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Community Mobilization Challenging Gender Power Imbalances: Women Sex Workers' Capacity to Engage in Health-Enhancing Practices in Southern India. AIDS Behav 2022; 26:1238-1250. [PMID: 34590177 DOI: 10.1007/s10461-021-03481-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
Research on women sex workers' condom use with non-paying intimate partners suggests social norms of gender power in these relationships constrain women's health-enhancing sexual practice. Theorizing gender relations and sexual practice as structural informs our analysis of elements of community mobilization interventions (CMI) that link to sex workers' capacity to engage consistently in health-enhancing practices, in this case, condom use. We use data from a survey of women (who exchanged sex for money in the preceding 12 months) conducted in the context of an HIV-prevention intervention in southern India. Results of multinomial logistic regression indicate: higher odds of health-enhancing sexual practice with intimate partners and paying clients among women sex workers expressing collective efficacy; lower odds of health-diminishing sexual practice with clients among women sex workers empowered through peer interactions; lower odds of health-diminishing sexual practice with clients and lower odds of health-enhancing sexual practice with partners among women sex worker living in households structured by normative gender power relations. We suggest future research on how CMI promoting health-enabling social environments with women in sex work contribute to their capacity to engage in health-enhancing practices.
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Ali S, Chaudhuri S, Ghose T, Jana S, Dolui R. Sexual health communication between sex worker mothers and their children in India. CULTURE, HEALTH & SEXUALITY 2022; 24:533-547. [PMID: 33541240 DOI: 10.1080/13691058.2021.1871648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 12/31/2020] [Indexed: 06/12/2023]
Abstract
In India, relatively little is known about sex worker mothers' beliefs regarding sexual health communication with their children. Using qualitative data collected in Kolkata, India, this study used the Parent Expansion of the Theory of Planned Behaviour to examine sex worker mothers' beliefs about sexual health communication and factors shaping these beliefs. Sex worker mothers' beliefs about sexual health communication were shaped by societal norms and collectivising processes often driven by Durbar Mahila Samanwaya Committee (DMSC), a sex workers' collective in Kolkata, India. Specifically, we found that challenging stigma, assuming ownership over one's body and health, and making relevant material resources and knowledge accessible and meaningful were key in supporting mothers to overcome barriers around sexual health communication. These collectivising processes shaped mothers' beliefs about sexual health communication and facilitated their ability to engage in it. Future research, policies and programmes should consider the far-reaching impact of community-led structural interventions on sex worker mothers and their children.
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Affiliation(s)
- Samira Ali
- Graduate College of Social Work, University of Houston, Houston, TX, USA
| | - Sambuddha Chaudhuri
- Center of Policy Studies, India Institute of Technology Bombay, Bombay, India
| | - Toorjo Ghose
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ratan Dolui
- Durbar Mahila Samanwaya Committee, Kolkata, India
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Mantsios A, Muraleetharan O, Donastorg Y, Perez M, Gomez H, Shembilu C, Beckham SW, Karver TS, Davis W, Likindikoki S, Mbwambo J, Barrington C, Kerrigan D. "She is the one who knows": A qualitative exploration of oral and injectable PrEP as part of a community empowerment approach to HIV prevention among female sex workers in the Dominican Republic and Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000981. [PMID: 36712835 PMCID: PMC9880901 DOI: 10.1371/journal.pgph.0000981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite documented interest among female sex workers (FSW), uptake of oral pre-exposure prophylaxis (PrEP) for HIV prevention has been low. Recent trials and regulatory approval of long-acting injectable (LAI) PrEP offer new hope for the potential of this biomedical intervention. We examined FSW's PrEP-related interest and preferences regarding both oral and LAI PrEP situating these dynamics within their specific social and occupational realities. We conducted this work using qualitative methods across two distinct contexts by conducting 40 in-depth interviews with FSW in Tanzania and the Dominican Republic. Textual data was coded using iterative thematic content analysis. Analytic summaries were developed and reviewed to identify recurring themes. We systematically organized themes within each country and then compared across settings. Women in both settings expressed strong interest in PrEP seeing it as an important option to protect themselves in their work. Most participants preferred LAI PrEP due to expectations of reduced stigma and concerns about daily pill adherence and side effects. Occupational factors such as alcohol use, overnight dates with clients, and fear of violence from clients were identified as barriers to daily oral PrEP. LAI PrEP was seen as having the potential to reduce stress related to oral PrEP. Women who preferred pills discussed fear of needles, skepticism about the injections, and others relayed that taking a daily pill would not be challenging for them. There was a pre-dominant sentiment that women know best whether they are better suited for oral or LAI PrEP. Participants stressed the importance of FSW understanding both options to ensure informed decision-making around PrEP and described community-led peer education as key to delivering trusted information. Community empowerment approaches led by FSW which address structural and psychosocial constraints and promote safe work environments may facilitate equitable access and uptake of PrEP among FSW across settings.
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Affiliation(s)
- Andrea Mantsios
- Public Health Innovation & Action, New York, New York, United States of America
- * E-mail:
| | - Ohvia Muraleetharan
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Yeycy Donastorg
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Martha Perez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Catherine Shembilu
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Tahilin Sanchez Karver
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Wendy Davis
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
| | - Samuel Likindikoki
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
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Nugroho A, Erasmus V, Krier SE, Reviagana KP, Laksmono PA, Widihastuti A, Richardus JH. Client perspectives on an outreach approach for HIV prevention targeting Indonesian MSM and transwomen. Health Promot Int 2021; 35:916-924. [PMID: 31504514 PMCID: PMC7585524 DOI: 10.1093/heapro/daz075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study explored clients’ perspective on an outreach approach to promote HIV testing in Indonesia targeting men who have sex with men (MSM) and transgender women (transwomen or waria). Semi-structured qualitative interviews were conducted with 32 individuals (21 MSM and 11 waria) who had received services from outreach workers (OWs) in five cities in Indonesia. Participants in this study reported positive experiences with the outreach approach and perceived OWs as their motivators in accessing HIV testing as well as HIV care and treatment. OWs provided easy-to-understand HIV information. Clients expected OWs to be well-trained and more creative in performing outreach. They perceived that the Internet and social media have helped them considerably to stay in touch with OWs. Yet, they expressed that such virtual contacts could not simply replace the face-to-face contact, especially for waria. Furthermore, clients suggested outreach to be delivered in a more appealing manner, for example through activities that may facilitate clients learning professional or life skills. They also asserted that as an HIV prevention approach, outreach needs to use more positive framing and go beyond HIV and health contents, chiefly for the youth. Future outreach programmes should facilitate OWs in providing tailored services based on the level and type of support that the clients need, and in applying varied proportion and levels of sophistication in the use of online and virtual platforms for outreach.
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Affiliation(s)
- Adi Nugroho
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,School of Public Health, Faculty of Medicine, Lambung Mangkurat University, Banjarbaru, Indonesia.,GWL-INA Network, Jakarta, Indonesia
| | - Vicki Erasmus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sarah E Krier
- Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Center for LGBT Health Research, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kusnindyah P Reviagana
- School of Public Health, Faculty of Medicine, Lambung Mangkurat University, Banjarbaru, Indonesia
| | | | | | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Whitford K, Mitchell E, Lazuardi E, Rowe E, Tasya IA, Wirawan DN, Wisaksana R, Subronto YW, Prameswari HD, Kaldor JM, Bell S. A strengths-based analysis of social influences that enhance HIV testing among female sex workers in urban Indonesia. Sex Health 2021; 18:77-83. [PMID: 33588987 DOI: 10.1071/sh20085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 11/23/2022]
Abstract
Background HIV prevalence among female sex workers in Indonesia remains high and large proportions of female sex workers have never been tested for HIV. International research highlights the importance of community-led strategies to increase HIV testing in this population. Little qualitative research has been conducted to address these issues in Indonesia or other Asia-Pacific countries. This paper documents social influences that enhance HIV testing among female sex workers in urban Indonesia. METHODS This was an interpretive qualitative study in Yogyakarta, Denpasar and Bandung. In total, 57 female sex workers participated in 11 focus group discussions, and four participated in individual semi-structured interviews. Deductive and inductive thematic analysis techniques were used to identify narratives of strengths pertaining to uptake of HIV testing. RESULTS Participants described supportive relationships with peers, community-based organisations and 'bosses'. Participants reported trusted networks with peers within which to share information about HIV testing and receive emotional support. Relationships with community outreach workers facilitated HIV testing through reminders, accompanied visits, and emotional/informational support. Community-based organisations worked with health services to facilitate mobile, community-based testing to overcome employment- and family-related constraints that inhibited women's clinic attendance. 'Bosses' employed a variety of practices to encourage HIV testing among their workers. CONCLUSIONS Relationships, practices and action in community- and workplace-based settings outside formal health service spaces enhanced HIV testing among female sex workers. Community- or workplace-based HIV testing with outreach support from health services, peer-led HIV testing within existing social and work-based networks, and working with bosses to implement HIV prevention strategies can address low HIV testing rates in this key population.
