The Sonagachi Project: a sustainable community intervention program

Individual and Collective Forms of Stigma Resistance: Pathways Between HIV and Sex Work Stigma and Viral Suppression Among Female Sex Workers in the Dominican Republic

Intersecting forms of stigma including both HIV and sex work stigma have been known to impede HIV prevention and optimal treatment outcomes among FSW. Recent research has indicated that intersectional stigma can be resisted at the community and individual level. We assessed pathways between HIV stigma, sex work stigma, social cohesion and viral suppression among a cohort of 210 FSW living with HIV in the Dominican Republic. Through Poisson regression we explored the relationship between HIV outcomes and internalized, anticipated and enacted HIV and sex work stigma, and resisted sex work stigma. We employed structural equation modeling to explore the direct effect of various forms of stigma on HIV outcomes, and the mediating effects of multi-level stigma resistance including social cohesion at the community level and occupational dignity at the individual level. 76.2% of FSW were virally suppressed and 28.1% had stopped ART at least once in the last 6 months. ART interruption had a significant negative direct effect on viral suppression (OR = 0.26, p < 0.001, 95% CI: 0.13-0.51). Social cohesion had a significant positive direct effect on viral suppression (OR = 2.07, p = 0.046, 95% CI: 1.01-4.25). Anticipated HIV stigma had a significant negative effect on viral suppression (OR = 0.34, p = 0.055, 95% CI: 0.11-1.02). This effect was mediated by the interaction between cohesion and dignity which rendered the impact of HIV stigma on viral suppression not significant. Findings demonstrate that while HIV stigma has a negative impact on viral suppression among FSW, it can be resisted through individual and collective means. Results reinforce the importance of community-driven, multi-level interventions.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

Exploring the impact of military conflict on sex work in Ukraine: Women's experiences of economic burden

Little is known about the impact of military conflict on sex work from the perspective of sex workers. We attempt to explore the meaning of conflict on sex work by asking women about the changes that they have experienced in their lives and work since the beginning of the 2014 military conflict in eastern Ukraine. The findings in this article are based on qualitative interviews with 43 cisgender women living and practicing sex work in Dnipro, eastern Ukraine. Our analysis highlights the meanings that sex workers have linked to the conflict, with financial concerns emerging as a dominant theme. The conflict therefore functions as a way of understanding changing economic circumstances with both individual and broader impacts. By better understanding the meaning of conflict as expressed by sex workers, we can begin to adapt our response to address emerging, and unmet, needs of the community.

Community Mobilization is Associated with HIV Testing Behaviors and Their Psychosocial Antecedents Among Zambian Adults: Results from a Population-Based Study

Community mobilization (CM) is a vital yet under-explored avenue for increasing HIV testing in generalized HIV epidemic settings. Using multi-stage cluster sampling, a population-based sample of 3535 Zambian adults (mean age: 28 years, 50% women) were recruited from 14 districts to complete a household survey. Exploratory factor analysis (EFA) was used to re-validate a 23-item, 5-factor CM scale. Multivariable logistic and Poisson regression were then used to identify associations of CM with HIV testing behaviors and their psychosocial antecedents. A 21-item, 3-factor ("Leadership", "Collective Action Capacity", and "Social Cohesion") CM solution emerged from EFA (Cronbach's α 0.88). Among men and in rural settings, higher CM was significantly (p < 0.05) associated with elevated odds of HIV testing and more past-year HIV testing discussion sources, controlling for socio-demographics and sexual behaviors. Results underscore the importance of prioritizing CM to cultivate more favorable environments for HIV testing uptake, especially for men and rural residents.

Matching Intent With Intensity: Implementation Research on the Intensity of Health and Nutrition Programs With Women's Self-Help Groups in India

Adding health interventions to women's groups primarily formed for financial purposes, such as self-help groups, is a widely used strategy to reach low-income women. An analysis of implementation intensity highlights the importance of ensuring that women's groups have sufficient time and population coverage to address health issues.

Introduction:

In India, a large network of self-help groups (SHGs) implements interventions to improve women's and children's health and nutrition. There is growing evidence on the effectiveness of women's group interventions to improve health but limited information on implementation intensity, including how often groups meet, for how long, and with whom, despite this often being cited as a key factor for success. We aimed to assess the implementation intensity of large SHG-based health and nutrition interventions with rural, low-income women, to inform program design, delivery, and measurement.

Methods:

We synthesized process data from surveys, meeting observations, and process evaluations across 8 maternal and child health and nutrition interventions in India. We examined the implementation intensity of 3 common intervention delivery channels: group meetings, home visits, and community-level activities.

Results:

SHG members spent approximately 30 minutes in monthly meetings discussing health or nutrition. SHG dissolution or limited participation in meetings was a common challenge. Beyond group meetings, home visits reached approximately 1 in 3 households with an SHG member. Pregnant and breastfeeding women's participation in community events varied across interventions.

Discussion:

Interventions that aim to capitalize on existing networks of financial women's groups not specifically formed for health and nutrition objectives, such as SHGs, will need to have an implementation intensity that matches the ambition of their health objectives: substantial changes in behavioral or mortality outcomes are unlikely to be achieved with relatively light intensity. Interventions that require sustained interactions with members to achieve health outcomes need to ensure adequate community and individual outreach to supplement group meetings, as well as improved participation through more intensive community mobilization approaches. Evaluations of group-based interventions should report on implementation intensity to support the interpretation of evaluation evidence and to inform further scale-up.

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.

Sexual health communication between sex worker mothers and their children in India

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.

