 among 4393 FSWs, and (2) routine programme monitoring data collected by (a) 92 implementing partners between July 2017 and June 2018, and (b) Learning Site in Mombasa (2014 to 2015) and Nairobi (2013). We present national, sub-national and implementing partner level cascades.

RESULTS

At the national level, the population size estimates for FSW were 133,675 while the programme coverage targets were 174,073. Programme targets as denominator, during the period 2017 to 2018, 156,220 (90%) FSWs received peer education and contact, 148,713 (85%) received condoms and 83,053 (48%) received condoms as per their estimated need. At the outcome level, 92% of FSWs used condoms at the last sex with their client but 73% reported consistent condom use. Although 96% of FSWs had ever tested for HIV, 85% had tested in the last three months. Seventy-nine per cent of the HIV-positive FSWs were enrolled in HIV care, 73% were currently enrolled on antiretroviral therapy (ART) and 52% had attended an ART clinic in the last month. In the last six months, 48% of the FSWs had experienced police violence but 24% received violence support. National and sub-national level cascades showed proportions of FSWs lost at each step of programme implementation and variability in programme achievement. Hotspot and sub-population level cascades, presented as examples, demonstrate development and use of these cascades at the implementation level.

CONCLUSIONS

HIV prevention programme cascades, drawing on multiple data sources to provide an understanding of gaps in programme outputs and outcomes, can provide powerful information for monitoring and improving HIV prevention programmes for FSWs at all levels of implementation and decision-making. Complexity of prevention programmes and the paucity of consistent data can pose a challenge to development of these cascades.

Disrupting gender norms in health systems: making the case for change

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

The Effect of HIV Self-Testing Delivery Models on Female Sex Workers' Sexual Behaviors: A Randomized Controlled Trial in Urban Uganda

HIV self-testing increases recent and frequent HIV testing among female sex workers (FSWs) in urban Uganda. Using results from a randomized controlled trial, we aim to establish the effect of HIV self-testing delivery models on FSWs’ sexual behaviors in this setting. Clusters of one peer educator and eight participants were 1:1:1 randomized to: (1) direct provision of an HIV self-test, (2) provision of a coupon for facility collection of an HIV self-test, or (3) referral to standard-of-care HIV testing services. Sexual behaviors were self-reported at 1 and 4 months. From October to November 2016, 960 participants were enrolled and randomized. At 4 months, there were no statistically significant differences in participants’ sexual behaviors, including inconsistent condom use, across study arms. We do not find any changes in sexual risk-taking among FSWs in response to the delivery of HIV self-tests. Routine policies for HIV self-testing are likely a behaviorally safe component of comprehensive HIV prevention strategies.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.

METHODS

Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.

RESULTS

In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.

CONCLUSION

In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

Social Capital, Depressive Symptoms, and HIV Viral Suppression Among Young Black, Gay, Bisexual and Other Men Who Have Sex with Men Living with HIV

Social capital, the sum of an individual's resource-containing social network connections, has been proposed as a facilitator of successful HIV care engagement. We explored relationships between social capital, psychological covariates (depression, stigma and internalized homonegativity), and viral suppression in a sample of young Black gay, bisexual and other men who have sex with men (YB-GBMSM). We recruited 81 HIV-positive YB-GBMSM 18-24 years of age from a clinic setting. Participants completed a cross-sectional survey, and HIV-1 viral load (VL) measurements were extracted from the medical record. Sixty-five percent (65%) were virally suppressed (HIV-1 VL ≤ 40 copies/ml). Forty-seven percent (47%) had a positive depression screen. Depressive symptoms affected viral suppression differently in YB-GBMSM with lower vs. higher social capital (p = 0.046, test for statistical interaction between depression and social capital). The odds of viral suppression among YB-GBMSM with lower social capital was 93% lower among those with depressive symptoms (OR 0.07, p = 0.002); however, there was no association between depressive symptoms and viral suppression among those with higher social capital. Our results suggest that social capital may buffer the strong negative effects of depressive symptoms on clinical outcomes in YB-GBMSM living with HIV. In addition to treating depression, there is a role for interventions to augment social capital among YB-GBMSM living with HIV as a strategy for enhancing care engagement.

Changes in engagement in HIV prevention and care services among female sex workers during intensified community mobilization in 3 sites in Zimbabwe, 2011 to 2015

INTRODUCTION

'Sisters with a Voice', Zimbabwe's nationally scaled comprehensive programme for female sex workers (FSWs), intensified community mobilization activities in three sites to increase protective behaviours and utilization of clinical services. We compare indicators among FSWs at the beginning and after implementation.

METHODS

We used mixed methods to collect data at three sites: in-depth interviews (n = 22) in 2015, routine clinical data from 2010 to 2015, and two respondent driven sampling surveys in 2011 and 2015, in which participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Estimates were weighted using RDS-1 and estimate convergence assessed in both years. We assessed differences in six indicators between 2011 and 2015 using logistic regression adjusted for age, duration in sex work and education.

RESULTS

870 FSWs were recruited from the three sites in 2011 and 915 in 2015. Using logistic regression to adjust for socio-demographic differences, we found higher estimates of the proportion of HIV-positive FSWs and HIV-positive FSWs who knew their status and reported being on ART in Mutare and Victoria Falls in 2015 compared to 2011. Reported condom use with clients did not differ by year; however, condom use with regular partners was higher in 2015 in Mutare and Hwange. Reported HIV testing in the last six months among HIV-negative FSWs was higher in 2015 across sites: for instance, in Victoria Falls it was 13.4% (95% CI 8.7% to 19.9%) in 2011 and 80.8% (95% CI 74.0 to 87.7) in 2015. FSWs described positive perceptions of the Sisters programme, ease of engaging with health services, and improved solidarity among peers. Programme data showed increases in service use by 2015 across all sites.

CONCLUSIONS

Improvements in key HIV care engagement indicators were observed among FSWs in two sites and in testing and prevention indicators across the three sites after implementation of an intensified community mobilization intervention. Engagement with services for FSWs is critical for countries to reach 90-90-90 targets.

The contributions and future direction of Program Science in HIV/STI prevention

Background

Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health.

Discussion

To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States.

Conclusion

In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

"Who has ever loved a drug addict? It's a lie. They think a 'teja' is as bad person": multiple stigmas faced by women who inject drugs in coastal Kenya

BACKGROUND

A tenth of all people who inject drugs in Kenya are women, yet their social contexts and experiences remain poorly understood. This paper reports how multiple forms of stigma are experienced by women who inject drugs in coastal Kenya and the impact that they have on their ability to access essential health services.