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Affiliation(s)
- Kate Whitford
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; and Corresponding author.
| | - Elke Mitchell
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Elan Lazuardi
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; and Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Emily Rowe
- Kerti Praja Foundation, Denpasar, Indonesia
| | - Irma Anintya Tasya
- Clinical Infectious Disease Research Center, Faculty of Medicine, Universitas Padjajaran, Bandung, Indonesia
| | - Dewa N Wirawan
- Kerti Praja Foundation, Denpasar, Indonesia; and Department of Public Health and Preventive Medicine, Faculty of Medicine, Universities Udayana, Denpasar, Indonesia
| | - Rudi Wisaksana
- Clinical Infectious Disease Research Center, Faculty of Medicine, Universitas Padjajaran, Bandung, Indonesia; and Department of Internal Medicine, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Yanri W Subronto
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; and Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Hellen D Prameswari
- HIV AIDS and STI Sub-directorate, Directorate of Communicable Disease Prevention and Control, Directorate General of Disease Prevention and Control, Ministry of Health of Indonesia, Jakarta, Indonesia
| | - John M Kaldor
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Stephen Bell
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; and Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia; and Kirby Institute, Level 6, Wallace Wurth Building, UNSW Sydney, Kensington, NSW, Australia
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Faini D, Munseri P, Bakari M, Sandström E, Faxelid E, Hanson C. "I did not plan to have a baby. This is the outcome of our work": a qualitative study exploring unintended pregnancy among female sex workers. BMC Womens Health 2020; 20:267. [PMID: 33261591 PMCID: PMC7709442 DOI: 10.1186/s12905-020-01137-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND High number of unintended pregnancies-often leading to induced abortions-are reported among female sex workers (FSWs), highlighting a major unmet need for contraception. To better understand barriers to contraceptive use, we explored FSW's pregnancy perceptions and experiences of unintended pregnancy. We hypothesized that sex work exacerbates barriers to contraceptive use and that FSW's pregnancy perceptions and experiences of unintended pregnancy influence future commitment to contraceptive use. METHODS We conducted in-depth interviews with 11 FSWs (January-June 2019) in Dar es Salaam, Tanzania. We purposively sampled FSWs with a positive pregnancy test from those participating in a HIV vaccine preparedness cohort. We used open ended questions to explore how FSWs make decisions when facing barriers to contraceptive use, dealing with unintended pregnancy and adhering to contraceptive use after experiencing unintended pregnancy. All interviews were conducted in Kiswahili, audio-recorded, transcribed and translated into English. Grounded theory approach was used to analyse transcripts. Open and selective coding was performed using Nvivo software. RESULTS FSWs reported that sex work impedes good contraceptive behaviour because sex workers felt unable to negotiate consistent condom use, avoided health services due to stigma, missed monthly contraceptive supplies because of inconvenient clinic operating hours or skipped contraceptive pills when intoxicated after taking alcohol. FSWs who perceived pregnancy to be a burden terminated the pregnancy because of fear of loss of income during pregnancy or child rearing expenses in case child support was not assured by their partners. FSWs who perceived pregnancy to be a blessing decided to keep the pregnancy because they desired motherhood and hoped that children would bring prosperity. Family planning counselling and availability of contraceptives during postpartum care influenced the initiation of contraception among FSWs. Financial hardships related to childrearing or painful abortion experiences influenced FSWs' commitment to good contraceptive practices. CONCLUSION Our results demonstrate that FSWs face barriers to initiating and adhering to contraceptive use because of sex work stigma, inability to negotiate condoms and failure to access medical services at their convenience. Our findings underscore the need to integrate contraceptive services with HIV programs serving FSWs in their areas of work.
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Affiliation(s)
- Diana Faini
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences (MUHAS), 9 United Nations Road, Dar es Salaam, Tanzania.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Muhammad Bakari
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Eric Sandström
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Faxelid
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Mahapatra B, Walia M, Patel SK, Battala M, Mukherjee S, Patel P, Subramanium B, Atmavilas Y, Saggurti N. Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India. PLoS One 2020; 15:e0235094. [PMID: 32609731 PMCID: PMC7329078 DOI: 10.1371/journal.pone.0235094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/08/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex through consistent use of condoms sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying relationship between strengthening of COs, vulnerability reduction, and sustaining of consistent condom use behavior among FSWs. Methods We used a longitudinal study design to assess the change in outcomes. A three-stage sampling design was used to select FSWs for the study. Panel data of 2085 FSWs selected from 38 COs across five states of India was used to examine the change in various outcomes from 2015 (Survey Round 1) to 2017 (Survey Round 2). The CO level program pillar measuring institutional development assessed performance of COs in six domains critical for any organization’s functionality and sustainability: governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization. Overall, 32 indicators from all these domains were used to compute the CO strength score. A score was computed by taking mean of average dimension scores. The overall score was divided into two groups based on the median cutoff; COs which scored below the median were considered to have low CO strength, while COs which scored above or equal to median were considered to have high CO strength. Multivariable regression modeling techniques were used to examine the effect of program pillars on outcome measures. Results Analyses showed a significant improvement in the strength of the COs over time; percentage of COs having high strength improved from 50% in 2015 to 87% in Round 2. The improvement in CO’s strength increased financial security (Adjusted Odds Ratio [AOR]: 2.18, p<0.01), social welfare security (AOR: 1.71, p<0.01), and socio-legal security (AOR: 2.20, p<0.01) among FSWs. Further, improvement in financial security led to significant increase in consistent condom use with client among FSWs (AOR: 1.69, p<0.01) who were members of COs having high strength. Sustained consistent condom use was positively associated with young age (<30 years), ability to negotiate with clients for condom use, membership in self-help groups, high self-efficacy, self-confidence, and client solicitation in streets and brothels. Conclusions Improving financial security and strengthening FSW led CO can improve sustained and consistent condom use. In addition, the program should focus on enhancing ability of FSWs to negotiate with clients for condom use, promote membership in self-help groups and target FSWs who are 30 years or older, and soliciting from homes to sustain consistent condom use across all FSWs.
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Affiliation(s)
| | | | | | | | | | - Prachi Patel
- Catalyst Management Services, Bengaluru, Karnataka, India
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Campbell L, Masquillier C, Thunnissen E, Ariyo E, Tabana H, Sematlane N, Delport A, Dube LT, Knight L, Kasztan Flechner T, Wouters E. Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review . INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3808. [PMID: 32471153 PMCID: PMC7312869 DOI: 10.3390/ijerph17113808] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 01/12/2023]
Abstract
Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact.
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Affiliation(s)
- Linda Campbell
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
| | - Caroline Masquillier
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
| | - Estrelle Thunnissen
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
| | - Esther Ariyo
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Bellville 7535, South Africa; (H.T.); (N.S.); (A.D.); (L.T.D.); (L.K.)
| | - Neo Sematlane
- School of Public Health, University of the Western Cape, Bellville 7535, South Africa; (H.T.); (N.S.); (A.D.); (L.T.D.); (L.K.)
| | - Anton Delport
- School of Public Health, University of the Western Cape, Bellville 7535, South Africa; (H.T.); (N.S.); (A.D.); (L.T.D.); (L.K.)
| | - Lorraine Tanyaradzwa Dube
- School of Public Health, University of the Western Cape, Bellville 7535, South Africa; (H.T.); (N.S.); (A.D.); (L.T.D.); (L.K.)
| | - Lucia Knight
- School of Public Health, University of the Western Cape, Bellville 7535, South Africa; (H.T.); (N.S.); (A.D.); (L.T.D.); (L.K.)
| | - Tair Kasztan Flechner
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
| | - Edwin Wouters
- Centre for Population, Family and Health, University of Antwerp, 2000 Antwerp, Belgium; (C.M.); (E.T.); (E.A.); (T.K.F.); (E.W.)
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Busza J, Chiyaka T, Musemburi S, Fearon E, Davey C, Chabata S, Mushati P, Dirawo J, Napierala S, Phillips AN, Cowan FM, Hargreaves JR. Enhancing national prevention and treatment services for sex workers in Zimbabwe: a process evaluation of the SAPPH-IRe trial. Health Policy Plan 2020; 34:337-345. [PMID: 31157368 DOI: 10.1093/heapol/czz037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 11/13/2022] Open
Abstract
Targeted HIV interventions for female sex workers (FSW) combine biomedical technologies, behavioural change and community mobilization with the aim of empowering FSW and improving prevention and treatment. Understanding how to deliver combined interventions most effectively in sub-Saharan Africa is critical to the HIV response. The Sisters' Antiretroviral Programme for Prevention of HIV: an Integrated Response (SAPPH-Ire) randomized controlled trial in Zimbabwe tested an intervention to improve FSW engagement with HIV services. After 2 years, results of the trial showed no significant difference between study arms in proportion of FSW with HIV viral load ≥1000 copies/ml as steep declines occurred in both. We present the results of a process evaluation aiming to track the intervention's implementation, assess its feasibility and accessibility, and situate trial results within the national HIV policy context. We conducted a mixed methods study using data from routine programme statistics, qualitative interviews with participants and respondent driven surveys. The intervention proved feasible to deliver and was acceptable to FSW and providers. Intervention clinics saw more new FSW (4082 vs 2754), performed over twice as many HIV tests (2606 vs 1151) and nearly double the number of women were diagnosed with HIV (1042 vs 546). Community mobilization meetings in intervention sites also attracted higher numbers. We identified some gaps in programme fidelity: offering pre-exposure prophylaxis took time to engage FSW, viral load monitoring was not performed, and ratio of peer educators to FSW was lower than intended. During the trial, reaching FSW with HIV testing and treatment became a national priority, leading to increasing attendance at both intervention and control clinics. Throughout Zimbabwe, antiretroviral therapy coverage improved and HIV-stigma declined. Zimbabwe's changing HIV policy context appeared to contribute to positive improvements across the HIV care continuum for all FSW over the course of the trial. More intense community-based interventions for FSW may be needed to make further gains.