Sex work community participation in criminalized environments: a community-based cohort study of occupational health impacts in Vancouver, Canada: 2010-2019

Background

Sex work criminalization and occupational stigma pose barriers to sex workers’ access to support services, including community participation — engagement with sex work specific community organizing at both formalized and grassroots capacities. In light of gaps in evidence regarding impacts of community participation on sex workers’ occupational health in higher-income settings, we evaluated engagement in community participation and associations with occupational sexual health outcomes among sex workers in Vancouver, Canada.

Methods

Prospective data from a community-based cohort of 943 women sex workers in Vancouver, British Columbia (2010–2019). We used logistic regression with generalised estimating equations (GEE) to model correlates of community participation, and a confounder modeling approach to examine the association of community participation on sexually transmitted infection (STI) seropositivity.

Results

Among participants, 38.1% were Indigenous, 31.4% identified as women of colour (e.g., East Asian, Southeast Asian, Black) and 29.3% were im/migrants to Canada. Over a quarter (28.3%, n = 267) serviced in informal indoor spaces, while 38.0% (n = 358) serviced clients in outdoor/public and 31.4% (n = 296) in formal in-call spaces. 8.9% of participants reported sex work community participation at least once over the 9-year study. In multivariable GEE analysis, Indigenous (adjusted odds ratio(aOR) 1.71, 95% confidence interval (CI) 0.88–3.32) and trans women (aOR 4.69, 95%CI 2.43–9.06) had higher odds of community participation; women of colour had lower odds (aOR 0.18, 95%CI 0.06–0.57). In a multivariable GEE confounder model, community participation was independently associated with lower odds of STI seropositivity (aOR 0.66, 95% CI0.45–0.96).

Conclusion

Sex workers who engaged in sex work community participation faced reduced odds of STI seropositivity. Building off reserach evaluating community interventions in low and middle income contexts, our study provides some of the first quantitative evidence on community participation among sex workers in Canada, and is the first to examine this in relation to sexual health outcomes. This research demonstrates the need to scale up community participation access for sex workers, via linguistically diverse community spaces, anti-stigma initiatives, and decriminalization to reduce barriers faced by racialized sex workers and support occupational health and rights for all sex workers.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

Socioeconomic Burdens of the COVID-19 Pandemic on LMIC Populations with Increased HIV Vulnerabilities

Purpose of Review

To review the impact of the COVID-19 pandemic and its public health response on key populations at risk of HIV infection, with a focus on sex workers.

Recent Findings

Since last year several groups have documented how the COVID-19 pandemic has impacted the livelihoods and health of sex workers. We focus on case studies from Kenya, Ukraine, and India and place these in the broader global context of sex worker communities, drawing on common themes that span geographies.

Summary

COVID-19-associated lockdowns have significantly disrupted sex work, leading to economic and health challenges for sex workers, ranging from HIV-related services to mental health and exposure to violence. Several adaptations have been undertaken by sex workers and frontline workers, including migration, a move to mobile services, and struggling to find economic supports. Strengthening community-based responses for future pandemics and other shocks is critical to safeguard the health of marginalized populations.

Resourcefulness of homeless young people who practise sex work in Pakistan: a qualitative study

Background Many homeless young people in Pakistan use sex work as a way to generate income, particularly if they have few other options for work. Because it is highly stigmatised, little attention has been paid to the strategies homeless young people use to practise sex work, and what this suggests about their capacities and strengths. Methods Semi-structured interviews were conducted with 29 homeless young people (aged 16-25years) from Rawalpindi, Pakistan, including nine cisgender heterosexual men, six cisgender heterosexual women, seven cisgender gay men, and seven transgender heterosexual women. Results Participants sought memberships in street-based peer groups where financial gains were contingent on dancing and sex work. To practise their work successfully, participants learned novel skills and mobilised material resources available to them on the streets. Participants talked about how they acquired and benefitted from skills related to beautification, dancing, communication, and sexual services to achieve the necessary standards for entertainment and sex work. Access to material resources like makeup, clothes, rented rooms, mobile phones and condoms made dancing and sex work possible and safer for participants. Conclusions Participants' improvisation with limited resources on the streets has important implications for policy and programs. Showcasing the resourcefulness and capacities of young people encourages a different way of thinking about them. This potential could be utilised in productive ways if they were given the chance to receive mainstream and technical education, better health support and access to the formal job market.

Beyond remedicalisation: a community-led PrEP demonstration project among sex workers in India

Global health policy-makers have called for demonstration projects to better understand pre-exposure prophylaxis' (PrEP) effectiveness across geographies and populations. Ashodaya, a sex worker collective, initiated a PrEP project in Mysore, India. We conducted a project ethnography to explore the role that community participation played within the project. Although the project proved immensely successful in terms of retention and adherence, to explain these findings we point towards Ashodaya's history of collectivisation around sexual health-a history of community action that has given rise to new spaces of belonging and accumulated knowledges that became instrumental in the formulation of strategies to confront anticipated challenges during the project. These strategies included: (1) the participation of community leaders as the first participants to take PrEP, followed by the sharing of their experiences through testimonials to their peers; (2) the endorsement of PrEP among community leaders living with HIV, to avoid social divisions around HIV status; and (3) ongoing community-level support from outreach workers that went beyond administering PrEP to address the various needs of the community. These community-led approaches demonstrate that communities hold key insights into the delivery of clinically-oriented interventions, suggesting the vital role they continue to play in planning and implementing new prevention technologies.

Sexual risk-taking among homeless young people in Pakistan

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.