METHODS

In 2015, in-depth interviews and focus group discussions were held with 45 women who inject drugs in two coastal towns. These data were supplemented with in-depth interviews with five individual stakeholders involved in service provision to this population. Data were analyzed thematically using NVivo.

RESULTS

Women who inject drugs experience multiple stigmas, often simultaneously. These included the external stigma and self-stigma of injection drug use, external gender-related stigma of being a female injecting drug user, and the external stigma of being HIV positive (i.e., among those living with HIV). Stigma led to rejection, social exclusion, low self-esteem, and delay or denial of services at health facilities.

CONCLUSION

HIV and harm reduction programs should incorporate interventions that address different forms of stigma among women who inject drugs in coastal Kenya. Addressing stigma will require a combination of individual, social, and structural interventions, such as collective empowerment of injecting drug users, training of healthcare providers on issues and needs of women who inject drugs, peer accompaniment to health facilities, addressing wider social determinants of stigma and discrimination, and expansion of harm reduction interventions to change perceptions of communities towards women who inject drugs.

A community-based qualitative study on the experience and understandings of intimate partner violence and HIV vulnerability from the perspectives of female sex workers and male intimate partners in North Karnataka state, India

Background

Research has increasingly documented the important role that violence by clients and the police play in exacerbating HIV vulnerability for women in sex work. However few studies have examined violence in the intimate relationships of women in sex work, or drawn on community partnerships to explore the social dynamics involved. A community-based participatory research study was undertaken by community and academic partners leading intimate partner violence (IPV) and HIV prevention programs in Bagalkot district, Karnataka state, India. The purpose was to explore the experience and understandings of intimate partner violence and HIV/AIDS among women in sex work and their intimate partners in Bagalkot that would inform both theory and practice.

Methods

A community-based, interpretive qualitative methodology was used. Data was collected between July and October 2014 through in-depth interviews with 38 participants, including 10 couples, 13 individual female sex workers, and 5 individual male intimate partners. Purposive sampling was done to maximize variation on socio-demographic characteristics. Thematic content analysis was conducted through coding and categorization for each interview question in NVivo 10.0, followed by collaborative analysis to answer the research questions.

Results

The results showed that an array of interrelated, multi-level factors underlay the widespread acceptance and perpetuation of violence and lack of condom use in participants’ intimate relationships. These included individual expectations that justified violence and reflected societal gender norms, compounded by stigma, legal and economic constraints relating to sex work. The results demonstrate that structural vulnerability to IPV and HIV must be addressed not only on the individual and relationship levels to resolve relevant triggers of violence and lack of condom use, but also the societal-level to address gender norms and socio-economic constraints among women in sex work and their partners.

Conclusion

The study contributes to a better understanding on the interplay of individual agency and structural forces at a time when researchers and program planners are increasingly pondering how best to address complex and intersecting social and health issues. Ongoing research should assess the generalizability of the results and the effectiveness of structural interventions aiming to reduce IPV and HIV vulnerability in other contexts.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0554-8) contains supplementary material, which is available to authorized users.

Evaluations of Structural Interventions for HIV Prevention: A Review of Approaches and Methods

Structural interventions alter the social, economic, legal, political, and built environments that underlie processes affecting population health. We conducted a systematic review of evaluations of structural interventions for HIV prevention in low- and middle-income countries (LMICs) to better understand methodological and other challenges and identify effective evaluation strategies. We included 27 peer-reviewed articles on interventions related to economic empowerment, education, and substance abuse in LMICs. Twenty-one evaluations included clearly articulated theories of change (TOCs); 14 of these assessed the TOC by measuring intermediary variables in the causal pathway between the intervention and HIV outcomes. Although structural interventions address complex interactions, no evaluation included methods designed to evaluate complex systems. To strengthen evaluations of structural interventions, we recommend clearly articulating a TOC and measuring intermediate variables between the predictor and outcome. We additionally recommend adapting study designs and analytic methods outside traditional epidemiology to better capture complex results, influences external to the intervention, and unintended consequences.

Effects of exposure to an intensive HIV-prevention programme on behavioural changes among female sex workers in Nairobi, Kenya

While Kenya has had a long-standing national HIV-prevention programme, evidence on the level of exposure to its interventions and related effects on behavioural changes among female sex workers (FSWs) is limited. Using cross-sectional behavioural data collected in 2013 from 1 357 FSWs aged 18 years and above in Nairobi, Kenya, this study explores the relationship between FSW programme exposure levels and behavioural outcomes including condom use, sexually transmitted infection (STI)-treatment, and empowerment measures like disclosure of self-identity and violence reporting. We categorised programme exposure levels as none, moderate and intensive. Multivariate logistic regression was used for analysis. Overall, 35% of the FSWs were not exposed to any HIV prevention programme, whereas about 24% had moderate and 41% had intensive exposure. FSWs having intensive programme exposure had a higher likelihood of using condoms consistently with occasional clients (AOR: 1.57; 95% CI: 1.08-2.31) and seeking treatment for STIs (AOR: 3.37; 95% CI: 1.63-7.02) compared to FSWs with no or moderate exposure. Intensive programme exposure was also associated with higher self-disclosure of sex-work identity (AOR: 1.63; 95% CI: 1.19-2.24), reporting of violence to police (AOR: 2.45; 95% CI: 1.03-5.84), and negotiation of condom use at last sex when the client was under the influence of alcohol (AOR: 1.63; 95% CI: 0.94-2.82). Although HIV prevention programmes in Kenya have been underway for over a decade, programme efforts were largely focused on saturating the coverage (intervention breadth). Strategies should now focus on ensuring improved quality of contacts through intensified programme exposure (intervention depth) to enhance gains in behavioural change among FSWs and preventing the burden of HIV infection among them.