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Affiliation(s)
- Joanna Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe
| | - Sithembile Musemburi
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe
| | - Elizabeth Fearon
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Calum Davey
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Sungai Chabata
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe
| | - Sue Napierala
- RTI International, 351 California Street, Suite 500, San Francisco, CA, USA
| | - Andrew N Phillips
- Institute for Global Health, UCL, Royal Free Hospital, Rowland Hill Street, London, UK and
| | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, UK
| | - James R Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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Treves-Kagan S, Maman S, Khoza N, MacPhail C, Peacock D, Twine R, Kahn K, Lippman SA, Pettifor A. Fostering gender equality and alternatives to violence: perspectives on a gender-transformative community mobilisation programme in rural South Africa. CULTURE, HEALTH & SEXUALITY 2020; 22:127-144. [PMID: 31429663 PMCID: PMC7905832 DOI: 10.1080/13691058.2019.1650397] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/28/2019] [Indexed: 06/10/2023]
Abstract
Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels.
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Affiliation(s)
- Sarah Treves-Kagan
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
- Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California San Francisco, CA, USA
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Nomhle Khoza
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine MacPhail
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Health and Society, University of Wollongong, Wollongong, NSW, Australia
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dean Peacock
- Division of Social and Behavioural Sciences, University of Cape Town School of Public Health, Cape Town, South Africa
- Sonke Gender Justice, Cape Town, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheri A. Lippman
- Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California San Francisco, CA, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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Brown AF, Ma GX, Miranda J, Eng E, Castille D, Brockie T, Jones P, Airhihenbuwa CO, Farhat T, Zhu L, Trinh-Shevrin C. Structural Interventions to Reduce and Eliminate Health Disparities. Am J Public Health 2020; 109:S72-S78. [PMID: 30699019 DOI: 10.2105/ajph.2018.304844] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.
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Affiliation(s)
- Arleen F Brown
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Grace X Ma
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Jeanne Miranda
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Eugenia Eng
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Dorothy Castille
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Teresa Brockie
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Patricia Jones
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Collins O Airhihenbuwa
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Tilda Farhat
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Lin Zhu
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
| | - Chau Trinh-Shevrin
- Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue
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Patel SK, Mukherjee S, Mahapatra B, Battala M, Jayaram M, Kumta S, Atmavilas Y, Saggurti N. Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey. PLoS One 2019; 14:e0223961. [PMID: 31639161 PMCID: PMC6804955 DOI: 10.1371/journal.pone.0223961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/02/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India. Data and methods This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment. Results There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5–4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs. Conclusions Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.
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Affiliation(s)
| | | | | | | | | | - Sameer Kumta
- Bill & Melinda Gates Foundation, New Delhi, India
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Survey measures versus incentivized measures of risk preferences: Evidence from sex workers' risky sexual transactions. Soc Sci Med 2019; 238:112497. [PMID: 31446372 DOI: 10.1016/j.socscimed.2019.112497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 11/21/2022]
Abstract
Survey measures of risk attitudes are primarily used in the health literature, although incentivized measures of risk preferences are being increasingly used in other fields. We exploit the unique setting of commercial female sex workers in Bangladesh to investigate whether incentivized measures of risk preferences, or non-incentivized survey measures of risk preferences, best identify the risky commercial sex decisions that they make. The study uses survey data collected during February-April 2016, and October-November 2016 from eight brothels in Bangladesh. Wave 1 includes 1,332 female sex workers, Wave 2 includes 1,185 female sex workers. Our findings suggest that researchers can reliably use survey measures to elicit risk preferences on health.
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Coupland H, Page K, Stein E, Carrico A, Evans J, Dixon T, Sokunny M, Phou M, Maher L. Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 64:70-78. [PMID: 30583088 DOI: 10.1016/j.drugpo.2018.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 11/29/2018] [Accepted: 12/03/2018] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Heidi Coupland
- The Kirby Institute for Infection and Immunity, Faculty of Medicine, Level 6, Wallace Wurth Building, UNSW, Sydney, Australia; Drug Health Services, Sydney Local Health District & Discipline of Addiction Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Kimberly Page
- Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Centre, Albuquerque, NM, USA.
| | - Ellen Stein
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Adam Carrico
- Department of Public Health Sciences, University of Miami, Florida, USA.
| | - Jennifer Evans
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Thomas Dixon
- Faculty of Law, The University of Sydney, Sydney, Australia.
| | | | - Maly Phou
- FHI360 Cambodia, Phnom Penh, Cambodia.
| | - Lisa Maher
- The Kirby Institute for Infection and Immunity, Faculty of Medicine, Level 6, Wallace Wurth Building, UNSW, Sydney, Australia; The Burnet Institute, Melbourne, Australia.
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Lippman SA, Leddy AM, Neilands TB, Ahern J, MacPhail C, Wagner RG, Peacock D, Twine R, Goin DE, Gómez‐Olivé FX, Selin A, Tollman SM, Kahn K, Pettifor A. Village community mobilization is associated with reduced HIV incidence in young South African women participating in the HPTN 068 study cohort. J Int AIDS Soc 2018; 21 Suppl 7:e25182. [PMID: 30334377 PMCID: PMC6192897 DOI: 10.1002/jia2.25182] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/20/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW. METHODS We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates. RESULTS There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role. CONCLUSIONS These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Anna M Leddy
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Torsten B Neilands
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Jennifer Ahern
- Division of EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Catherine MacPhail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- School of Health and SocietyUniversity of WollongongWollongongNSWAustralia
- Wits Reproductive Health and HIV Research InstituteUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
| | - Dean Peacock
- Sonke Gender JusticeCape TownSouth Africa
- School of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Dana E Goin
- Division of EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - F Xavier Gómez‐Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amanda Selin
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
- INDEPTH NetworkAccraGhana
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Mahapatra B, Bhattacharya R, Atmavilas Y, Saggurti N. Measuring vulnerability among female sex workers in India using a multidimensional framework. PLoS One 2018; 13:e0204055. [PMID: 30252879 PMCID: PMC6155505 DOI: 10.1371/journal.pone.0204055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/31/2018] [Indexed: 11/18/2022] Open
Abstract
Measuring vulnerability and identifying determinants of vulnerability are key to designing interventions for marginalized groups like sex workers. The current study introduces a new approach of measuring vulnerability among female sex workers (FSWs) by adopting a multidimensional poverty measurement framework. A multidimensional vulnerability index was created from four dimensions and 16 indicators using a dual cut-off approach. The study found that 55% of FSWs were multidimensionally vulnerable with 48% of intensity in vulnerability. The overall value of multidimensional vulnerability index was 0.265. FSWs in Maharashtra were most vulnerable (82%). Lack of financial security contributed mostly to FSWs’ vulnerability. Further, compared to less vulnerable FSWs, multidimensionally vulnerable ones were more to engage in behaviors that put them at risk such as inconsistent use of condoms with clients, alcohol consumption, engaging in anal sex with clients and experiencing sexually transmitted infections. Findings suggest that structural, social and financial vulnerabilities of FSWs need to be addressed concurrently.
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Affiliation(s)
| | - Ruchira Bhattacharya
- Population Council, Zone 5A, India Habitat Center, New Delhi, India
- National Institute of Rural Development and Panchayati Raj, Rajendranagar Mandal, Hyderabad, India
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation, The Capital Court, New Delhi, India
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17
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Pettifor A, Lippman SA, Gottert A, Suchindran CM, Selin A, Peacock D, Maman S, Rebombo D, Twine R, Gómez‐Olivé FX, Tollman S, Kahn K, MacPhail C. Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa. J Int AIDS Soc 2018; 21:e25134. [PMID: 29972287 PMCID: PMC6058206 DOI: 10.1002/jia2.25134] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 05/09/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk. METHODS Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (post-intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes. RESULTS Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16). CONCLUSION Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly. CLINICAL TRIALS NUMBER ClinicalTrials.gov NCT02129530.
