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

Whose role is it anyways: Knowledge generation within the scope of sex work

Research within the context of sex work is challenging. The nature of the subject matter and stigma that surrounds sex work has often privileged a homogenous, academic practice of generating knowledge. Based on the lessons and experiences of an existing sex work programme and a recently completed national public health study with female sex workers (FSWs) in South Africa, we aim to highlight the significance and successes of privileging a bottom-up, community centric approach to the design, data collection, and knowledge generation. A FSW programme provided extensive peer educator skills training and learning opportunities. Lessons were applied to the implementation of a national study on FSW across South Africa. Planning workshops with community members and sites and pre- implementation training of all site staff was undertaken. 3005 FSWs were successfully enrolled and surveyed by their peers, over 6-months. Researchers have a lot to learn from community members and should remain vigilant to the power dynamics that their privilege creates throughout the research process. Those seeking to generate knowledge should practice meaningfully engagement and include population members on the study team in roles that allow them to proactively contribute to the process and create knowledge.

Community Mobilization Challenging Gender Power Imbalances: Women Sex Workers' Capacity to Engage in Health-Enhancing Practices in Southern India

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.

Stigma, Social Support, and Sexual Behavior Among Female Sex Workers at Risk for HIV in Malawi

Lack of social support and sex work stigma may hinder STI/HIV prevention for female sex workers (FSW). We explored the associations between sex work stigma and social support with sexual behaviors in Malawi. In 2017, 150 HIV-negative, venue-based FSW completed a behavioral survey containing sex work stigma items and social support. Linear binomial regression models were used to estimate prevalence differences of inconsistent condom use and substance use before sex by social support and stigma. A majority (93%) reported sex work-related internalized stigma. About 50% reported family or friend isolation. Social support was high (mean index: 86.53). Inconsistent condom use and substance use before sex had little to no association with stigma and social support. Malawian FSW largely internalize stigma and experience isolation from family and friends yet have high levels of social support. Large-scale evaluations should investigate the role of stigma and social support in STI/HIV prevention for FSW.

Understanding the capacity of community-based groups to mobilise and engage in social action for health: Results from Avahan

Community mobilisation improves outcomes from HIV to maternal and child health. Yet, little health research has explored why some community groups are better able to mobilise than others. We address this gap by considering the case of Avahan, the India AIDS Initiative, which sought to foster community mobilisation, including the creation of community-based groups serving men who have sex with men (MSM), female sex workers (FSWs), and injection drug users (IDUs). Using quantitative and qualitative data collected from 58 community-based groups from 2009-2012 across six Indian states, we analyse variation in groups' action on behalf of their members. Based on a mixed effects logistic regression, we find that older groups and those with bank accounts, crisis committees, or strategic relationships were most likely to take action on behalf of members by demanding rights or confronting gatekeepers and opinion leaders. Analysis of qualitative data reveals the types of action organisations took on behalf of members (mediation, removal of community members from harm, and advocacy), but also that sometimes organisations refused to take action, or community members declined their assistance. These findings indicate that organisations formalising, creating structures for social action, and building networks are important strategies to foster community mobilisation.

Factors associated with HIV infection among female sex workers in Brazil

BACKGROUND

Female sex workers (FSWs) are one of the most-at-risk population groups for human immunodeficiency virus (HIV) infection. This paper aims at identifying the main predictors of HIV infection among FSW recruited in the 2nd Biological and Behavioral Surveillance Survey in 12 Brazilian cities in 2016.

METHOD

Data were collected on 4245 FSW recruited by respondent driven sampling (RDS). Weights were inversely proportional to participants' network sizes. To establish the correlates of HIV infection, we used logistic regression models taking into account the dependence of observations resultant from the recruitment chains. The analysis included socio-demographic sex work characteristics, sexual behavior, history of violence, alcohol and drug use, utilization of health services, and occurrence of other sexually transmitted infections (STIs).