Female sex workers' empowerment strategies amid HIV-related socioeconomic vulnerabilities in Cameroon

Research has consistently demonstrated that female sex workers use a variety of empowerment strategies to protect one another and their families. This study examines the strategies Cameroonian sex workers employ to do so. In-depth interviews and focus-group discussions were conducted with 100 sex workers. Coded texts were analysed for recurring themes. Sex workers reported being concerned with physical violence and sexual assault and demands from authorities for bribes to avoid fines and/or imprisonment. Women described strategies such as 'looking out for' each other when faced with security threats. Many reported staying in sex work to provide for their children through education and other circumstances to allow them to lead a better life. Sex worker mothers reported not using condoms when clients offered higher pay, or with intimate partners, even when they understood the risk of HIV transmission to themselves. Concern for their children's quality of life took precedence over HIV-related risks, even when sex workers were the children's primary carers. A sex worker empowerment programme with a focus on family-oriented services could offer an effective and novel approach to increasing coverage of HIV prevention, treatment and care in Cameroon.

Achieving scale rapidly in public health: Applying business management principles to scale up an HIV prevention program in India

Numerous public-health interventions have demonstrated effectiveness in pilots or on a small scale, but have proven challenging to scale up for population-level impact. Avahan, the Bill & Melinda Gates Foundation's HIV prevention program in 6 states of India, confronted the challenge of rapidly scaling up services to reach 300,000 people most at risk of HIV. This meant working in diverse and complex environments with marginalized and largely hidden populations. This case report presents a number of business-management principles that the foundation drew upon to successfully scale up this public-health program: 1) strategy development through market segmentation and complexity analysis, 2) a dynamic and evolving strategy, 3) developing an implementation and management structure to match the strategy, 4) standardization with flexibility, 5) generating demand to balance supply, 6) a customer-centric approach, and 7) data-driven management. Lessons learned from this experience include the crucial role of data in guiding decision-making and strategic and programmatic change; the need for a central body to set strategy; a willingness to change course when experience and data demonstrate the need; and the importance of partnering with program beneficiaries at all stages of program design, operation, evaluation and sustainability. We believe these lessons are applicable to other development programs that seek to foster widespread and sustainable program benefits at scale.

Evaluation of Empowerment in Health Promotion Interventions: A Systematic Review

Although empowerment is one of the core principles of the World Health Organization's approach to health promotion, there are no standards, best practice recommendations, or guidelines for evaluating empowerment within interventions. For the development of effective empowerment promoting interventions, adequate study designs, methods, and indicators for assessing empowerment are essential. In order to better understand which evaluation procedures have been used so far, and which advantages and disadvantages are connected to them, we systematically reviewed empowerment-based health promotion interventions. We included 26 studies, which use a broad variety of quantitative, qualitative, and mixed-methods designs and various data collection methods; qualitative and mixed-methods designs predominated. The quantitative measurement instruments are heterogeneous: Mainly self-designed or modified scales are applied. All studies consider indicators reflecting individual competencies and motivations, whereas indicators capturing the organizational and political components of empowerment are less common. Involving target group members in the development of evaluation procedures and combining different data sources are mentioned as specific steps to improve the quality of data collection. Given the flexible and context-dependent nature of empowerment approaches, the development of a "gold standard" for its evaluation seems unrealistic. However, the analyzed studies can be used to deduce recommendations that may help to conduct high-quality evaluations of empowerment, for example, mixed-methods designs, participation of target groups, and reflective loops within the research team.

Dutiful daughters: HIV/AIDS, moral pragmatics, female citizenship and structural violence among Devadasis in northern Karnataka, India

Decades of research have documented how sex workers worldwide, particularly female sex workers (FSWs), shoulder a disproportionate burden of the HIV epidemic. In India, although a substantial progress has been made in controlling the epidemic, its prevalence among FSWs and the Devadasis (also called traditional sex workers) in northern Karnataka is still significantly high. On the other hand, much of the HIV prevention research has focused on their mapping and size estimation, typologies, bio-behavioural surveillance, condom use and other prevention technologies. In this article, drawing on critical theoretical perspectives, secondary historical sources and in-depth interviews, we unravel wider social, cultural and political economic complexities surrounding the lives of Devadasis, and specifically illuminate the moral pragmatics that shed light on their entry into sex trade and vulnerability to HIV. Findings from this research are extremely important since while much is known about Devadasis in social sciences and humanities, relatively little is known about the complexities of their lives within public health discourses related to HIV. Our work has direct implications for ongoing HIV prevention and health promotion efforts in the region and beyond.

Community mapping of sex work criminalization and violence: impacts on HIV treatment interruptions among marginalized women living with HIV in Vancouver, Canada

Despite the high HIV burden faced by sex workers, data on access and retention in antiretroviral therapy (ART) are limited. Using an innovative spatial epidemiological approach, we explored how the social geography of sex work criminalization and violence impacts HIV treatment interruptions among sex workers living with HIV in Vancouver over a 3.5-year period. Drawing upon data from a community-based cohort (AESHA, 2010-2013) and linked external administrative data on ART dispensation, GIS mapping and multivariable logistic regression with generalized estimating equations to prospectively examine the effects of spatial criminalization and violence near women's places of residence on 2-day ART interruptions. Analyses were restricted to 66 ART-exposed women who contributed 208 observations and 83 ART interruption events. In adjusted multivariable models, heightened density of displacement due to policing independently correlated with HIV treatment interruptions (AOR: 1.02, 95%CI: 1.00-1.04); density of legal restrictions (AOR: 1.30, 95%CI: 0.97-1.76) and a combined measure of criminalization/violence (AOR: 1.00, 95%CI: 1.00-1.01) were marginally correlated. The social geography of sex work criminalization may undermine access to essential medicines, including HIV treatment. Interventions to promote 'enabling environments' (e.g. peer-led models, safer living/working spaces) should be explored, alongside policy reforms to ensure uninterrupted treatment access.

Knowledge and exercise of human rights, and barriers and facilitators to claiming rights: a cross-sectional study of female sex workers and high-risk men who have sex with men in Andhra Pradesh, India

Background

HIV prevention interventions recognize the need to protect the rights of key populations and support them to claim their rights as a vulnerability reduction strategy. This study explores knowledge of human rights, and barriers and facilitators to claiming rights, among female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) who are beneficiaries of a community mobilization intervention in Andhra Pradesh, India.

Methods

Data are drawn from a cross-sectional survey (2014) among 2400 FSWs and 1200 HR-MSM. Human rights awareness was assessed by asking respondents if they had heard of human rights (yes/no); those reporting awareness of rights were asked to spontaneously name specific rights from the following five pre-defined categories: right to health; dignity/equality; education; property; and freedom from discrimination. Respondents were classified into two groups: more knowledgeable (could identify two or more rights) and less knowledgeable (could identify one or no right). Univariate and bivariate analyses and chi-square tests were used. Data were analyzed using STATA 11.2.