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Affiliation(s)
- Audrey Pettifor
- Department of EpidemiologyUniversity of North Carolina Gillings School of Global Public HealthChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Center for AIDS Prevention Studies (CAPS)Department of MedicineUniversity of California at San FranciscoSan FranciscoCAUSA
| | - Ann Gottert
- Population CouncilHIV and AIDS programWashingtonDCUSA
| | - Chirayath M Suchindran
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of BiostatisticsUniversity of North Carolina Gillings School of Global Public HealthChapel HillNCUSA
| | - Amanda Selin
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dean Peacock
- Sonke Gender JusticeCape TownSouth Africa
- School of Public HealthDivision of Social and Behavioural ScienceUniversity of Cape TownCape TownSouth Africa
| | - Suzanne Maman
- Department of Health BehaviorUniversity of North Carolina Gillings School of Global Public HealthChapel HillNC
| | | | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Francesc Xavier Gómez‐Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Epidemiology and Global Health UnitDepartment of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Epidemiology and Global Health UnitDepartment of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Catherine MacPhail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- School of HealthUniversity of New EnglandArmidaleNSWAustralia
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
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18
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Chang RC, Hail-Jares K, Zheng H, He N, Bouey JZH. Mitigating circumstances: A model-based analysis of associations between risk environment and infrequent condom use among Chinese street-based sex workers. PLoS One 2018; 13:e0195982. [PMID: 29763416 PMCID: PMC5953488 DOI: 10.1371/journal.pone.0195982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 04/03/2018] [Indexed: 12/01/2022] Open
Abstract
Background Little is known about how freelance street-based sex workers navigate condom use while soliciting. Traditional behavioural model may fail to account for the complex risk environment that most street-based sex workers work within. We examine first the association of self-efficacy and the infrequent condom use, then we investigated the roles of clients and venues frequented on this association. Method Using a purposive chain-referral sampling method, we surveyed 248 street-based sex workers in Shanghai. The survey focused on sex workers HIV risk factors, sex work patterns, HIV knowledge, and related HIV self-efficacy. Clients types and behaviours, and characteristics of the venues frequented by these commercial sex workers were also collected. We conducted a series of multiple logistic regression models to explore how the association between a sex worker’s self-efficacy with infrequent condom use change as client and venue characteristics were added to the models. Results We find that within the basic model, low self-efficacy was marginally associated with infrequent condom use (54.9% vs. 45.1%, AOR = 1.70, 95% CI = 0.95–3.03). As client- and venue- characteristics were added, the associations between self-efficacy and condom use were strengthened (AOR = 2.10 95% CI = 1.12–3.91 and 2.54 95% CI = 1.24–5.19 respectively). Those who reported middle-tiered income were more likely to report infrequent condom use compared to their peers of high income (AOR = 3.92 95% CI = 1.32–11.70) whereas such difference was not found between low income and high income sex workers. Visiting multiple venues and having migrant workers as clients were also associated with infrequent condom use. Conclusion Our findings suggest sex worker’s self-efficacy matters in their HIV risk behaviours only when environment characteristics were adjusted. Risk environment for street-based sex workers are complex. Programming addressing behavioural changes among female sex workers should adopt holistic, multilevel models with the consideration of risk environments.
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Affiliation(s)
- Ruth C. Chang
- Department of International Health, School of Nursing and Health Studies, Georgetown University, Washington DC, United States of America
| | - Katie Hail-Jares
- Griffith Criminology Institute, Griffith University, Mt. Gravatt, Queensland, Australia
| | - Huang Zheng
- Shanghai CSW&MSM Center, Xinjian St., Shanghai, China
| | - Na He
- Department of Epidemiology, Fudan University, Wu Jiao Chang, Yang Pu Qu, Shanghai, China
| | - Jennifer Z. H. Bouey
- Department of International Health, School of Nursing and Health Studies, Georgetown University, Washington DC, United States of America
- * E-mail:
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Blanchard AK, Nair SG, Bruce SG, Ramanaik S, Thalinja R, Murthy S, Javalkar P, Pillai P, Collumbien M, Heise L, Isac S, Bhattacharjee P. 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. BMC WOMENS HEALTH 2018; 18:66. [PMID: 29751752 PMCID: PMC5948786 DOI: 10.1186/s12905-018-0554-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 04/22/2018] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Andrea K Blanchard
- Department of Community Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, R3E 0W3, Canada.
| | - Sapna G Nair
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Sharon G Bruce
- Department of Community Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, R3E 0W3, Canada
| | | | - Satyanarayana Ramanaik
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Raghavendra Thalinja
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Srikanta Murthy
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Prakash Javalkar
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Priya Pillai
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Martine Collumbien
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Lori Heise
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shajy Isac
- Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
| | - Parinita Bhattacharjee
- Department of Community Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, R3E 0W3, Canada.,Karnataka Health Promotion Trust, No 1-4 5th Floor IT Park, Rajajinagar, Bengaluru, 560044, India
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20
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Benoit C, Jansson SM, Smith M, Flagg J. Prostitution Stigma and Its Effect on the Working Conditions, Personal Lives, and Health of Sex Workers. JOURNAL OF SEX RESEARCH 2018; 55:457-471. [PMID: 29148837 DOI: 10.1080/00224499.2017.1393652] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Researchers have shown that stigma is a fundamental determinant of behavior, well-being, and health for many marginalized groups, but sex workers are notably absent from their analyses. This article aims to fill the empirical research gap on sex workers by reviewing the mounting evidence of stigmatization attached to sex workers' occupation, often referred to as "prostitution" or "whore" stigma. We give special attention to its negative effect on the working conditions, personal lives, and health of sex workers. The article first draws attention to the problem of terminology related to the subject area and makes the case for consideration of prostitution stigmatization as a fundamental cause of social inequality. We then examined the sources of prostitution stigma at macro, meso, and micro levels. The third section focuses on tactics sex workers employ to manage, reframe, or resist occupational stigma. We conclude with a call for more comparative studies of stigma related to sex work to contribute to the general stigma literature, as well as social policy and law reform.
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Affiliation(s)
- Cecilia Benoit
- a Centre for Addictions Research of British Columbia , University of Victoria
| | - S Mikael Jansson
- a Centre for Addictions Research of British Columbia , University of Victoria
| | - Michaela Smith
- a Centre for Addictions Research of British Columbia , University of Victoria
| | - Jackson Flagg
- a Centre for Addictions Research of British Columbia , University of Victoria
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Leite GS, Murray L, Lenz F. The Peer and Non-peer: the potential of risk management for HIV prevention in contexts of prostitution. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2017; 18 Suppl 1:7-25. [PMID: 26630296 DOI: 10.1590/1809-4503201500050003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 12/18/2014] [Indexed: 11/22/2022] Open
Abstract
Sex workers have been the protagonists and focus of HIV prevention campaigns and research since the late 1980s in Brazil. Through a review of national and international literature, combined with a history of sex workers' involvement in the construction of the Brazilian response, this article explores the overlaps and disconnects between research and practice in contexts of prostitution over the past three decades. We review the scientific literature on the epidemiology of HIV among sex workers and prevention methodologies. We conclude that although research focus and designs often reinforce the idea that sex workers' vulnerability is due to their sexual relationships with clients, their greatest vulnerability has been found to be with their nonpaying intimate partners. Few studies explore their work contexts and structural factors that influence safe sex practices with both types of partners. The negative effects of criminalization, stigma, and exclusively biomedical and peer education-based approaches are well documented in the scientific literature and experiences of sex worker activists, as is the importance of prevention programs that combine empowerment and human rights-based approach to reduce HIV infection rates. We conclude that there is a need for actions, policies, and research that encompass the environment and context of sex workers' lives and reincorporate the human rights and citizenship frame that dominated the Brazilian response until the end of the 2000s. As part of HIV prevention efforts, female sex workers need to be considered above all as women, equal to all others.
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Affiliation(s)
| | - Laura Murray
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
| | - Flavio Lenz
- Graduate Program in Communication, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Elmes J, Skovdal M, Nhongo K, Ward H, Campbell C, Hallett TB, Nyamukapa C, White PJ, Gregson S. A reconfiguration of the sex trade: How social and structural changes in eastern Zimbabwe left women involved in sex work and transactional sex more vulnerable. PLoS One 2017; 12:e0171916. [PMID: 28225822 PMCID: PMC5321466 DOI: 10.1371/journal.pone.0171916] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 01/27/2017] [Indexed: 11/19/2022] Open
Abstract
Understanding the dynamic nature of sex work is important for explaining the course of HIV epidemics. While health and development interventions targeting sex workers may alter the dynamics of the sex trade in particular localities, little has been done to explore how large-scale social and structural changes, such as economic recessions-outside of the bounds of organizational intervention-may reconfigure social norms and attitudes with regards to sex work. Zimbabwe's economic collapse in 2009, following a period (2000-2009) of economic decline, within a declining HIV epidemic, provides a unique opportunity to study community perceptions of the impact of socio-economic upheaval on the sex trade. We conducted focus group discussions with 122 community members in rural eastern Zimbabwe in January-February 2009. Groups were homogeneous by gender and occupation and included female sex workers, married women, and men who frequented bars. The focus groups elicited discussion around changes (comparing contemporaneous circumstances in 2009 to their memories of circumstances in 2000) in the demand for, and supply of, paid sex, and how sex workers and clients adapted to these changes, and with what implications for their health and well-being. Transcripts were thematically analyzed. The analysis revealed how changing economic conditions, combined with an increased awareness and fear of HIV-changing norms and local attitudes toward sex work-had altered the demand for commercial sex. In response, sex work dispersed from the bars into the wider community, requiring female sex workers to employ different tactics to attract clients. Hyperinflation meant that sex workers had to accept new forms of payment, including sex-on-credit and commodities. Further impacting the demand for commercial sex work was a poverty-driven increase in transactional sex. The economic upheaval in Zimbabwe effectively reorganized the market for sex by reducing previously dominant forms of commercial sex, while simultaneously providing new opportunities for women to exchange sex in less formal and more risky transactions. Efforts to measure and respond to the contribution of sex work to HIV transmission need to guard against unduly static definitions and consider the changing socioeconomic context and how this can cause shifts in behavior.