Community-Based Strategies as Transformative Approaches for Health Promotion and Empowerment among Commercial Sex Workers in India

The current paper examines the utilization of community mobilization as a strategic health communication technique in an intervention to reduce human immunodeficiency virus (HIV) and sexually transmitted infections (STI) rates among marginalized and at-risk populations such as commercial female sex workers in a red-light district in India. The research documents the struggles of a historically exploited community in India to mitigate its marginalization through implementation of a multilayered strategy of capacity building and economic empowerment. Semi-structured interviews of 37 commercial female sex workers were conducted in a red-light district of India. Qualitative analysis of the interview transcripts showed the prevalence of three themes which demonstrated the different facets of the community mobilization framework within the context of a health communication intervention. The findings of this research delineate how STI risk reduction as well as participation and empowerment can be achieved through a community-based health promotion project targeted towards commercial female sex workers within the context of their lived realities of marginalization and oppression.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.

Designing Evidence-Based Preventive Interventions That Reach More People, Faster, and with More Impact in Global Contexts

This article demonstrates the substantial similarities globally among preventive, evidence-based interventions (EBIs) designed to address HIV by providing four examples: an HIV family-focused intervention, the Community Popular Opinion Leader intervention, a South African maternal/child health program, and an EBI for sex workers in India. Each identified the key problems in the target population, utilized well-established social cognitive theories, created processes for engaging the target population, set standards for staff accountability, and included routine data collection to facilitate iterative program improvements over time. Building EBIs based on these common, robust features is an alternative design strategy to replication with fidelity. These components provide a road map for researchers, especially those using new technologies, and for local providers seeking to deliver EBIs that match their clients' and communities' needs. Technology platforms and community organizations may serve as resources for designers of the next generation of EBIs, offering an alternative to repeatedly validating the same interventions and replicating them with fidelity.

The EMERALD (Enabling Mobilization, Empowerment, Risk Reduction, and Lasting Dignity) Study: Protocol for the Design, Implementation, and Evaluation of a Community-Based Combination HIV Prevention Intervention for Female Sex Workers in Baltimore, Maryland

Background

Cisgender female sex workers (FSWs) experience high rates of HIV and sexually transmitted infections (STIs), including chlamydia and gonorrhea. Community empowerment–based responses to the risk environment of FSWs have been associated with significant reductions in HIV and STI risk and associated risk behaviors; however, evaluations of US-based interventions targeting FSWs are limited.

Objective

The objective of this study is to describe the design, implementation, and planned evaluation strategy of an ongoing comprehensive community-level intervention in Baltimore City, Maryland, which aims to improve HIV and STI risk and cumulative incidence among FSWs. The two intervention components are the SPARC (Sex Workers Promoting Action, Risk Reduction, and Community Mobilization) drop-in center and the accompanying comprehensive mobile outreach program. The mission of SPARC is to provide low-barrier harm reduction services to FSWs, with a special focus on women who sell sex and use drugs. Services are provided through a harm reduction framework and include reproductive health and sexual health care; medication-assisted treatment; legal aid; counseling; showers, lockers, and laundry; and the distribution of harm reduction tools, including naloxone and sterile drug use supplies (eg, cookers, cotton, syringes, and pipes).

Methods

The SPARC intervention is being evaluated through the EMERALD (Enabling Mobilization, Empowerment, Risk Reduction, and Lasting Dignity) study, which consists of a prospective 2-group comparative nonrandomized trial (n=385), a cross-sectional survey (n=100), and in-depth interviews assessing SPARC implementation (n=45). Participants enrolled in the nonrandomized trial completed a survey and HIV and STI testing at 4 intervals (baseline and 6, 12, and 18 months). Participants recruited from predefined areas closest to SPARC comprised the intervention group, and participants from all other areas of Baltimore were included in the control group.

Results

We hypothesize that addressing structural drivers and more immediate medical needs, in combination with peer outreach, will improve the HIV and STI risk environment, leading to community empowerment, and reduce the HIV and STI cumulative incidence and behavioral risks of FSWs. Data collection is ongoing. A baseline description of the cohort is presented.

Conclusions

In the United States, structural interventions aimed at reducing HIV and STIs among FSWs are scarce; to our knowledge, this is the first intervention of its kind in the United States. The results of the EMERALD study can be used to inform the development of future interventions targeting FSWs and other at-risk populations.

Trial Registration

ClinicalTrials.gov NCT04413591; https://clinicaltrials.gov/ct2/show/NCT04413591.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23412

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade

This paper examines the prevalence of and potential for community mobilization (CM) and its association with HIV/STI risk, substance use, and violence victimization among women, particularly those using substances, in the sex trade in Tijuana, Mexico.

METHODS

195 women participated in Mujeres Unidas (K01DA036439 Urada) under a longitudinal survey study, "Proyecto Mapa de Salud" (R01DA028692, PI: Brouwer). Local health/social service providers (N = 16) were also interviewed.

RESULTS

39% of women who participated in community mobilization activities used substances. In adjusted analyses (n = 135), participation in CM activities (n = 26) was more likely among women who did not report substance use (AOR: 4.36, CI: 1.11-17.16), perceived a right to a life free from violence (AOR: 9.28, CI: 2.03-59.26), talked/worked with peers in the sex trade to change a situation (AOR: 7.87, CI: 2.03-30.57), witnessed violence where they worked (AOR: 4.45, CI: 1.24-15.96), and accessed free condoms (AOR: 1.54, CI: 1.01-2.35). Forty-five of the women using substances demonstrated their potential for engaging in asset-based community development (ABCD) with service providers in Mujeres Unidas meetings.

CONCLUSION

Women using substances, vs. those who did not, demonstrated their potential to engage in ABCD strategies. Women's empowerment, safety, and health could be enhanced by communities engaging in ABCD strategies that build and bridge social capital for marginalized women who otherwise have few exit and recovery options.