Results

Overall 17% FSWs and 8% HR-MSM were not aware of their rights. Among those aware, 62% and 31% respectively were aware of just one or no right (less knowledgeable); only around half (54% vs 57%) were aware of health rights, and fewer (20% vs 16%) aware of their right to freedom from discrimination. Notably, 27% and 17% respectively had not exercised their rights. Barriers to claiming rights among FSWs and HR-MSM were neighbors (35% vs 37%), lack of knowledge (15% vs 14%), stigma (13% vs 22%) and spouse (19% FSWs). Community organizations (COs) were by far the leading facilitator in claiming rights (57% vs 72%).

Conclusions

The study findings show that awareness of human rights is limited among FSWs and HR-MSM, and a large proportion have not claimed their rights, elevating their HIV vulnerability. For a sustained HIV response, community mobilization efforts must focus on building key populations’ awareness of rights, and addressing the multiple barriers to claiming rights, with a view to creating a safe environment where vulnerable groups can demand and use services without fear of stigma, discrimination and violation of rights.

Barriers to Viral Suppression Among Female Sex Workers: Role of Structural and Intimate Partner Dynamics

OBJECTIVE

Despite global evidence that sex workers (SWs) are disproportionately impacted by HIV, data on HIV treatment outcomes among SWs living with HIV remains sparse. This study examined the correlates of undetectable plasma viral load (pVL) among street- and off-street SWs living with HIV and on antiretroviral therapy (ART) in Metro Vancouver, Canada.

METHODS

Analyses drew on data (2010-2014) from a longitudinal cohort of SWs (An Evaluation of Sex Workers Health Access) and confidential linkages with the Drug Treatment Program (DTP) data on ART dispensation and outcomes. Bivariate and multivariable generalized linear mixed-effects models were used to identify longitudinal correlates of undetectable pVL (<50 copies/mL).

RESULTS

Of the 72 SWs living with HIV who had ever used ART, 38.9% had an undetectable pVL at baseline. Although 84.7% had undetectable pVL at least once over the study period, 18.1% exhibited sustained undetectable pVL. In multivariable generalized linear mixed-effects model analyses, ≥95% pharmacy refill adherence (adjusted odds ratio (AOR) = 4.21; 95% confidence interval (CI) 2.16 to 8.19) and length of time since diagnosis (AOR = 1.06; 95% CI: 1.00 to 1.13) were positively correlated with undetectable pVL. Having an intimate male partner (AOR = 0.35; 95% CI: 0.16 to 0.78) and being homelessness were negatively correlated with undetectable pVL (AOR = 0.22; 95% CI: 0.10 to 0.47).

DISCUSSION/CONCLUSIONS

There is a need to more closely consider the social and structural contexts that shape SWs' experiences on ART and impact treatment outcomes, including the gendered power dynamics within intimate partnerships. Future research on HIV care among SWs is urgently needed, alongside structural and community-led interventions to support SWs' access to and retention in care.

The limitations of 'Black MSM' as a category: Why gender, sexuality, and desire still matter for social and biomedical HIV prevention methods

The USA faces disproportionate and increasing HIV incidence rates among Black men who have sex with men (BMSM). New biomedical technologies such as pre-exposure prophylaxis (PrEP) have been developed to address their HIV risk. Very little consideration, however, has been given to the diversity obscured by 'BMSM' as a category, to how this diversity relates to men's sexual partnering strategies, or to the relevance of these issues for new HIV prevention methods. We conducted a community-based ethnography from June 2013 to May 2014 documenting factors that affect the acceptance of and adherence to PrEP among BMSM. We conducted in-depth interviews with 31 BMSM and 17 community stakeholders, and participant observation. To demonstrate the diversity of social identities, we present a taxonomy of indigenous categories organised along the axes of sexual identity, sexual positioning, and gender performance. We analyse how HIV prevention strategies, such as PrEP, may be more effective if programmes consider how gender, sexuality, and sexual desire shape sexual partnering strategies. This article underlines the importance of attending to the diversity of sexual and social subjectivities among BMSM, of bringing the study of sexuality back into HIV prevention, and of integrating biomedical prevention approaches into community-based programmes.

Strategies for reducing police arrest in the context of an HIV prevention programme for female sex workers: evidence from structural interventions in Karnataka, South India

Introduction

Female sex workers (FSWs) frequently experience violence in their work environments, violating their basic rights and increasing their vulnerability to HIV infection. Structural interventions addressing such violence are critical components of comprehensive HIV prevention programmes. We describe structural interventions developed to address violence against FSWs in the form of police arrest, in the context of the Bill and Melinda Gates Foundation's India AIDS Initiative (Avahan) in Karnataka, South India. We examine changes in FSW arrest between two consecutive time points during the intervention and identify characteristics that may increase FSW vulnerability to arrest in Karnataka.

Methods

Structural interventions with police involved advocacy work with senior police officials, sensitization workshops, and integration of HIV and human rights topics in pre-service curricula. Programmes for FSWs aimed to enhance collectivization, empowerment and awareness about human rights and to introduce crisis response mechanisms. Three rounds of integrated behavioural and biological assessment surveys were conducted among FSWs from 2004 to 2011. We conducted bivariate and multivariate analyses using data from the second (R2) and third (R3) survey rounds to examine changes in arrests among FSWs over time and to assess associations between police arrest, and the sociodemographic and sex work-related characteristics of FSWs.

Results

Among 4110 FSWs surveyed, rates of ever being arrested by the police significantly decreased over time, from 9.9% in R2 to 6.1% in R3 (adjusted odds ratio (AOR) [95% CI]=0.63 [0.48 to 0.83]). Arrests in the preceding year significantly decreased, from 5.5% in R2 to 2.8% in R3 (AOR [95% CI]=0.59 [0.41 to 0.86]). FSWs arrested as part of arbitrary police raids also decreased from 49.6 to 19.5% (AOR [95% CI]=0.21 [0.11 to 0.42]). Certain characteristics, including financial dependency on sex work, street- or brothel-based solicitation and high client volumes, were found to significantly increase the odds of arrest for participants.

Conclusion

Structural interventions addressing police arrest of FSWs are feasible to implement. Based on our findings, the design of violence prevention and response interventions in Karnataka can be tailored to focus on FSWs, who are disproportionately vulnerable to arrest by police. Context-specific structural interventions can reduce police arrests, create a safer work environment for FSWs and protect fundamental human rights.