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Affiliation(s)
- Jocelyn Elmes
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Kundai Nhongo
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Helen Ward
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Catherine Campbell
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, United Kingdom
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Peter J. White
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Khan S, Lorway R, Chevrier C, Dutta S, Ramanaik S, Roy A, Bhattacharjee P, Mishra S, Moses S, Blanchard J, Becker M. Dutiful daughters: HIV/AIDS, moral pragmatics, female citizenship and structural violence among Devadasis in northern Karnataka, India. Glob Public Health 2017; 13:1065-1080. [PMID: 28102112 DOI: 10.1080/17441692.2017.1280070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Shamshad Khan
- a Department of Communication , University of Texas at San Antonio , San Antonio , TX , USA
| | - Robert Lorway
- b Center for Global Public Health, Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Claudyne Chevrier
- b Center for Global Public Health, Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Sumit Dutta
- c Department of Sociology , Dr. K. N. Modi University , Niwai , Rajasthan , India
| | - Satyanarayana Ramanaik
- d Centre for Multi-Disciplinary Development Research , Dharwad , India.,f Karnataka Health Promotion Trust , Bengaluru , India
| | - Anu Roy
- e Independent Consultant , Stanford , CA , USA
| | | | - Sharmistha Mishra
- g Department of Medicine , St. Michael's Hospital, University of Toronto , Toronto , Canada
| | - Stephen Moses
- b Center for Global Public Health, Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - James Blanchard
- b Center for Global Public Health, Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Marissa Becker
- b Center for Global Public Health, Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
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Lippman SA, Pettifor A, Rebombo D, Julien A, Wagner RG, Kang Dufour MS, Kabudula CW, Neilands TB, Twine R, Gottert A, Gómez-Olivé FX, Tollman SM, Sanne I, Peacock D, Kahn K. Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial. Implement Sci 2017; 12:9. [PMID: 28095904 PMCID: PMC5240325 DOI: 10.1186/s13012-016-0541-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/27/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care. METHODS/DESIGN Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM. DISCUSSION Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa. TRIAL REGISTRATION NCT02197793 Registered July 21, 2014.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - Dumisani Rebombo
- Sonke Gender Justice, 4th Floor Westminster House, 122 Longmarket Street, 8001, Cape Town, South Africa
| | - Aimée Julien
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 90187, Umeå, Sweden
| | - Mi-Suk Kang Dufour
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Ann Gottert
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Helen Joseph Hospital, Perth Road, Westdene, 2092, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice, 4th Floor Westminster House, 122 Longmarket Street, 8001, Cape Town, South Africa
- Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Falmouth Rd, Observatory 7925, Cape Town, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 90187, Umeå, Sweden
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Lippman SA, Neilands TB, MacPhail C, Peacock D, Maman S, Rebombo D, Twine R, Selin A, Leslie HH, Kahn K, Pettifor A. Community Mobilization for HIV Testing Uptake: Results From a Community Randomized Trial of a Theory-Based Intervention in Rural South Africa. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S44-S51. [PMID: 27930611 PMCID: PMC5147031 DOI: 10.1097/qai.0000000000001207] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action. METHODS We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization. RESULTS Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores. CONCLUSIONS There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.
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Affiliation(s)
- Sheri A. Lippman
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Torsten B. Neilands
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
| | - Catherine MacPhail
- School of Health, University of New England, Armidale, New South Wales, Australia
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice, Cape Town, South Africa
- School of Public Health, University of Cape Town, South Africa
| | - Suzanne Maman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Dumisani Rebombo
- Sonke Gender Justice, Cape Town, South Africa
- School of Public Health, University of Cape Town, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amanda Selin
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hannah H. Leslie
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA; and
| | - Kathleen Kahn
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Ganju D, Patel SK, Prabhakar P, Adhikary R. 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. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2016; 16:29. [PMID: 27855692 PMCID: PMC5112884 DOI: 10.1186/s12914-016-0102-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 10/18/2016] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Deepika Ganju
- HIV and AIDS Program, Population Council, 142 Golf Links, New Delhi, 110003, India.
| | - Sangram Kishor Patel
- HIV and AIDS Program, Population Council, 142 Golf Links, New Delhi, 110003, India
| | - Parimi Prabhakar
- India HIV/AIDS Alliance, Sarovar Centre, Secretariat Road, Hyderabad, 500063, India
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Fehrenbacher AE, Chowdhury D, Ghose T, Swendeman D. Consistent Condom Use by Female Sex Workers in Kolkata, India: Testing Theories of Economic Insecurity, Behavior Change, Life Course Vulnerability and Empowerment. AIDS Behav 2016; 20:2332-2345. [PMID: 27170035 PMCID: PMC5016559 DOI: 10.1007/s10461-016-1412-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Consistent condom use (CCU) is the primary HIV/STI prevention option available to sex workers globally but may be undermined by economic insecurity, life-course vulnerabilities, behavioral factors, disempowerment, or lack of effective interventions. This study examines predictors of CCU in a random household survey of brothel-based female sex workers (n = 200) in two neighborhoods served by Durbar (the Sonagachi Project) in Kolkata, India. Multivariate logistic regression analyses indicated that CCU was significantly associated with perceived HIV risk, community mobilization participation, working more days in sex work, and higher proportion of occasional clients to regular clients. Exploratory analyses stratifying by economic insecurity indicators (i.e., debt, savings, income, housing security) indicate that perceived HIV risk and community mobilization were only associated with CCU for economically secure FSW. Interventions with FSW must prioritize economic security and access to social protections as economic insecurity may undermine the efficacy of more direct condom use intervention strategies.
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Affiliation(s)
- Anne E Fehrenbacher
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E Young Drive South, Los Angeles, CA, 90095, USA
| | - Debasish Chowdhury
- Public Health Foundation of India (PHFI), Sector-44, Plot No-47, Gurgaon, 122003, India
| | - Toorjo Ghose
- School of Social Policy & Practice, University of Pennsylvania, 3701 Locust Walk, Caster D17, Philadelphia, 19104, USA
| | - Dallas Swendeman
- Center for HIV Identification, Prevention and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA.
- Department of Epidemiology, Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, 90024, USA.
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Social Cohesion Among Sex Workers and Client Condom Refusal in a Canadian Setting: Implications for Structural and Community-Led Interventions. AIDS Behav 2016; 20:1275-83. [PMID: 26499335 DOI: 10.1007/s10461-015-1230-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Relationship between Community Collectivization and Financial Vulnerability of Female Sex Workers in Southern India. PLoS One 2016; 11:e0156060. [PMID: 27227998 PMCID: PMC4881938 DOI: 10.1371/journal.pone.0156060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 05/09/2016] [Indexed: 11/25/2022] Open
Abstract
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.
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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 Behav 2016; 20:776-87. [PMID: 26286343 PMCID: PMC4799261 DOI: 10.1007/s10461-015-1171-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Community collectivization is an integral part of condom use and HIV risk reduction interventions among key population. This study assesses community collectivization among female sex workers (FSWs), and explores its relationship with sex workers' consistent condom use (CCU) with different partners considering the interaction effect of time and collectivization. Data were drawn from two rounds of cross-sectional surveys collected during 2010 (N1 = 1986) and 2012 (N2 = 1973) among FSWs in Andhra Pradesh, India. Results of the multiple logistic regression analysis show that, CCU with regular and occasional clients increased over the inter-survey period among FSWs with a high collective efficacy (AOR 2.9 and 6.1) and collective agency (AOR 14.4 and 19.0) respectively. The association of high levels of collectivization with CCU and self-efficacy for condom use are central to improve the usefulness and sustainability of HIV prevention programs worldwide.