Successful integration of HIV pre-exposure prophylaxis into a community-based HIV prevention program for female sex workers in Kolkata, India

We assessed the impact of pre-exposure prophylaxis (PrEP) in the context of a community-based HIV program among female sex workers (FSWs) in Kolkata, India. This was an open-label, uncontrolled demonstration trial. HIV seronegative FSWs over 18 years were eligible. Participants were administered daily tenofovir/emtricitabine (TDF-FTC) with follow-up visits at months 1, 3, 6, 9, 12, and 15. Drug adherence was monitored by self-report, and a random subset of participants underwent plasma TDF testing. 843 women were screened and 678 enrolled and started on PrEP. Seventy-nine women (11%) did not complete all scheduled visits: four women died of reasons unrelated to PrEP and 75 withdrew, for a 15-month retention rate of 89%. Self-reported daily adherence was over 70%. Among those tested for TDF, the percentage of women whose level reached ≥40 ng/mL was 65% by their final visit. There were no HIV seroconversions, and no evidence of significant changes in sexual behavior. This study demonstrated the feasibility and effectiveness of PrEP for FSWs in Kolkata, with very high levels of adherence to PrEP and no HIV seroconversions. The integration of PrEP into an existing community-based HIV prevention program ensured community support and facilitated adherence.

In Search of 'Success': The Politics of Care and Responsibility in a PrEP Demonstration Project

We illustrate the lively existence of the notion of success in the unfolding of a PrEP project led by a sex worker organization in India. In what we call the "search for success," particular attention is placed on the role that care plays among sex workers guiding the project. Drawing on our ethnographic work, we highlight how the search for success underlines particular affective dispositions that are underscored by overlapping temporal registers: in the early stages of fostering adherence; when project fatigue sets in; and as the project draws to a close, in the anticipation of what comes next for the organization.

Social innovation in sexual health: a scoping review towards ending the HIV epidemic

As donor financial support decreases, ending the HIV epidemic in Asia will require novel and sustainable approaches. Social innovation, a community-engaged process that links social change and health improvement, may be useful for helping to end the HIV epidemic in Asia. A scoping review to examine social innovation strategies in sexual health for the Asian region was conducted. The research identified focused on three types of social innovation: (1) microfinance; (2) social entrepreneurship; and (3) social enterprise. Microfinance provides financial opportunities (e.g. banking services, job opportunities) to spur local entrepreneurship and healthier behaviours. Social entrepreneurship uses business principles and tools (e.g. crowdsourcing, human-centred design) to improve health. Social enterprise is a business with a social mission. Further research is needed to measure the efficacy and cost-effectiveness of social innovation strategies in improving HIV services.

Violence in Commercial Sex Work: A Case Study on the Impact of Violence Among Commercial Female Sex Workers in India and Strategies to Combat Violence

Violence is one of the primary contextual factors that significantly raise sex workers' sexually transmitted infection risk. The current study examines how violence affects sexual health behavior among commercial female sex workers in a red light district in Calcutta, India. The study which employs in-depth interviews of 37 commercial female sex workers also discusses an innovative multilayered strategy devised by the sex workers to combat violence through a community mobilization drive. The current study shows that the sex workers can confront the system that precipitates violence and actively engage with it to mitigate the impact of structural barriers to empowerment.

Vulnerability mapping: A conceptual framework towards a context-based approach to women's empowerment

•Women's empowerment interventions are not as effective as hoped or intended.•Could be an issue with intervention design and implementation.•Research reveals that there are several limitations to existing women's empowerment approaches.•These include disregard of context, a non-holistic approach, difficulty measuring variables, etc.•Vulnerability mapping may be able to address these limitations; we present an adapted framework.

Women Trading Sex in a U.S.-Mexico Border City: A Qualitative Study of the Barriers and Facilitators to Finding Community and Voice

Poverty and income inequality can increase a woman's decision to engage in risky transactional sex, and may lead to unimaginable harms, such as violence, substance use, and human trafficking. This study examines the facilitators and barriers to finding community and voice among women trading sex in Tijuana, Mexico, and what factors, such as socio-structural support, violence, and substance use, may impact their potential to engage with others, including human service providers. Sixty qualitative in-depth interviews were conducted with women trading sex in Tijuana, Mexico. Researchers met with participants for in-depth-face-to-face structured interviews. Data were coded using ATLAS.ti. Participants were aged 19-73 (mean: 37), 98% were of Mexican nationality, 90% reported trading sex independent of the control of others, with 58% identified as independent and street-based. Thirty percent of women trading sex reported substance use (excluding marijuana) and 20% reported injection drug use within 30 days. The majority reported no involvement in mobilization activities, but 85% expressed interest. However, barriers included stigma, cultural gender norms, partner violence, and privacy in regards to disclosure of sex trade involvement, moral conflict (revealing one's involvement in sex trade), involvement in substance use, human trafficking, and feeling powerless. Facilitators were having a safe space to meet, peer support, self-esteem, feeling heard, knowledge of rights, economic need to support families, and staying healthy. Findings imply the potential to go beyond mobilizing limited groups of women in the sex trade and instead involve whole community mobilization; that is, to reach and include the more vulnerable women (substance use, trafficked) in supportive services (social services, exit strategies, better healthcare opportunities, and/or education for healthcare providers to help break societal stigmas regarding women in the sex trade) and to change the status of women in society in general.

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.

Strategies to promote the meaningful involvement of sex workers in HIV prevention and care

PURPOSE OF REVIEW

We review the recent evidence regarding strategies for engaging sex workers in HIV prevention and care programs. We searched Pub Med on 19 March 2019 using terms 'Sex Work' And 'HIV infections'. Our search was limited to articles published since 2017.