Correlates of unprotected sex with male clients among female sex workers in 13 Mexican cities

This study examined correlates of unprotected vaginal and anal sex (UVA) with male clients among female sex workers (FSWs). Baseline data were gathered from 1089 FSWs recruited from 13 cities across Mexico enrolled in an evidence-based sexual risk reduction intervention. We used generalised estimating equations (GEE) to predict total UVA while controlling for the nested structure of the data. Total UVA with clients in the past month was examined in relation to selected sociodemographic, substance-use, and micro- and macro-environmental factors. A greater number of UVA acts was associated with three micro-level environmental factors (i.e. never getting condoms for free, unaffordability of condoms, greater number of clients per month), and three macro-level environmental factors (i.e. lower health and higher education indices, greater population size of city). These findings suggest the development of social and structural approaches to HIV prevention for FSWs in Mexico, including modification of venue-based policies that pressure FSWs to maximise client volume, changes to the work environment that promote availability and affordability of condoms, and improved population health. Moreover, our findings call for the development of context-specific HIV interventions that take into account variations in the sexual risk behaviours and HIV risk environments of FSWs throughout Mexico.

Social Cohesion Among Sex Workers and Client Condom Refusal in a Canadian Setting: Implications for Structural and Community-Led Interventions

Community empowerment can be a powerful determinant of HIV risk among sex workers (SWs). This study modeled the impact of social cohesion on client condom refusal among SWs in Vancouver. Longitudinal data were drawn from a prospective cohort of SWs (2010-2013). Lippman and colleagues' Social Cohesion Scale measured SWs' connectedness (i.e., perception of mutual aid, trust, support). Multivariable logistic regression examined the independent effect of social cohesion on client condom refusal. Of 654 SWs, 22 % reported baseline client condom refusal and 34 % over 3 years. The baseline median social cohesion score was 24 (IQR 20-29, range 4-45). In the final confounding model, for every one-point increase in the social cohesion score, average odds of condom refusal decreased by 3 % (AOR 0.97; 95 % CI 0.95-0.99). Community empowerment can have a direct protective effect on HIV risk. These findings highlight the need for a legal framework that enables collectivization and SW-led efforts in the HIV response.

Relationship between Community Collectivization and Financial Vulnerability of Female Sex Workers in Southern India

Introduction

Studies exploring the linkages between financial vulnerabilities and community collectivization of female sex workers (FSWs) are scarce in India despite having potential policy implications. To fill this gap in the literature, this study attempts to understand the financial vulnerabilities among FSWs and assess the relationship between community collectivization and financial vulnerabilities in southern India.

Data and Methods

Data were drawn from a cross-sectional, behavioral tracking survey (BTS)—2014, conducted among FSWs (N = 2400) in Andhra Pradesh, a southern state of India under the Avahan-India AIDS initiative program. Adjusted odds ratios (AOR) and their 95% confidence intervals (CI) were estimated through multivariate logistic regression, to assess the independent relationships of the degree of community collectivization indicators with financial vulnerability indicators, adjusting for socio-demographic characteristics.

Results

Most FSWs (87%) reported having either one or more financial vulnerability and nearly one-fifth had a high financial vulnerability. The risk of facing financial vulnerability was significantly lower among FSWs with a high degree of perceived collective efficacy (15% vs 31%; AOR: 0.4; 95% CI: 0.3–0.5) and collective agency (4% vs 21%; AOR: 0.2; 95% CI: 0.1–0.3) as compared to their respective counterparts, after controlling for their individual socio-demographic characteristics. FSWs with a high degree of collective efficacy are also less likely to report different components of financial vulnerability (e.g. income, saving, expenditure, and debt).

Conclusion

This study finding suggests that community-led interventions such as improving collectivization are promising strategies to address financial vulnerabilities and a path to a sustainable reduction of HIV risk. This study calls for further evidence-based research and measurement of the effects of community-led approaches in addressing the financial vulnerabilities of the key population at risk for HIV.

Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Enhancing the Ethical Conduct of HIV Research with Migrant Sex Workers: Human Rights, Policy, and Social Contextual Influences

BACKGROUND

Migrant sex workers are often highly marginalized and disproportionately experience health and social inequities, including high prevalence of HIV, sexually transmitted infections, and human rights violations. In recent years, research involving migrant sex workers has increased, yet many knowledge gaps remain regarding how best to protect research participant rights and welfare. Our objective was to identify key challenges and opportunities related to the responsible conduct of HIV research with migrant sex workers.

METHODS

Focus groups and interviews conducted with 33 female sex workers ≥18 years old at the Guatemala-Mexico border from June 2013-February 2014 were analyzed. Participants were recruited through community outreach by a local HIV prevention organization to sex work establishments such as bars, hotels, street corners, and truck stops.

RESULTS

Key themes influencing research engagement for migrant sex workers included researcher mistrust and fear related to research participation, rooted in the social isolation frequently faced by recent migrants; intersecting concerns related to immigration status, fear of criminalization, and compliance with sex work regulations; and perceived benefits and risks of HIV/STI testing for migrants (e.g., immigration implications, stigma) represent potential barriers and opportunities for the responsible conduct of research involving migrant sex workers.

CONCLUSIONS

Results highlight the intersection between the human rights vulnerabilities of migrant sex workers and barriers to research participation, including social isolation of migrants and policy/legal barriers related to immigration and sex work. Findings illustrate the need for researchers to develop population-tailored procedures to address fears related to immigration and criminalization, and to reinforce positive and non-stigmatizing relationships with migrant sex workers. Community-led efforts to reduce stigma and foster community organization and supports for migrant sex workers are recommended, as are broader policy shifts that move away from punitive legal approaches towards approaches that safeguard and prioritize the human rights of migrant sex workers.

Structural Barriers to Antiretroviral Therapy Among Sex Workers Living with HIV: Findings of a Longitudinal Study in Vancouver, Canada

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants (n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.