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Affiliation(s)
- Shanti Vejella
- />India HIV/AIDS Alliance, Sarovar Center, Secretariat Road, Hyderabad, India
| | - Sangram Kishor Patel
- />HIV and AIDS Program, Population Council, 142, Golf Links, New Delhi, 110003 India
| | - Niranjan Saggurti
- />HIV and AIDS Program, Population Council, 142, Golf Links, New Delhi, 110003 India
| | - Parimi Prabhakar
- />India HIV/AIDS Alliance, Sarovar Center, Secretariat Road, Hyderabad, India
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Chevrier C, Khan S, Reza-Paul S, Lorway R. 'No one was there to care for us': Ashodaya Samithi's community-led care and support for people living with HIV in Mysore, India. Glob Public Health 2015; 11:423-36. [PMID: 26548553 DOI: 10.1080/17441692.2015.1091488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Under the umbrella of the Bill and Melinda Gates-funded HIV initiative in India, the Mysore-based sex workers' (SWs) collective Ashodaya Samithi focused on improving its members' living and working conditions through community-led structural interventions, including community mobilisation, advocacy, peer-led support, and health promotional activities. Based on four months of ethnographic fieldwork, this article examines the care and support activities of one of its sub-wings, Ashraya, which specifically focuses on people living with HIV and AIDS (PLHIV). We first discuss the stigma-related perceptions and experiences of participants in relation to health-care settings and work environment, families and communities, and within varied HIV support networks. We then explore how Ashraya's community-led interventions attempt to challenge the structural forces feeding on and creating stigma. We argue that the current policy focus on the involvement of SWs' collectives in sexually transmitted infection (STI) prevention in India is rather limited and should be expanded along the continuum of care and support offered to PLHIV. As suggested in this paper, SWs' organisations may have greater potential to contribute to more than STI prevention work, both within and outside their communities, than currently recognised.
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Affiliation(s)
- Claudyne Chevrier
- a Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Shamshad Khan
- b Department of Communication , University of Texas , San Antonio , TX , USA
| | - Sushena Reza-Paul
- a Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Robert Lorway
- a Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
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Mtetwa S, Busza J, Davey C, Wong-Gruenwald R, Cowan F. Competition is not necessarily a barrier to community mobilisation among sex workers: an intervention planning assessment from Zimbabwe. BMC Public Health 2015; 15:787. [PMID: 26275906 PMCID: PMC4537541 DOI: 10.1186/s12889-015-2118-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 08/04/2015] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Sibongile Mtetwa
- Centre for Sexual Health, HIV and AIDS Research Zimbabwe, Harare, Zimbabwe.
| | - Joanna Busza
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Calum Davey
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Ramona Wong-Gruenwald
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) HIV Prevention Project, Harare, Zimbabwe.
| | - Frances Cowan
- Centre for Sexual Health, HIV and AIDS Research Zimbabwe, Harare, Zimbabwe. .,Centre for Sexual Health & HIV Research, Research Department of Infection &Population Health, University College London, London, UK.
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Lim RBT, Wong ML, Tan PH, Govender M. Heterosexual men who patronise entertainment establishments versus brothels in an Asian urban setting - which group practises riskier sexual behaviours? BMC Public Health 2015; 15:777. [PMID: 26272078 PMCID: PMC4535740 DOI: 10.1186/s12889-015-2132-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 08/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sex work has shifted from brothels to entertainment establishments (EEs) in Asia. Men who patronise EEs could act as a bridging population for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) transmission through unprotected sex with the female EE workers to their spouses and regular partners. The aim of this study was to compare the prevalence and factors associated with risky sexual behaviours among the heterosexual men who patronised the EEs and brothels in Singapore. METHODS This was a cross-sectional survey involving 569 heterosexual men (297 recruited from brothels and 272 from EEs). A 2-stage sampling involving proportional stratified random sampling of the brothels and EEs, followed by time location sampling of the men, was conducted. For multivariable analysis, we used a mixed effects logistic model with backward elimination to account for clustering by venue and to obtain the adjusted odds ratio (aOR) for the association of various factors with consistent condom use in vaginal and oral sex respectively. RESULTS Men who patronised EEs were younger, more likely to be single, more highly-educated and comprised more professionals compared to the brothel group. On multivariable analysis, consistent condom use for vaginal sex decreased at the EE setting (aOR 0.64; 95 % CI: 0.42 -0.97) and with alcohol use before sex (aOR 0.67; 95 % CI: 0.46 - 0.98) and increased with perceived high risk of getting HIV/STIs from partner (aOR 2.08; 95 % CI: 1.30 - 3.32) and partner's request for condom use (aOR 5.48; 95 % CI: 1.20 - 25.11). For consistent condom use with oral sex, this decreased at the EE setting (aOR 0.64; 95 % CI: 0.39 - 0.98) and with alcohol use before sex (aOR 0.50; 95 % CI: 0.31 - 0.81) and increased with partner's request for condom use (aOR 5.19; 95 % CI: 1.38 - 19.57). CONCLUSIONS Men who patronised EEs practised risker sexual behaviours compared to the brothel group. Priority should be given for intervention programmes to target men who patronise EEs, which could involve the female EE workers, the EE owners as well as the managers for effective HIV/STI prevention.
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Affiliation(s)
- Raymond Boon Tar Lim
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, 117549, Singapore, Singapore.
| | - Mee Lian Wong
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, 117549, Singapore, Singapore.
| | - Poh Huat Tan
- Duke-National University of Singapore Graduate Medical School, 8 College Road, 169857, Singapore, Singapore.
| | - Mandy Govender
- Health Promotion Board, 3 Second Hospital Avenue, 168937, Singapore, Singapore.
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Pettifor A, Lippman SA, Selin AM, Peacock D, Gottert A, Maman S, Rebombo D, Suchindran CM, Twine R, Lancaster K, Daniel T, Gómez-Olivé FX, Kahn K, MacPhail C. A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention. BMC Public Health 2015; 15:752. [PMID: 26245910 PMCID: PMC4527273 DOI: 10.1186/s12889-015-2048-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/10/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Community mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa. METHODS Community Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18-35 years at baseline and endline about two years later. CONCLUSIONS This is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective. TRIAL REGISTRATION ClinicalTrials.gov NCT02129530.
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Affiliation(s)
- Audrey Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
- Honorary appointments at MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and Wits Reproductive Health and HIV Institute (WHRI), University of the Witwatersrand, Johannesburg, South Africa.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sheri A Lippman
- Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Amanda M Selin
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ann Gottert
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - Chirayath M Suchindran
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Lancaster
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine MacPhail
- Honorary appointments at MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and Wits Reproductive Health and HIV Institute (WHRI), University of the Witwatersrand, Johannesburg, South Africa
- CRN for Mental Health and Wellbeing, University of New England, Armidale, NSW, Australia
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Structural Interventions for HIV Prevention Among Women Who Use Drugs: A Global Perspective. J Acquir Immune Defic Syndr 2015; 69 Suppl 2:S140-5. [PMID: 25978480 DOI: 10.1097/qai.0000000000000638] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We briefly review extant literature on the contextual sources of HIV risk among drug users—the drug user risk environment—and on structural interventions to address drug user vulnerability to HIV. We argue that issues of gender inequality and gendered power relations are largely absent from this literature. We then identify 5 contextual factors that are critical for understanding women's HIV-related vulnerability and whose impacts are exacerbated among women who use drugs, including a division of reproductive labor in which women bear primary responsibility for family caretaking, women's lack of full access to or control of productive resources and decision making, women's vulnerability to sexual and physical violence, and especially, intimate partner violence, women's (particularly heterosexual women's) relationship dependency and limited power in sexual interactions, and harmful gender norms that reinforce these other factors. We discuss a range of structural interventions and structural intervention approaches with the potential to address these contextual factors and call for more research, both to better understand the risk environment of women who use drugs and the impacts of structural interventions on it. We argue that our understanding of and ability to impact on the HIV-related risk environment of drug users is incomplete if we do not fully incorporate the analysis of gender inequality and gendered power relations.
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Swendeman D, Fehrenbacher AE, Ali S, George S, Mindry D, Collins M, Ghose T, Dey B. "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. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1011-23. [PMID: 25583373 PMCID: PMC4382371 DOI: 10.1007/s10508-014-0404-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 08/26/2014] [Accepted: 09/17/2014] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Dallas Swendeman
- Center for HIV Identification, Prevention & Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA,
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Richter M, Chersich MF, Vearey J, Sartorius B, Temmerman M, Luchters S. Migration status, work conditions and health utilization of female sex workers in three South African cities. J Immigr Minor Health 2015; 16:7-17. [PMID: 23238581 PMCID: PMC3895178 DOI: 10.1007/s10903-012-9758-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intersections between migration and sex work are underexplored in southern Africa, a region with high internal and cross-border population mobility, and HIV prevalence. Sex work often constitutes an important livelihood activity for migrant women. In 2010, sex workers trained as interviewers conducted cross-sectional surveys with 1,653 female sex workers in Johannesburg (Hillbrow and Sandton), Rustenburg and Cape Town. Most (85.3%) sex workers were migrants (1396/1636): 39.0% (638/1636) internal and 46.3% (758/1636) cross-border. Cross-border migrants had higher education levels, predominately worked part-time, mainly at indoor venues, and earned more per client than other groups. They, however, had 41% lower health service contact (adjusted odds ratio = 0.59; 95% confidence interval = 0.40-0.86) and less frequent condom use than non-migrants. Police interaction was similar. Cross-border migrants appear more tenacious in certain aspects of sex work, but require increased health service contact. Migrant-sensitive, sex work-specific health care and health education are needed.