RECENT FINDINGS

Community empowerment approaches where sex workers work collaboratively to address their specific priorities and concerns, including those beyond HIV, are those most likely to meaningfully engage sex workers. Community-driven programs that combine structural, behavioral and biomedical approaches can facilitate improved HIV outcomes by tackling barriers to uptake and retention of services along all steps in the prevention and care cascades. Microplanning, network-based recruitment and mobile-phone interventions can also help reach and support sex workers to mobilize and to engage with a range of services. Sex worker-led groups and initiatives including economic strengthening and community drug refill groups can both build social cohesion and address structural barriers to HIV outcomes including financial insecurity. Interventions which focus narrowly on increasing uptake of specific steps in prevention and care cascades outside the context of broader community empowerment responses are likely to be less effective.

SUMMARY

Comprehensive, community-driven approaches where sex workers mobilize to address their structural, behavioral and biomedical priorities work across HIV prevention and treatment cascades to increase uptake of and engagement with prevention and care technologies and promote broader health and human rights. These interventions need to be adequately supported and taken to scale.

Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India

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.

Identifying Opportunities for Collaboration Across the Social Sciences to Reach the 10-10-10: A Multilevel Approach

BACKGROUND

The national and global strategy to combat HIV, often referred to as the "90-90-90," aims to diagnose 90% of people living with HIV, get 90% of those diagnosed onto antiretroviral treatment (ART), and achieve viral suppression in 90% of those on ART. The remaining 10-10-10 who will be undiagnosed, not on ART, or not virally suppressed, include vulnerable persons and populations most affected by social determinants of health. Given their foci on the social determinants of health at the individual, social, and structural levels, social scientists are in a prime position to help reach the 10-10-10. A potentially effective way for social scientists to achieve this goal is to examine the issues that affect the 10-10-10 using a multilevel framework, to understand at what levels their own approaches fit within such a multilevel framework, and to seek intentional collaborations with other social scientists who may work at different levels but whose approaches may complement their own within multilevel collaborations.

APPROACH

The present article describes how a multilevel framework can guide collaboration across disciplines within the social sciences toward the common goal of reaching the 10-10-10.

CONCLUSIONS

Within a multilevel framework, social scientists can work collaboratively to address the needs of individuals among the 10-10-10 within the social and structural contexts (eg, social norms, stigma, poverty, and barriers to care) that affect their health. Such an approach draws on the unique strengths and approaches of different social-science disciplines while also building capacity for individuals most affected by social determinants of health.

HIV-Related Implementation Research for Key Populations: Designing for Individuals, Evaluating Across Populations, and Integrating Context

INTRODUCTION

Key populations, including men who have sex with men, transgender people, sex workers, people who inject drugs, and incarcerated populations, experience high burdens of HIV and urgently need effective interventions. Yet the evidence base for implementation research (IR) with key populations remains weak and poses specific challenges to epidemiologic inference. We apply the Consolidated Framework for IR to consider specific challenges and recommendations for IR with key populations.

DISCUSSION

Individuals within key populations exist within inner and outer settings-including organizational structures, legal (eg, criminalization), and funding environments-which influence the design, adoption and fidelity of interventions, and the potential sustainability of intervention scale-up. Underlying vulnerabilities and external stressors experienced at the individual level (eg, homelessness, violence) further impact participation and retention in IR. Thus, researchers should account for representation in the research process, beginning with community engagement in IR design and consideration of enumeration/sampling methods for key populations who lack probabilistic sampling frames. Interventions for key populations require substantial adaptation and complexity (eg, individually tailored, multicomponent) to ensure appropriateness; however, there is tension between the need for complexity and challenges to internal validity (fidelity) and external validity (generalizable scale-up). Finally, integrating contextual, sampling, and implementation elements into analytic approaches is critical for effectiveness evaluation.

CONCLUSIONS

Translation of efficacious findings at the individual level to effectiveness at the population level requires recognition of risk heterogeneity. Recognizing the nuances of working with key populations is essential to ensure that individuals are represented by design and therefore gains in population health can be achieved.

Sex Worker Community-led Interventions Interrupt Sexually Transmitted Infection/Human Immunodeficiency Virus Transmission and Improve Human Immunodeficiency Virus Cascade Outcomes: A Program Review from South India

A review of a community-led sex worker program in 2 districts of South India that has achieved near elimination of curable sexually transmitted infections and optimal human immunodeficiency virus cascade outcomes.

Supplemental digital content is available in the text.

Ashodaya Samithi, an organization run by and for female, male, and transgender sex workers in Mysore, India, has worked since 2004 to prevent sexually transmitted infection (STI)/human immunodeficiency virus (HIV) transmission and improve HIV cascade outcomes. We reviewed published and programmatic data, including measures of coverage, uptake, utilization and retention, and relate STI/HIV outcomes to evolving phases of community mobilization. Early interventions designed “for” sex workers mapped areas of sex work and reached half the sex workers in Mysore with condoms and STI services. By late 2005, when Ashodaya Samithi registered as a community-based organization, interventions were implemented “with” sex workers as active partners. Microplanning was introduced to enable peer educators to better organize and monitor their outreach work to reach full coverage. By 2008, programs were run “by” sex workers, with active community decision making. Program data show complete coverage of community outreach and greater than 90% clinic attendance for quarterly checkups by 2010. Reported condom use with last occasional client increased from 65% to 90%. Surveys documented halving of HIV and syphilis prevalence between 2004 and 2009, while gonorrhoea declined by 80%. Between 2005 and 2013, clinic checkups tripled, whereas the number of STIs requiring treatment declined by 99%. New HIV infections also declined, and Ashodaya achieved strong cascade outcomes for HIV testing, antiretroviral treatment linkage, and retention. Program performance dropped markedly during several periods of interrupted funding, then rebounded when restored. Ashodaya appear to have achieved rapid STI/HIV control with community-led approaches including microplanning. Available data support near elimination of curable STIs and optimal cascade outcomes.