Sexually transmitted infection screening uptake and knowledge of sexually transmitted infection symptoms among female sex workers participating in a community randomised trial in Peru

This study aims to evaluate condom use, sexually transmitted infection (STI) screening, and knowledge of STI symptoms among female sex workers in Peru associated with sex work venues and a community randomised trial of STI control. One component of the Peru PREVEN intervention conducted mobile-team outreach to female sex workers to reduce STIs and increase condom use and access to government clinics for STI screening and evaluation. Prevalence ratios were calculated using multivariate Poisson regression models with robust standard errors, clustering by city. As-treated analyses were conducted to assess outcomes associated with reported exposure to the intervention. Care-seeking was more frequent in intervention communities, but differences were not statistically significant. Female sex workers reporting exposure to the intervention had a significantly higher likelihood of condom use, STI screening at public health clinics, and symptom recognition compared to those not exposed. Compared with street- or bar-based female sex workers, brothel-based female sex workers reported significantly higher rates of condom use with last client, recent screening exams for STIs, and HIV testing. Brothel-based female sex workers also more often reported knowledge of STIs and recognition of STI symptoms in women and in men. Interventions to promote STI detection and prevention among female sex workers in Peru should consider structural or regulatory factors related to sex work venues.

Finding what works: Predicting health or social service linkage in drug using, African American, female sex workers in Miami, FL

Female sex workers (FSWs) encounter numerous challenges in accessing health and social services. In this study of drug using, African American FSWs, the authors examine specific factors associated with health or social service linkage among participants in a randomized intervention trial. Respondent linkage was significantly associated with individual factors (living alone, severe internal mental distress, and traumatic victimization) and project-related variables (attending five case management sessions and client engagement rating). In the multivariate model, higher client engagement and session attendance remained significant. The researchers conclude by discussing the importance of intervention attendance and engagement as key contributors to health and social service linkage among FSWs.

Evidence synthesis in international development: a critique of systematic reviews and a pragmatist alternative

Systematic reviews are an instrument of Evidence-Based Policy designed to produce comprehensive, unbiased, transparent and clear assessments of interventions' effectiveness. From their origins in medical fields, systematic reviews have recently been promoted as offering important advances in a range of applied social science fields, including international development. Drawing on a case study of a systematic review of the effectiveness of community mobilisation as an intervention to tackle HIV/AIDS, this article problematises the use of systematic reviews to summarise complex and context-specific bodies of evidence. Social development interventions, such as 'community mobilisation' often take different forms in different interventions; are made successful by their situation in particular contexts, rather than being successful or unsuccessful universally; and have a rhetorical value that leads to the over-application of positively valued terms (e.g. 'community mobilisation'), invalidating the keyword search process of a systematic review. The article suggests that the policy interest in definitive summary statements of 'the evidence' is at odds with academic assessments that evidence takes multiple, contradictory and complex forms, and with practitioner experience of the variability of practice in context. A pragmatist philosophy of evidence is explored as an alternative. Taking this approach implies expanding the definition of forms of research considered to be 'useful evidence' for evidence-based policy-making; decentralising decisions about 'what works' to allow for the use of local practical wisdom; and prioritising the establishment of good processes for the critical use of evidence, rather than producing context-insensitive summaries of 'the evidence'.

Intimate-Partner and Client-Initiated Violence among Female Street-Based Sex Workers in China: Does a Support Network Help?

Background

Globally, female street-based sex workers are vulnerable to gender-based violence. Previous research has shown having a peer social network can reduce sex workers’ risks of victimization. However, mechanisms of how social network impacts violence among female street-based sex workers are still far from clear.

Methods

Our study was based on data abstracted from a paper-and-pencil survey administered among 218 female street-based sex workers in Shanghai, China. We focused on self-reported client-initiated violence and intimate-partner violence in emotional, physical, and sexual forms. Social networks were characterized by the size and sources of financial and psychosocial support (e.g. family, friends, and peers). Multi-variable logistic regression was used to estimate adjusted odds ratios (AOR) of each type of violence exposure by social network structure after the adjustment of age, education, and years in Shanghai.

Results

The street-based female sex workers in our study were primarily rural-to-urban migrants (95.7%) with an average age of 41 years old. 24.3% and 62.8% of the sex workers reported intimate-partner violence and client-initiated violence respectively. Lack of financial support, as defined by having only one individual or none in her peer support system to help financially, was significantly associated with self-reported intimate-partner violence (AOR: 2.5; 95% CI: 1.1–5.9). Respondents who reported client-initiated violence, by contrast, were more likely to report lacked psychosocial support from family (AOR: 2.2, 95% CI: 1.0–4.6) and peers (AOR: 5.1, 95% CI: 2.2–11).

Conclusion

This study is one of the first to systematically analyze the associations between social network and gender-based violence among street-based female sex worker. We reported a high prevalence of both types of gender-based violence and their complex associations with family, friends, and peer support network. Policies with goals to reduce violence against women may apply these findings to leverage social network in the interventions against gender-based violence.

Competition is not necessarily a barrier to community mobilisation among sex workers: an intervention planning assessment from Zimbabwe

BACKGROUND

Community mobilization among female sex workers (SWs) is recognized as an effective strategy to empower SWs and increase their uptake of health services. Activities focus on increasing social cohesion between SWs by building trust, strengthening networks, and encouraging shared efforts for mutual gain. Several studies, however, suggest that high levels of interpersonal competition between SWs can pose a barrier to collective action and support. We conducted a study to examine levels of perceived competition between SWs in Mutare, Hwange and Victoria Falls in Zimbabwe in order to inform development of a community-based intervention for HIV prevention and treatment. This paper focuses on our qualitative findings and their implications for the design of HIV programming in the Zimbabwean context.

METHODS

Following a respondent driven sampling (RDS) survey, we explored issues related to social cohesion amongst SWs in Mutare, Hwange and Victoria Falls through in-depth interviews conducted with 22 SWs. Interviews examined dynamics of SWs' relationships and extent of social support, and were analyzed using thematic content analysis using the constant comparative method. Findings are contextualised against descriptive data extracted from the survey, which was analysed using Stata 12, adjusting for RDS.

RESULTS

Across all sites, women described protecting each other at night, advising each other about violent or non-paying clients, and paying fines for each other following arrest. In Mutare, women gave additional examples, including physically attacking problem clients, treatment adherence support and shared saving schemes. However, interviews also highlighted fierce competition between women and deep mistrust. This reflects the reported mix of competition and support from the survey of 836 women (Mutare n = 370, Hwange n = 237, Victoria Falls n = 229). In Mutare, 92.8 % of SWs agreed there was a lot of competition; 87.9 % reported that SWs support each other. This contrasted with Victoria Falls and Hwange where fewer agreed there was competition between SWs (70.5 % and 78.0 %), but also fewer reported that SWs support each other at work (55.2 % and 51.2 %).