RESULTS

HIV prevalence was estimated as 5.3% (4.4%-6.2%). The odds ratio (OR) of an HIV-positive recruiter choosing an HIV-positive participant was 3.9 times higher than that of an HIV-negative recruiter (P < .001). Regarding socio-demographic and sex work characteristics, low educational level, street as the main work venue, low price per sexual encounter, and longer exposure time as a sex worker were found to be associated with HIV infection, even after controlling for the homophily effect. The OR of being HIV infected among FSW who had been exposed to sexual violence at least once in a lifetime (OR = 1.5, P = .028) and the use of illicit drugs at least once a week were highly significant as well, particularly for frequent crack use (OR = 3.6, P < .001). Among the sexual behavior indicators, not using condoms in some circumstances were significantly associated with HIV infection (OR = 1.8, P = .016). Regarding the occurrence of other STI, the odds of being HIV infected was significantly higher among FSW with a reactive treponemal test for syphilis (OR = 4.6, P < .001).

CONCLUSIONS

The main factors associated with HIV infection identified in our study characterize a specific type of street-based sex work in Brazil and provided valuable information for developing interventions. However, there is a further need of addressing social and contextual factors, including illicit drug use, violence, exploitation, as well as stigma and discrimination, which can influence sexual behavior.

A human rights-focused HIV intervention for sex workers in Metro Manila, Philippines: evaluation of effects in a quantitative pilot study

OBJECTIVES

This study evaluated a brief human rights-focused HIV community mobilization intervention for sex workers in the Philippines, a country with one of the fastest rising number of HIV cases worldwide.

METHODS

Five single-session group interventions to reduce sexual risk and increase HIV testing among 86 sex workers in Manila were evaluated with pre-post-test data via Wilcoxon's signed-ranks and Mann-Whitney tests. The 4-h intervention, Kapihan (August-November, 2013), integrated human rights with HIV skill-building. Demographic data, violence/trafficking victimization, human rights knowledge, and intentions to HIV test and treat were collected.

RESULTS

Participants were median aged 23; female (69 %); had children (55; 22 % had 3+ children); used drugs (past 3 months: 16 %); sexually/physically abused by clients (66 %); 20 % street sex workers ever took an HIV test. Pre-post-test scores significantly improved in knowledge of HIV (z = -8.895, p < 0.001), reproductive health (z = -3.850, p < 0.001), human rights (z = -4.391, p < 0.001), ethical rights of research participants (z = -5.081, p < 0.001), and intentions to HIV test (z = -4.868, p < 0.001).

CONCLUSIONS

Integrating human rights into HIV interventions may empower sex workers to address their health and human rights and test for HIV.

Empty rituals? A qualitative study of users' experience of monitoring & evaluation systems in HIV interventions in western India

In global health initiatives, particularly in the context of private philanthropy and its 'business minded' approach, detailed programme data plays an increasing role in informing assessments, improvements, evaluations, and ultimately continuation or discontinuation of funds for individual programmes. The HIV/AIDS literature predominantly treats monitoring as unproblematic. However, the social science of audit and indicators emphasises the constitutive power of indicators, noting that their effects at a grassroots level are often at odds with the goals specified in policy. This paper investigates users' experiences of Monitoring and Evaluation (M&E) systems in the context of HIV interventions in western India. Six focus groups (totalling 51 participants) were held with employees of 6 different NGOs working for government or philanthropy-funded HIV interventions for sex workers in western India. Ten donor employees were interviewed. Thematic analysis was conducted. NGO employees described a major gap between what they considered their "real work" and the indicators used to monitor it. They could explain the official purposes of M&E systems in terms of programme improvement and financial accountability. More cynically, they valued M&E experience on their CVs and the rhetorical role of data in demonstrating their achievements. They believed that inappropriate and unethical means were being used to meet targets, including incentives and coercion, and criticised indicators for being misleading and inflexible. Donor employees valued the role of M&E in programme improvement, financial accountability, and professionalising NGO-donor relationships. However, they were suspicious that NGOs might be falsifying data, criticised the insensitivity of indicators, and complained that data were under-used. For its users, M& E appears an 'empty ritual', enacted because donors require it, but not put to local use. In this context, monitoring is constituted as an instrument of performance management rather than as a means of rational programme improvement.