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Affiliation(s)
- Marlise Richter
- Department of Obstetrics and Gynaecology, International Centre for Reproductive Health, Ghent University, Ghent, Belgium,
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Kongelf A, Bandewar SVS, Bharat S, Collumbien M. Is scale-up of community mobilisation among sex workers really possible in complex urban environments? The case of Mumbai, India. PLoS One 2015; 10:e0121014. [PMID: 25811484 PMCID: PMC4374852 DOI: 10.1371/journal.pone.0121014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India's national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation's Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments. METHODS AND FINDINGS Between March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as 'sex workers'. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more 'hidden' ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and 'pimps' continued to restrict access to sex workers and the heterogeneous 'community' of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported. CONCLUSION Large-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services.
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Affiliation(s)
- Anine Kongelf
- London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London United Kingdom
| | - Sunita V. S. Bandewar
- Independent Senior Researcher in Global Health, Bioethics and Program Evaluation, C-5, Mantri Avenue—I, Panchavati, Pashan Rd, Pune, India
| | - Shalini Bharat
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Martine Collumbien
- London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London United Kingdom
- * E-mail:
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Wamoyi J, Wight D, Remes P. The structural influence of family and parenting on young people's sexual and reproductive health in rural northern Tanzania. CULTURE, HEALTH & SEXUALITY 2015; 17:718-732. [PMID: 25597368 PMCID: PMC4419469 DOI: 10.1080/13691058.2014.992044] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 11/23/2014] [Indexed: 06/04/2023]
Abstract
This paper explores the structural role of the family and parenting in young people's sexual and reproductive health. The study involved eight weeks of participant observation, 26 in-depth interviews, and 11 group discussions with young people aged 14-24 years, and 20 in-depth interviews and 6 group discussions with parents/carers of children in this age group. At an individual level, parenting and family structure were found to affect young people's sexual behaviour by influencing children's self-confidence and interactional competence, limiting discussion of sexual health and shaping economic provision for children, which in turn affected parental authority and daughters' engagement in risky sexual behaviour. Sexual norms are reproduced both through parents' explicit prohibitions and their own behaviours. Girls are socialised to accept men's superiority, which shapes their negotiation of sexual relationships. Interventions to improve young people's sexual and reproductive health should recognise the structural effects of parenting, both in terms of direct influences on children and the dynamics by which structural barriers such as gendered power relations and cultural norms around sexuality are transmitted across generations.
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Affiliation(s)
- Joyce Wamoyi
- National Institute for Medical Research, Mwanza, Tanzania
| | - Daniel Wight
- Medical Research Council, Social and Public Health Sciences Unit, Glasgow, UK
| | - Pieter Remes
- National Institute for Medical Research, Mwanza, Tanzania
- Medical Research Council, Social and Public Health Sciences Unit, Glasgow, UK
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BHARAT SHALINI, RAMAKRISHNA JAYASHREE, HEYLEN ELSA, EKSTRAND MARIAL. Gender-based attitudes, HIV misconceptions and feelings towards marginalized groups are associated with stigmatization in Mumbai, India. J Biosoc Sci 2014; 46:717-32. [PMID: 24524379 PMCID: PMC5444386 DOI: 10.1017/s0021932014000054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Summary This study examined the association of gender-based attitudes, HIV misconceptions and community feelings for marginalized groups with stigmatizing responses towards people with HIV/AIDS in Mumbai, India. Participants included 546 men and women sampled in hospital settings during 2007-2008. Structured measures were used to assess avoidance intentions and denial of rights of people with HIV/AIDS. Mean age of participants was 32 years; 42% had less than 10 years of education. Higher HIV transmission misconceptions (β=0.47; p<0.001), more traditional gender attitudes (β=0.11; p<0.01) and more negative feelings towards HIV-positive people (β=0.23; p<0.001) were related to higher avoidance intentions. Endorsement of denial of rights was also significantly associated with higher transmission misconceptions (β=0.20; p<0.001), more traditional gender attitudes (β=0.33; p<0.001) and greater negative feelings towards HIV-positive people (β=0.12; p<0.05), as well as with a lower education level (β=-0.10; p<0.05). The feelings respondents had towards people with HIV/AIDS were more strongly correlated with their feelings towards those with other diseases (tuberculosis, leprosy) than with feelings they had towards those associated with 'immoral' behaviour (e.g. sex workers). Eliminating HIV transmission misconceptions and addressing traditional gender attitudes are critical for reducing HIV stigma in Indian society.
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Affiliation(s)
- SHALINI BHARAT
- Centre for Health and Social Science, School of Health
Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | - JAYASHREE RAMAKRISHNA
- Department of Health Education, National Institute of Mental
Health and Neurosciences, Bangalore, India
| | - ELSA HEYLEN
- Center for AIDS Prevention Studies, University of
California, San Francisco, CA, USA
| | - MARIA L. EKSTRAND
- Center for AIDS Prevention Studies, University of
California, San Francisco, CA, USA
- St John’s Research Institute, St John’s
National Academy of Health Sciences, Bangalore, India
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George A, Blankenship KM, Biradavolu MR, Dhungana N, Tankasala N. Sex workers in HIV prevention: From Social Change Agents to Peer Educators. Glob Public Health 2014; 10:28-40. [PMID: 25359518 PMCID: PMC6176771 DOI: 10.1080/17441692.2014.966251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Vassall A, Chandrashekar S, Pickles M, Beattie TS, Shetty G, Bhattacharjee P, Boily MC, Vickerman P, Bradley J, Alary M, Moses S, Watts C. Community mobilisation and empowerment interventions as part of HIV prevention for female sex workers in Southern India: a cost-effectiveness analysis. PLoS One 2014; 9:e110562. [PMID: 25333501 PMCID: PMC4204894 DOI: 10.1371/journal.pone.0110562] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 09/19/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Most HIV prevention for female sex workers (FSWs) focuses on individual behaviour change involving peer educators, condom promotion and the provision of sexual health services. However, there is a growing recognition of the need to address broader societal, contextual and structural factors contributing to FSW risk behaviour. We assess the cost-effectiveness of adding community mobilisation (CM) and empowerment interventions (eg. community mobilisation, community involvement in programme management and services, violence reduction, and addressing legal policies and police practices), to core HIV prevention services delivered as part of Avahan in two districts (Bellary and Belgaum) of Karnataka state, Southern India. METHODS An ingredients approach was used to estimate economic costs in US$ 2011 from an HIV programme perspective of CM and empowerment interventions over a seven year period (2004-2011). Incremental impact, in terms of HIV infections averted, was estimated using a two-stage process. An 'exposure analysis' explored whether exposure to CM was associated with FSW's empowerment, risk behaviours and HIV/STI prevalence. Pathway analyses were then used to estimate the extent to which behaviour change may be attributable to CM and to inform a dynamic HIV transmission model. FINDINGS The incremental costs of CM and empowerment were US$ 307,711 in Belgaum and US$ 592,903 in Bellary over seven years (2004-2011). Over a 7-year period (2004-2011) the mean (standard deviation, sd.) number of HIV infections averted through CM and empowerment is estimated to be 1257 (308) in Belgaum and 2775 (1260) in Bellary. This translates in a mean (sd.) incremental cost per disability adjusted life year (DALY) averted of US$ 14.12 (3.68) in Belgaum and US$ 13.48 (6.80) for Bellary--well below the World Health Organisation recommended willingness to pay threshold for India. When savings from ART are taken into account, investments in CM and empowerment are cost saving. CONCLUSIONS Our findings suggest that CM and empowerment is, at worst, highly cost-effective and, at best, a cost-saving investment from an HIV programme perspective. CM and empowerment interventions should therefore be considered as core components of HIV prevention programmes for FSWs.