CONCLUSIONS

Women reported being most likely to support each other when confronted with serious danger but maintained high levels of competition for clients, suggesting competition at work does not represent a barrier to support. Examples of practical assistance between SWs provide entry points for our planned community mobilization activities, which aim to broaden trust and support among SWs while acknowledging their professional competition.

Harms to Adults from Others' Heavy Drinking in Five Indian States

AIMS

The aims of this study were to assess a wide range of alcohol-related harms from known heavy drinkers in Indian respondents' lives, and to assess respondents' characteristics and drinking patterns associated with reporting these harms.

METHODS

Household interviews were administered in five Indian states from October 2011 to May 2012. For the secondary data analyses in this study, participants were Indians, ages 15-70, who self-reported having a heavy drinker in their lives (n = 5,375). We assessed the proportion of respondents reporting seventeen types of alcohol-related harms from a heavy drinker.

RESULTS

Approximately 83% of respondents reported at least one alcohol-related harm from a heavy drinker in their lives. Twenty-five percent of respondents reported physical harm, 6% reported sexual harm and 50% reported emotional harm or neglect. Controlling for other factors, being in the upper income quartiles was associated with reporting ≥5 harm types. Among females, being age 25-39 and married/cohabitating predicted reporting ≥5 harm types, while among males, being age 25-39 or age 40-70 and living in a rural area increased the odds. Among females, binge drinkers had 46% lower odds of reporting ≥5 harm types than abstainers; among males, binge drinkers had 54% greater odds.

CONCLUSION

Regardless of respondents' own drinking pattern, a substantial proportion of respondents reported experiencing a range of harms from a known heavy drinker; interventions are needed to reduce these harms.

"Whatever I have, I have made by coming into this profession": the intersection of resources, agency, and achievements in pathways to sex work in Kolkata, India

This article investigated the complex interplay of choice, socioeconomic structural factors, and empowerment influencing engagement in sex work. The analysis was focused on pathways into and reasons for staying in sex work from in-depth qualitative interviews with participants (n = 37) recruited from the Durbar community-led structural intervention in Kolkata, India. Kabeer's theory of empowerment focused on resources, agency, and achievements was utilized to interpret the results. Results identified that contexts of disempowerment constraining resources and agency set the stage for initiating sex work, typically due to familial poverty, loss of a father or husband as a breadwinner, and lack of economic opportunities for women in India. Labor force participation in informal sectors was common, specifically in domestic, construction, and manufacturing work, but was typically insufficient to provide for families and also often contingent on sexual favors. The availability of an urban market for sex work served as a catalyst or resource, in conjunction with Durbar's programmatic resources, for women to find and exercise agency and achieve financial and personal autonomy not possible in other work or as dependents on male partners. Resources lost in becoming a sex worker due to stigma, discrimination, and rejection by family and communities were compensated for by achievements in gaining financial and social resources, personal autonomy and independence, and the ability to support children and extended family. Durbar's programs and activities (e.g., savings and lending cooperative, community mobilization, advocacy) function as empowering resources that are tightly linked to sex workers' agency, achievements, and sex work pathways.

Outreach strategies for the promotion of HIV testing and care: closing the gap between health services and female sex workers in Benin

BACKGROUND

Regular voluntary counseling and testing is a key component of the fight against HIV/AIDS. In Benin, the project SIDA-1/2/3 established to decrease HIV/sexually transmitted infection (STIs) among female sex workers (FSWs), implemented a multifaceted intervention, including outreach activities. The objective of this article was to present potential advantages and limitations of 3 categories of outreach interventions designed to increase the use of testing services among FSWs in Benin.

METHODS

This analysis is based on ethnographic fieldwork conducted in Benin from June to December 2012.

RESULTS

Sixty-six FSWs and 24 health care workers were interviewed. Their narratives revealed 3 main factors impeding the development of appropriate HIV testing behavior. These negative elements can be positioned along a continuum of health care behaviors, with each stage of this continuum presenting its own challenges: fear or lack of motivation to use testing services, inaccessibility of care when the decision to go has been made, and a perceived lack of quality in the care offered at the health care center. Many of these needs seem to be addressed in the outreach strategies tested. However, the study also exposed some potential barriers or limitations to the success of these strategies when applied in this specific context, due to social disruption, mobility, access to care, and hard to reach population.

CONCLUSIONS

To increase the use of testing services, an outreach strategy based on community workers or peer educators, along with improved access to testing services, would be well adapted to this context and appreciated by both FSWs and health care workers.

Changes in HIV and syphilis prevalence among female sex workers from three serial cross-sectional surveys in Karnataka state, South India

OBJECTIVES

This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India.

DESIGN

Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time.

SETTING

Five districts in Karnataka state, India.

PARTICIPANTS

7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included.

INTERVENTIONS

The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation.

RESULTS

HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8% (adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low.

CONCLUSIONS

The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up

A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.

Global epidemiology of HIV among female sex workers: influence of structural determinants

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

The impact of community mobilisation on HIV prevention in middle and low income countries: a systematic review and critique

While community mobilisation (CM) is increasingly advocated for HIV prevention, its impact on measurable outcomes has not been established. We performed a systematic review of the impact of CM within HIV prevention interventions (N = 20), on biomedical, behavioural and social outcomes. Among most at risk groups (particularly sex workers), the evidence is somewhat consistent, indicating a tendency for positive impact, with stronger results for behavioural and social outcomes than for biomedical ones. Among youth and general communities, the evidence remains inconclusive. Success appears to be enhanced by engaging groups with a strong collective identity and by simultaneously addressing the socio-political context. We suggest that the inconclusiveness of the findings reflects problems with the evidence, rather than indicating that CM is ineffective. We discuss weaknesses in the operationalization of CM, neglect of social context, and incompatibility between context-specific CM processes and the aspiration of review methodologies to provide simple, context-transcending answers.