Social Capital and HIV Testing Uptake among Indirect Female Sex Workers in Bali, Indonesia

Indirect female sex workers (FSWs), a type of FSW working under the cover of entertainment enterprises (e.g., karaoke lounge, bar, etc.), remain as an important key population for HIV transmission, signaling the need of appropriate interventions targeting HIV-related behaviors. This study aimed to investigate the association between social capital and HIV testing uptake. A cross-sectional study was conducted among 200 indirect FSWs in Denpasar, Bali. The dependent variable was HIV testing uptake in the last six months preceding the survey. The main independent variables were social capital constructs: social cohesion (perceived peer support and trust) and social participation. Variables of socio-demographic characteristics were controlled in this study to adjust the influence of social capital. Binary logistic regression was performed. The prevalence of HIV testing in the last six months was 72.50%. The multivariate analysis showed that only peer support from the social capital constructs was associated with HIV testing uptake. Indirect FSWs who perceived a high level of support within FSWs networks were 2.98-times (95% CI = 1.43–6.24) more likely to report for HIV testing. Meanwhile, perceived trust and social participation did not show significant associations in relation to HIV testing uptake. As social cohesion (support) within FSWs’ relationships can play an important role in HIV testing uptake, existing HIV prevention programs should consider support enhancement to develop a sense of belonging and solidarity.

Essential elements of a community empowerment approach to HIV prevention among female sex workers engaged in project Shikamana in Iringa, Tanzania

Globally, female sex workers bear a disproportionate burden of HIV, with those in sub-Saharan Africa being among the most affected. Community empowerment approaches have proven successful at preventing HIV among this population. These approaches facilitate a process whereby sex workers take collective ownership over programmes to address the barriers they face in accessing their health and human rights. Limited applications of such approaches have been documented in Africa. We describe the community empowerment process among female sex workers in Iringa, Tanzania, in the context of a randomised controlled trial of a community empowerment-based model of combination HIV prevention. We conducted 24 in-depth interviews with participants from the intervention community and 12 key informant interviews with HIV care providers, police, venue managers, community advisory board members and research staff. Content analysis was employed, and salient themes were extracted. Findings reveal that the community empowerment process was facilitated by the meaningful engagement of sex workers in programme development, encouraging sex worker ownership over the programme, providing opportunities for solidarity and capacity building, and forming partnerships with key stakeholders. Through this process, sex workers mobilised their collective agency to access their health and human rights including HIV prevention, care and treatment.

"I Couldn't Afford to Resist": Condom Negotiations Between Male Sex Workers and Male Clients in Mombasa, Kenya

Male sex workers in Kenya face a disproportionate burden of HIV and often engage in condomless sex with their commercial partners, yet little is known about how condom negotiations between male sex workers and clients take place. We conducted semi-structured interviews with 25 male sex workers and 11 male clients of male sex workers in Mombasa, Kenya, to examine barriers and facilitators to condom use and how condom use negotiation takes place in these interactions. Participants reported positive attitudes toward condom use and perceived condom use to be a health-promoting behavior. Barriers to condom use included extra-payment for condomless sex, low perceived HIV/STI risk with some sexual partners, perceived reduced pleasure associated with using condoms, alcohol use, and violence against male sex workers by clients. Future interventions should address individual- and structural-level barriers to condom use to promote effective condom use negotiation between male sex workers and male clients.

The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore, India

To inform PrEP roll out, Ashodaya Samithi, a sex workers' collective, conducted a community-led prospective demonstration project among female sex workers in Mysore and Mandya, India. Following a community preparedness phase and pre-screening, participants were recruited for clinical screening and enrolment, provided PrEP as part of combination HIV prevention, and followed for 16 months. Adherence was measured by self-reported pill intake and by tenofovir blood level testing among a subset of participants. Of the 647 participants enrolled, 640 completed follow-up. Condom use remained stable and no HIV seroconversions occurred. Self-reported daily PrEP intake over the last month was 97.97% at the end of the study. Tenofovir blood levels >40 ng/mL (consistent with steady state dosing) were detected among 80% (n = 68/85) and 90.48% (n = 76/84) of participants at month 3 and 6, respectively. Our study holds important insights for rolling out PrEP in community settings as part of targeted HIV prevention interventions.

Women's Empowerment and HIV Testing Uptake: A Meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African Countries

BACKGROUND

There is a growing body of evidence suggesting that women's empowerment can help achieve better health behaviours and outcomes. However, few have looked at the impact of women's empowerment on HIV testing in Sub-Saharan Africa (SSA). This study investigated the association between women's empowerment and HIV testing among women in 33 countries across SSA.

METHODS

Cross-sectional data from the most recent Demographic and Health Surveys (2005-2018) of 33 countries in SSA were used. Confounder adjusted logistic regression analysis was completed separately for each of the 33 DHS datasets to produce the adjusted Odds Ratio (OR) for the association between women empowerment and HIV testing. The regression analysis strictly accounted for the three design elements (weight, cluster and strata) to produce an estimate representative of the respective countries. Finally, an Individual Participant Data (IPD) meta-analysis approach was used to statistically pool the effect of women empowerment on HIV testing.

RESULTS

There was a wide variation in the percentage of women who were empowered among the countries studied, with only a few countries such as South Africa, Angola and Ghana having a high prevalence of negative attitudes toward wife beating. HIV testing was higher in Angola, Lesotho, Uganda and South Africa. While participation in one or two of the three decisions had been marginally associated with lower odds of HIV testing across the SSA regions (0.89; 95%CI: 0.83, 0.97); the corresponding prediction interval crossed the null. Being involved in the three decisions (0.92; 95%CI: 0.84, 1.00) and disagreement to wife-beating (0.99; 95%CI: 0.94, 1.05) had no statistical relationship with HIV testing uptake.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The two indirect indicators of women empowerment could not predict HIV testing uptake. Further studies are recommended to establish the nature of the relationship between HIV testing and women's empowerment that is measured through standard tools.