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Affiliation(s)
- Anna Vassall
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sudhashree Chandrashekar
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- St John's Research Institute, Bangalore, India
| | - Michael Pickles
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Tara S. Beattie
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Peter Vickerman
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Bradley
- URESP, Centre de recherche du CHU de Québec, Québec, Canada
| | - Michel Alary
- URESP, Centre de recherche du CHU de Québec, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | | | | | - Charlotte Watts
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Structural approaches for prevention of sexually transmitted HIV in general populations: definitions and an operational approach. J Int AIDS Soc 2014; 17:19052. [PMID: 25204872 PMCID: PMC4159948 DOI: 10.7448/ias.17.1.19052] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/17/2014] [Accepted: 08/07/2014] [Indexed: 01/06/2023] Open
Abstract
Introduction Although biomedical HIV prevention efforts have seen a number of recent promising developments, behavioural interventions have often been described as failing. However, clear lessons have been identified from past efforts, including the need to address influential social, economic and legal structures; to tailor efforts to local contexts; and to address multiple influencing factors in combination. Despite these insights, there remains a pervasive strategy to try to achieve sexual behaviour change through single, decontextualized, interventions or sets of activities. With current calls for structural approaches to HIV as part of combination HIV prevention, though, there is a unique opportunity to define a structural approach to HIV prevention as one which moves beyond these past limitations and better incorporates our knowledge of the social world and the lessons from past efforts. Discussion A range of interlinked concepts require delineation and definition within the broad concept of a structural approach to HIV. This includes distinguishing between “structural factors,” which can be seen as any number of elements (other than knowledge) which influence risk and vulnerability, and “structural drivers,” which should be reserved for situations where an empirically established relationship to a target group is known. Operationalizing structural approaches similarly can take different paths, either working to alter structural drivers or alternatively working to build individual and community resilience to infection. A “structural diagnostic approach” is further defined as the process one undertakes to develop structural intervention strategies tailored to target groups. Conclusions For three decades, the HIV prevention community has struggled to reduce the spread of HIV through sexual risk behaviours with limited success, but equally with limited engagement with the lessons that have been learned about the social realities shaping patterns of sexual practices. Future HIV prevention efforts must address the multiple factors influencing risk and vulnerability, and they must do so in ways tailored to particular settings. Clarity on the concepts, terminology and approaches that can allow structural HIV prevention efforts to achieve this is therefore essential to improve the (social) science of HIV prevention.
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Beattie TSH, Mohan HL, Bhattacharjee P, Chandrashekar S, Isac S, Wheeler T, Prakash R, Ramesh BM, Blanchard JF, Heise L, Vickerman P, Moses S, Watts C. Community mobilization and empowerment of female sex workers in Karnataka State, South India: associations with HIV and sexually transmitted infection risk. Am J Public Health 2014; 104:1516-25. [PMID: 24922143 DOI: 10.2105/ajph.2014.301911] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Tara S H Beattie
- Tara S. H. Beattie, Lori Heise, Peter Vickerman, Charlotte Watts, and Sudha Chandrashekar are with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Harnalli L. Mohan, Parinita Bhattacharjee, Shajy Isac, and Ravi Prakash are with the Karnataka Health Promotion Trust (KHPT), Bangalore, India. Tisha Wheeler is with the Futures Group, Durham, NC. Banadakoppa M. Ramesh, James F. Blanchard, and Stephen Moses are with The University of Manitoba, Winnipeg
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Moore L, Chersich MF, Steen R, Reza-Paul S, Dhana A, Vuylsteke B, Lafort Y, Scorgie F. Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review. Global Health 2014; 10:47. [PMID: 24916108 PMCID: PMC4074148 DOI: 10.1186/1744-8603-10-47] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation. Methods In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community. Results Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations. Conclusions Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.
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Affiliation(s)
- Lizzie Moore
- MatCH (Maternal, Adolescent and Child Health), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
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Steen R, Zhao P, Wi TE, Punchihewa N, Abeyewickreme I, Lo YR. Halting and reversing HIV epidemics in Asia by interrupting transmission in sex work: experience and outcomes from ten countries. Expert Rev Anti Infect Ther 2014; 11:999-1015. [PMID: 24124797 DOI: 10.1586/14787210.2013.824717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
HIV epidemics spread rapidly through Asian sex work networks two decades ago under conditions of high vulnerability, low condom use, intact male foreskins and ulcerative STIs. Experiences implementing interventions to prevent transmission in sex work in ten Asian countries were reviewed. All report increasing condom use trends in sex work. In the seven countries where condom use exceeds 80%, surveillance and other data indicate declining HIV trends or low and stable HIV prevalence with declining STI trends. All four countries with national-level HIV declines among sex workers have also documented significant HIV declines in the general population. While all interventions in sex work included outreach, condom programing and STI services, the largest declines were found in countries that implemented structural interventions on a large scale. Thailand and Cambodia, having controlled transmission early, are closest to providing universal access to HIV care, support and treatment and are exploring HIV elimination strategies.
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Affiliation(s)
- Richard Steen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Netherlands
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Ranebennur V, Gaikwad S, Ramesh S, Bhende A. Addressing vulnerabilities of female sex workers in an HIV prevention intervention in Mumbai and Thane: experiences from the Aastha project. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2014; 6:9-18. [PMID: 24600249 PMCID: PMC3933664 DOI: 10.2147/hiv.s54062] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background It is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility, and literacy, for effective human immunodeficiency virus (HIV) prevention. This paper describes and examines the association of the Aastha HIV/sexually transmitted infection (STI) prevention project in Mumbai and Thane, India, on the relationship between vulnerability and behavioral outcomes. Materials and methods Data were drawn from the Behavioural Tracking Survey, a cross-sectional behavioral study conducted in 2010 with 2,431 FSWs recruited in Mumbai and Thane. The key independent measures used were program exposure and “vulnerability index”, a composite index of literacy, factors of dependence (alternative livelihood options, current debt, and children), and aspects of sex work (mobility and duration in sex work). Dependent measures included service uptake, self-confidence, self-identity, and individual agency. Logistic regression analysis was used to examine the study objectives. Results Of the analytical sample of 2,431 FSWs, 1,295 (53.3%) were categorized as highly vulnerable. Highly vulnerable FSWs who were associated with the Aastha program for more than a year were more likely to have accessed crisis-response services in the past 6 months (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.4–3.6; P<0.001), to have visited a clinic to get a checkup for STI symptoms (AOR 2.4, 95% CI 1.2–4.8; P<0.015), not to be ashamed to disclose identity as an FSW to health workers (AOR 2.1, 95% CI 1.2–3.5; P<0.008), and to be confident in supporting a fellow FSW in crisis (AOR 1.7, 95% CI 1.0–2.8, P<0.033) compared to those less vulnerable with similar exposure to the Aastha program. Conclusion It is critical for HIV/STI interventions to consider vulnerabilities of FSWs at project inception and address them with focused strategies, including a segmented service-delivery model and community involvement, in order to strengthen the structural response to HIV prevention.
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Affiliation(s)
| | | | - Sowmya Ramesh
- HIV/AIDS Programs, Population Council, New Delhi, India
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Wirtz AL, Pretorius C, Beyrer C, Baral S, Decker MR, Sherman SG, Sweat M, Poteat T, Butler J, Oelrichs R, Semini I, Kerrigan D. Epidemic impacts of a community empowerment intervention for HIV prevention among female sex workers in generalized and concentrated epidemics. PLoS One 2014; 9:e88047. [PMID: 24516580 PMCID: PMC3916392 DOI: 10.1371/journal.pone.0088047] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/20/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented. Methods We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant. Results Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size. Discussion A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.
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Affiliation(s)
- Andrea L. Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland, United States of America
- * E-mail:
| | - Carel Pretorius
- Futures Institute, Glastonbury, Connecticut, United States of America
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michele R. Decker
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Population, Family, and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Susan G. Sherman
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael Sweat
- Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Tonia Poteat
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jennifer Butler
- HIV and Key Populations, United Nations Population Fund, New York, New York, United States of America
| | - Robert Oelrichs
- Human Development Network, The World Bank, Washington, District of Columbia, United States of America
| | - Iris Semini
- Human Development Network, The World Bank, Washington, District of Columbia, United States of America
| | - Deanna Kerrigan
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Pollack LM, Woods WJ, Blair J, Binson D. Presence of an HIV Testing Program Lowers the Prevalence of Unprotected Insertive Anal Intercourse inside a Gay Bathhouse among HIV-negative and HIV-unknown Patrons. JOURNAL OF HIV/AIDS & SOCIAL SERVICES 2014; 13:306-323. [PMID: 25383057 PMCID: PMC4219510 DOI: 10.1080/15381501.2013.864175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This study sought to determine whether the presence of HIV testing inside a gay bathhouse reduced sexual risk behavior among patrons. A two-stage, time probability, cluster sample design recruited men exiting a northern California bathhouse in the last 5 weeks of 2001 (N=440), when no HIV testing was offered inside the bathhouse, and again in the last 5 weeks of 2002 (N=412) when HIV testing was offered 5 days a week. Separate logistic regression analyses compared a 2002 HIV testing exposure subgroup to both a 2001 non-exposure subgroup and a 2002 non-exposure subgroup for differences in sexual risk behavior during the bathhouse visit. Prevalence of unprotected insertive anal intercourse was significantly lower in the 2002 exposure subgroup than in the 2002 non-exposure subgroup. Similar results obtained when HIV-positive respondents were excluded. These results indicate on-site HIV testing has a preventive effect on some sexual risk behavior inside the bathhouse.
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Affiliation(s)
- Lance M Pollack
- Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco
| | - William J Woods
- Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco
| | | | - Diane Binson
- Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco
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Hayes-Larson E, Grau LE, Khoshnood K, Barbour R, Khuat OTH, Heimer R. Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups. Harm Reduct J 2013; 10:33. [PMID: 24268108 PMCID: PMC4176489 DOI: 10.1186/1477-7517-10-33] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 11/05/2013] [Indexed: 11/10/2022] Open
Abstract
Background A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi. Methods Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model. Results Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership. Conclusions Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.
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