Sex workers in HIV prevention: From Social Change Agents to Peer Educators

We utilised a comparative ethnographic approach to study the implementation of a community mobilisation intervention addressing HIV risk among female sex workers (FSWs) in India, as implemented first by an non-governmental organisation and after oversight of the intervention was transitioned to the government. We demonstrate that the work of peer outreach workers changed from Social Change Agents within a community-led structural intervention (CLSI) to Peer Educators within a targeted intervention (TI). In the CLSI approach, built on the assumption that FSW risk for HIV is rooted in power inequality and structural vulnerability, peer outreach workers mobilised their peers through community-based organisations to address underlying conditions of inequality and vulnerability. In contrast, the TI approach, which views FSW risk as a function of limited knowledge and barriers to services, addressed peers' access to information and health services. Analysis of changes in the function of peer outreach workers reveals critical differences of which we discuss four: assumptions about conditions that produce HIV risk; degree of emphasis placed on collective mobilising and building collective power; extent to which community mobilisation and HIV prevention goals are linked; and the intervention's use of peer input. We discuss the implications of these findings for HIV prevention programming.

HIV infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed

PURPOSE OF REVIEW

This article reviews the current state of the epidemiological literature on female sex work and HIV from the past 18 months. We offer a conceptual framework for structural HIV determinants and sex work that unpacks intersecting structural, interpersonal, and individual biological and behavioural factors.

RECENT FINDINGS

Our review suggests that despite the heavy HIV burden among female sex workers (FSWs) globally, data on the structural determinants shaping HIV transmission dynamics have only begun to emerge. Emerging research suggests that factors operating at macrostructural (e.g., migration, stigma, criminalized laws), community organization (e.g., empowerment) and work environment levels (e.g., violence, policing, access to condoms HIV testing, HAART) act dynamically with interpersonal (e.g., dyad factors, sexual networks) and individual biological and behavioural factors to confer risks or protections for HIV transmission in female sex work.

SUMMARY

Future research should be guided by a Structural HIV Determinants Framework to better elucidate the complex and iterative effects of structural determinants with interpersonal and individual biological and behavioural factors on HIV transmission pathways among FSWs, and meet critical gaps in optimal access to HIV prevention, treatment, and care for FSWs globally.

CB. Structural and Interpersonal Benefits and Risks of Participation in HIV Research: Perspectives of Female Sex Workers in Guatemala

This study explored perceived benefits and risks of participation in HIV research among 33 female sex workers in Tecun Uman, Guatemala. Stigma associated with sex work and HIV was a critical barrier to research participation. Key benefits of participation included access to HIV/STI prevention and testing, as well as positive and trusting relationships between sex workers and research teams. Control exerted by managers had mixed influences on perceived research risks and benefits. Results underscore the critical need for HIV investigators to develop population-tailored procedures to reduce stigma, engage managers, and reinforce trusting, reciprocal relationships between sex work communities and researchers.

Complexities of short-term mobility for sex work and migration among sex workers: violence and sexual risks, barriers to care, and enhanced social and economic opportunities

Despite research on the health and safety of mobile and migrant populations in the formal and informal sectors globally, limited information is available regarding the working conditions, health, and safety of sex workers who engage in short-term mobility and migration. The objective of this study was to longitudinally examine work environment, health, and safety experiences linked to short-term mobility/migration (i.e., worked or lived in another city, province, or country) among sex workers in Vancouver, Canada, over a 2.5-year study period (2010-2012). We examined longitudinal correlates of short-term mobility/migration (i.e., worked or lived in another city, province, or country over the 3-year follow-up period) among 646 street and off-street sex workers in a longitudinal community-based study (AESHA). Of 646 sex workers, 10.84 % (n = 70) worked or lived in another city, province, or country during the study. In a multivariate generalized estimating equations (GEE) model, short-term mobility/migration was independently correlated with older age (adjusted odds ratio (AOR) 0.95, 95 % confidence interval (CI) 0.92-0.98), soliciting clients in indoor (in-call) establishments (AOR 2.25, 95 % CI 1.27-3.96), intimate partner condom refusal (AOR 3.00, 1.02-8.84), and barriers to health care (AOR 1.77, 95 % CI 1.08-2.89). In a second multivariate GEE model, short-term mobility for sex work (i.e., worked in another city, province, or country) was correlated with client physical/sexual violence (AOR 1.92, 95 % CI 1.02-3.61). In this study, mobile/migrant sex workers were more likely to be younger, work in indoor sex work establishments, and earn higher income, suggesting that short-term mobility for sex work and migration increase social and economic opportunities. However, mobility and migration also correlated with reduced control over sexual negotiation with intimate partners and reduced health care access, and mobility for sex work was associated with enhanced workplace sexual/physical violence, suggesting that mobility/migration may confer risks through less control over work environment and isolation from health services. Structural and community-led interventions, including policy support to allow for more formal organizing of sex work collectives and access to workplace safety standards, remain critical to supporting health, safety, and access to care for mobile and migrant sex workers.

Community mobilization and empowerment of female sex workers in Karnataka State, South India: associations with HIV and sexually transmitted infection risk

OBJECTIVES

We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.

METHODS

We conducted behavioral-biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.

RESULTS

By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI =  2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM.

CONCLUSIONS

CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.

Non-disclosure of violence among female sex workers: evidence from a large scale cross-sectional survey in India

OBJECTIVE

One of the indicators critical to the success of violence reduction programmes among female sex workers (FSWs) is the pattern of disclosure of violence. This study examines the rate of non-disclosure of violence among FSWs in India by perpetrators of violence and programme exposure.

METHODS

Data were drawn from a cross-sectional study conducted among FSWs in 2009 across four states of India: Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu. The analytical sample included 1341 FSWs who experienced physical violence in past six months. Multilevel logistic regression stratified by state was conducted to examine predictors of non-disclosure.

RESULTS

About 54% of FSWs did not disclose their experience of violence to anyone with considerable variations in the pattern of disclosure across states. Another 36% of FSWs shared the experience with NGO worker/peer. Compared to violence perpetrated by paying partners/stranger, that by non-paying partner were twice more likely to report non-disclosure (53% vs. 68%, Adjusted Odds Ratio [AOR]: 1.8, 95% Confidence Interval [CI]: 1.3-2.4). Similarly, FSWs who were not registered with an NGO/sex worker collective were 40% more likely to report non-disclosure of violence against those registered (58% vs. 53%, AOR: 1.4, 95% CI: 1.1-1.9).

CONCLUSIONS

Non-disclosure of physical violence is quite high among FSWs which can be a barrier to the success of violence reduction efforts. Immediate efforts are required to understand the reasons behind non-disclosure based on which interventions can be developed. Community collectivisation and designing gender-based interventions with the involvement of non-paying partners should be the way forward.