Community-Based Responses to Negative Health Impacts of Sexual Humanitarian Anti-Trafficking Policies and the Criminalization of Sex Work and Migration in the US

System-involvement resulting from anti-trafficking interventions and the criminalization of sex work and migration results in negative health impacts on sex workers, migrants, and people with trafficking experiences. Due to their stigmatized status, sex workers and people with trafficking experiences often struggle to access affordable, unbiased, and supportive health care. This paper will use thematic analysis of qualitative data from in-depth interviews and ethnographic fieldwork with 50 migrant sex workers and trafficked persons, as well as 20 key informants from legal and social services, in New York and Los Angeles. It will highlight the work of trans-specific and sex worker–led initiatives that are internally addressing gaps in health care and the negative health consequences that result from sexual humanitarian anti-trafficking interventions that include policing, arrest, court-involvement, court-mandated social services, incarceration, and immigration detention. Our analysis focuses on the impact of criminalization on sex workers and their experiences with sexual humanitarian efforts intended to protect and control them. We argue that these grassroots community-based efforts are a survival-oriented reaction to the harms of criminalization and a response to vulnerabilities left unattended by mainstream sexual humanitarian approaches to protection and service provision that frame sex work itself as the problem. Peer-to-peer interventions such as these create solidarity and resiliency within marginalized communities, which act as protective buffers against institutionalized systemic violence and the resulting negative health outcomes. Our results suggest that broader public health support and funding for community-led health initiatives are needed to reduce barriers to health care resulting from stigma, criminalization, and ineffective anti-trafficking and humanitarian efforts. We conclude that the decriminalization of sex work and the reform of institutional practices in the US are urgently needed to reduce the overall negative health outcomes of system-involvement.

Process elements contributing to community mobilization for HIV risk reduction and gender equality in rural South Africa

Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the ‘One Man Can’ intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a ‘better life’ and associated with behaviour change in the intervention’s main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization—specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.

Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey

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.

Community Organization Membership, Financial Security, and Social Protection among Female Sex Workers in India

The purpose of this study is to examine the female sex workers’ (FSWs) community organization (CO) membership, their financial and social protection security, and the relationship between these factors among FSWs in India. Data from 4098 FSWs collected under the Avahan-III baseline evaluation survey—2015 in 5 high HIV prevalence states (Maharashtra, Tamil Nadu, Karnataka, Telangana, and Andhra Pradesh) in India were used here. More than three-fifths (77%) were registered CO members, of whom 79% had been CO members for more than 1 year. The likelihood of having high financial security (19% versus 10%; adjusted odds ratio [AOR]: 1.7; 95% confidence interval [CI]: 1.3-2.1) and social protection security (13% versus 6%; AOR: 1.6; 95% CI: 1.2-2.0) was 2 times higher among FSWs who were CO members compared to those who were not. The study offers important insights into furthering CO membership to address financial and social vulnerability as a path to a sustainable reduction of HIV risk.

Psychological factors associated with protected sex among indirect female sex workers in Denpasar, Bali, Indonesia

A cross-sectional study was conducted among indirect FSWs (a type of FSWs who provide sex services under the cover of entertainment or recreational enterprises) in Denpasar, Bali from August to October 2017 to investigate factors associated with protected sex with clients using the Health Belief Model (HBM) framework. The protected sex as a dependent variable was identified through self-reported consistency in using condoms with clients in the last month. Independent variables consisted of six HBM constructs and three main groups of modifying factors (personal, sex work, and interventional factors). Binary logistic regression was employed to identify the determinants. The prevalence of protected sex with clients in last month was 50.17% (95%CI = 41.50-80.83). Indirect FSWs were more likely to use condoms consistently if they completed senior high school or higher. Meanwhile, those working in a karaoke lounge, bar, or café were less likely to have protected sex than those in a massage parlour, spa, or beauty salon. Based on HBM, an increase of one-score of these following constructs increased likelihood of protected sex: perceived susceptibility, self-efficacy, and cues to action. Low protected sex among indirect FSWs indicates the need for public health interventions at individual, interpersonal, and institutional level.

Implementing Targeted Sampling: Lessons Learned from Recruiting Female Sex Workers in Baltimore, MD

Globally, HIV prevention interventions have proven efficacious among street-based female sex workers (FSWs); yet, there is a dearth of US-based HIV prevention research among this group. The lack of research among FSWs in the USA is partially driven by challenges in recruiting members of this population. The purpose of this research is to describe how targeted sampling was employed to recruit a cohort of street-based FSWs for a study that examined the role of police in shaping the HIV risk environments of street-based FSWs in Baltimore, MD. Our research demonstrates that targeted sampling can be an advantageous strategy for recruiting hidden populations that are mobile and geographically dispersed.

Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Background

Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries.

Methods

We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited.

Results

Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted.

Conclusions

The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.

Community-Based Mental Health Intervention Skills: Task Shifting in Low- and Middle-Income Settings

There is a global need to provide human resources for health in low- and middle-income countries. To increase access to care, task shifting has been implemented in community-based rehabilitation (CBR) programs where skills and responsibilities are transferred to local people with shorter and more focused training. Through realist review and synthesis, this research aimed to consolidate the literature when considering (a) what skills CBR workers are reportedly using and/or being trained in relating to mental health, (b) how different settings affect how these task shifting programs work, and (c) the evidence of effectiveness when community health workers come from within the community itself. A total of 11 databases (PubMed, ABI/Inform Global, CINAHL, Cochrane, Emerald, Google Scholar, PsycINFO, SAGE, Science Direct, Scopus, and Web of Science) were systematically searched for specific terms relating to mental health, CBR, and low- and middle-income country. A total of 27 publications were identified as fitting the criteria (4 qualitative, 20 quantitative including 10 randomized controlled trials, and 3 noninvestigatory editorials). Core skills have been identified along with themes that affect how programs work in particular contexts. The use of task shifting in this area may be a potentially viable option for increasing access to mental health care. This resulted in the development of a theory to explain the outcomes being observed. When Task-shifting mental health intervention skills collaboration, harnessing resources available within the community, and the provision of ongoing supervision interact to influence awareness gains, social bonding, the building of trust, and the development of skills and understanding within the community itself. This effects intervention buy-in, overall effectiveness and sustainability, mental health symptoms and local empowerment. These findings can be considered when developing training programs for CBR mental health workers, as well as policy and intervention program design.

Social-ecological factors associated with selling sex among men who have sex with men in Jamaica: results from a cross-sectional tablet-based survey

BACKGROUND

Globally, men who have sex with men (MSM) experience social marginalization and criminalization that increase HIV vulnerability by constraining access to HIV prevention and care. People who sell sex also experience criminalization, rights violations, and violence, which elevate HIV exposure. MSM who sell sex may experience intersectional stigma and intensified social marginalization, yet have largely been overlooked in epidemiological and social HIV research. In Jamaica, where same sex practices and sex work are criminalized, scant research has investigated sex selling among MSM, including associations with HIV vulnerability.

OBJECTIVE

We aimed to examine social ecological factors associated with selling sex among MSM in Jamaica, including exchanging sex for money, shelter, food, transportation, or drugs/alcohol (past 12 months).

METHODS

We conducted a cross-sectional survey with a peer-driven sample of MSM in Kingston, Ocho Rios, and Montego Bay. Multivariable logistic regression analyses were conducted to estimate intrapersonal/individual, interpersonal/social, and structural factors associated with selling sex.

RESULTS

Among 556 MSM, one-third (n = 182; 32.7%) reported selling sex. In the final multivariable model, correlates of selling sex included: individual/intrapersonal (lower safer sex self-efficacy [AOR: 0.85, 95% CI: 0.77, 0.94]), interpersonal/social (concurrent partnerships [AOR: 5.52, 95% CI: 1.56, 19.53], a higher need for social support [AOR: 1.08, 95% CI: 1.03, 1.12], lifetime forced sex [AOR: 2.74, 95% 1.65, 4.55]) and structural-level factors (sexual stigma [AOR: 1.09, 95% CI: 1.04, 1.15], food insecurity [AOR: 2.38, 95% CI: 1.41, 4.02], housing insecurity [AOR: 1.94, 95% CI: 1.16, 3.26], no regular healthcare provider [AOR: 2.72, 95% CI: 1.60, 4.64]).

CONCLUSIONS

This study highlights social ecological correlates of selling sex among MSM in Jamaica, in particular elevated stigma and economic insecurity. Findings suggest that MSM in Jamaica who sell sex experience intensified social and structural HIV vulnerabilities that should be addressed in multi-level interventions to promote health and human rights.

'That's how we help each other': Community savings groups, economic empowerment and HIV risk among female sex workers in Iringa, Tanzania

Female sex workers (FSW) are a socially and economically marginalized population heavily affected by HIV. Community empowerment approaches focus on FSW taking collective action to address structural barriers to their health and have demonstrated effectiveness in reducing HIV risk. This study examines the potential for community savings groups (locally called michezo) among FSW in Iringa, Tanzania to reduce HIV risk and promote economic and community empowerment. We conducted 27 in-depth interviews (IDIs) with 15 FSW over time and 4 focus group discussions (FGDs) with 35 FSW participating in michezo, and 10 key informant interviews (KIIs) with group collectors. Content analysis was used to identify salient themes around participants' sex work and financial realities; the role of savings groups in their lives and work; and experiences with social cohesion associated with group participation. Michezo were described as providing a safety net for times of financial need, allowing FSW to create greater financial security for themselves and their families. Participation in the groups was also reported to facilitate both individual agency, resulting in members' ability to negotiate condom use and be selective about clients, and a sense of collective identity and solidarity. Participants described group challenges including high mobility and low income of FSW making it difficult for women to fulfill their financial obligations to the group. As a result, participants reported preferences for joining michezo whose members were perceived as more stable (e.g. older, married, from more established venues). Group collectors and members were eager to have michezo formally registered and become recognized by the broader community. Findings indicate that savings groups promote individual agency to reduce sexual risk behaviors and foster community empowerment among FSW. The groups hold potential as an empowerment strategy to enable sex workers to address structural sources of HIV vulnerability and help them achieve socioeconomic inclusion.

HIV-Related Stigma Among Spanish-speaking Latinos in an Emerging Immigrant Receiving City

HIV-related stigma has been associated with a reluctance to test for HIV among Latinos. This study assessed community HIV-related stigma within an emerging Latino immigrant receiving city. We conducted a brief survey among a convenience sample of 312 Spanish-speaking Latinos in Baltimore, Maryland. HIV-related stigma was assessed through six items. Associations between stigma items, socio-demographic characteristics, and HIV testing history were considered. Gender, education, and religiosity were significantly associated with stigmatizing HIV-related beliefs. For example, men were 3.4 times more likely to hold more than three stigmatizing beliefs than women, and were also twice as likely as women to report feeling hesitant to test for HIV for fear of people's reaction if the test is positive. These findings can help inform future stigma interventions in this community. In particular, we were able to distinguish between drivers of stigma such as fear and moralistic attitudes, highlighting specific actionable items.

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs.