Elizabeth Reed

The context of economic insecurity and its relation to violence and risk factors for HIV among female sex workers in Andhra Pradesh, India.

Objective. We examined the context of economic insecurity and debt among female sex workers (FSWs), how this context varies among FSWs, and its association with experiences of violence and sexual risk factors for human immunodeficiency virus (HIV). Methods. We recruited FSWs aged ≥18 years (n=673) through respondent-driven sampling for a survey on HIV risk in this region. Using logistic regression models (adjusted for partner status, education, financial support, and literacy), we assessed the relation between debt and sexual and physical victimization as well as sexual risk. We also conducted qualitative interviews with a subsample of the survey participants and examined these for related themes. Results. In adjusted logistic regression models, FSWs who reported debt were more likely to report the following: recent physical violence (adjusted odds ratio [AOR] = 2.4, 95% confidence interval [CI] 1.5, 3.9), unprotected sex with occasional clients in the past week (AOR=2.3, 95% CI 1.2, 4.3), anal sex with clients in the past 30 days (AOR=2.0, 95% CI 1.1, 3.9), and at least one sexually transmitted infection symptom in the past six months (AOR=1.6, 95% CI 1.1, 2.4). FSWs with debt were more likely to report current husbands or other male partners, and less likely to report condom use with these partners, further increasing their sexual risk. Qualitative data elaborated on these findings. Conclusion. Findings indicate the violence- and HIV-related vulnerability of FSWs who report debt and further highlight how male partners may contribute to the debt and economic insecurity of FSWs.

Losing the “Gender” in Gender-Based Violence: The Missteps of Research on Dating and Intimate Partner Violence

A multitude of quantitative and qualitative research studies as well as volumes of health and criminal justice data from across the globe clearly demonstrate that male intimate partner violence (IPV) against women and girls is an issue of tremendous public health and human rights significance worldwide (i.e., the health and freedom of girls and women are affected at the population level; Amnesty International, 2004; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Rand, 2008; World Health Organization [WHO], 2003). However, there is continuing discord as to the basic frameworks used across studies and programs for understanding and addressing IPV, including dating violence, as a public health issue, particularly regarding the gendered basis of the problem (Reed, 2008; Swan & Snow, 2006). Multiple recent U.S. public health studies have discussed “mutual aggression” or “female perpetration” of IPV (e.g., Carney, Buttell, & Dutton, 2006; Romans, Forte, Cohen, Du Mont, & Hyman, 2007; Straus, 2007; Straus & Ramirez, 2007; Whitaker, Haileyesus, Swahn, & Saltzman, 2007), disregarding the gender-based framework at the

Male perpetration of teen dating violence: Associations with neighborhood violence involvement, gender attitudes, and perceived peer and neighborhood norms

This study aims to examine the link between male perpetration of teen dating violence (TDV) and neighborhood violence, as well as associations with gender attitudes and perceived peer and neighborhood norms related to violence among a sample of urban adolescent boys. Participants of this cross-sectional study (Nu2009=u2009275) were between the ages of 14 and 20xa0years and recruited from urban community health centers. Crude and adjusted logistic and linear regression models were used to examine TDV perpetration in relation to (a) neighborhood violence involvement, (b) perceptions of peer violence, (c) perceptions of neighborhood violence, and (d) gender attitudes. Slightly more than one in four (28%) boys reported at least one form of TDV perpetration; among boys who have ever had sex, almost half (45%) reported at least one form of TDV perpetration. In logistic and linear regression models adjusted for demographics, boys who reported TDV perpetration were more likely to report involvement in neighborhood violence (odds ratio (OR)u2009=u20093.1; 95% confidence interval (CI)u2009=u20091.7–5.5), beliefs that their friends have perpetrated TDV (ORu2009=u20092.7; 95%CIu2009=u20091.4–5.1), perceptions of violent activity within their neighborhood (ORu2009=u20093.0; 95%CIu2009=u20091.4–6.3), and greater support of traditional gender norms (βu2009=u20093.2, pu2009=u20090.002). The findings suggest that efforts are needed to address boys’ behaviors related to the perpetration of multiple forms of violence and require explicit efforts to reduce perceived norms of violence perpetration as well as problematic gender attitudes (e.g., increasing support for gender equity) across boys’ life contexts.

Police-Related Experiences and HIV Risk Among Female Sex Workers in Andhra Pradesh, India

Research suggests experiences with police are related to human immunodeficiency virus (HIV) sexual risk among women working as sex workers. However, little is known about the links between specific police-related behaviors and HIV vulnerability. We examine whether 5 police-related experiences are associated with measures of HIV risk and violence among a sample of female sex workers (FSWs) in Andhra Pradesh, India, and consider the implications for HIV prevention. FSWs at least 18 years of age (n = 835) were recruited through respondent-driven sampling for a cross-sectional survey conducted as part of Avahan, the India AIDS Initiative. Using logistic regression models adjusted for age, age at start of sex work, and sex work venue, we assessed police-related experiences reported by FSWs in relation to HIV risk behaviors and violence. Results showed having sex with police to avoid trouble, giving gifts to police to avoid trouble, having police take condoms away, experiencing a workplace raid, and being arrested were associated with sexually transmitted infection symptoms, inconsistent condom use, acceptance of more money for sex without a condom, and experience of client violence. These findings suggest a need for interventions targeting police-FSW interactions to reduce HIV vulnerability among FSWs.

Trends in condom use among female sex workers in Andhra Pradesh, India: the impact of a community mobilisation intervention

Background Community mobilisation interventions for HIV prevention among female sex workers (FSWs) aim to organise FSWs for collective action and challenge the structures of power that underlie HIV risk. Assessing intervention impact is challenging because the importance of direct individual exposure to intervention components may decrease over time as change occurs at social-normative, policy and other structural levels. In this paper, the authors examine changes over time in consistent condom use among FSWs in Rajahmundry, Andhra Pradesh, the location of a long-standing community mobilisation intervention. Methods The authors analyse cross-sectional data collected among FSWs at three time points (n=2276) using respondent-driven sampling. Multiple logistic regression was used to assess the association of programme exposure with consistent condom use and whether this association varied over time. Results The proportion of FSWs having no exposure or only receptive exposure to the intervention decreased over time, while active utilisation increased from 19.4% in 2006 to 48.5% in 2009–2010. Consistent condom use with clients also increased from 56.3% in 2006 to 75.3% in 2009–2010. Multivariate analysis showed that age, age at start of sex work, venue, living conditions and programme exposure were significantly associated with condom use. The positive association between programme exposure and consistent condom use did not vary significantly over time. Conclusions Findings indicate improvements in HIV risk reduction behaviour among FSWs and suggest that the intervention has substantial reach in the FSW population. The interventions strategies may be contributing to population-level HIV risk reduction among FSWs.

Brief Screening and Intervention for Alcohol and Drug Use in a College Student Health Clinic: Feasibility, Implementation, and Outcomes

Abstract Objective: Evaluation of the Brief Alcohol Screen and Intervention in College Students (BASICS) in a university primary care setting. Participants/Methods: Undergraduates (N = 449) participated in BASICS and electronic surveys assessing frequency/quantity of alcohol and drug use, psychosocial and mental health outcomes, and demographic information. Data were collected at baseline and 6-month follow-up between August 2006 and August 2008. Results: Drinking and drug use decreased between baseline and 6 months. Participants reported an increase in protective factors and in readiness to change alcohol-related behaviors, and a decrease in alcohol-related consequences and in distress symptoms. Heavy episodic drinking at baseline significantly moderated the changes in number of drinks in a typical week and in a typical weekend, and number of drinks on the occasion drank most on a weekend. Conclusions: BASICS can be implemented in a primary health care setting and university students may reduce their alcohol and/or drug use.

The role of housing in determining HIV risk among female sex workers in Andhra Pradesh, India: Considering women’s life contexts

Recent research on HIV prevention, regardless of the population, has increasingly recognized the relevance of contextual factors in determining HIV risk. Investigating such factors among female sex workers (FSW) is especially relevant in the South Indian state of Andhra Pradesh, where HIV rates are among the highest across Indian states and where HIV has largely affected FSW. Stable housing is a particular contextual challenge experienced by female sex workers in this region (as well as elsewhere); however, local studies have not examined the impact of this issue on HIV risk. In this paper, we examine residential instability, defined as a high frequency of reported evictions, among FSW and relation to experiences of violence (as a factor increasing risk for HIV) and sexual risk factors for HIV. Women were recruited through respondent-driven sampling for a survey on HIV risk. Using logistic regression models, we assessed: (1) residential instability and association with HIV sexual risk variables (including unprotected sex, reported STIs, and recent physical and sexual victimization) and (2) whether the association between residential instability and reported STI (as an indicator of HIV risk) was attenuated by individual risk behaviors and violence. In adjusted logistic regression models, FSW who reported residential instability were more likely to report: sexual violence, physical violence, accepting more money for unprotected sex, and a recent STI symptom. Violence associated with residential instability contributed to reported STIs; however, residential instability remained significantly associated with STIs beyond the influence of both violence and unprotected sex with clients. Findings highlight the interrelation among residential instability, violence, and HIV risk. Residential instability appears to be associated with womens HIV risk, above and beyond its association with individual risky sexual behaviors.

Factors associated with awareness and utilisation of a community mobilisation intervention for female sex workers in Andhra Pradesh, India

Objectives Examine factors associated with awareness and active utilisation of a community mobilisation intervention (CMI) to address HIV risk in female sex workers (FSWs) in a context characterised by multiple forms of sex work. Design Data came from two rounds, conducted in Spring 2006 and Spring 2007, of a serial cross-sectional survey of FSWs (n=812 in round 1, n=673 in round 2) recruited through respondent-driven sampling in Rajahmundry, Andhra Pradesh, India. Methods Descriptive statistics compared characteristics of programme aware and unaware FSWs and from among the aware, to characterise active program users. Multinomial logistic regression was used to assess factors associated with programme exposure. Results Between Rounds 1 and 2, programme awareness increased from 41.8% to 69.6% of respondents, and active utilisation (among those who were aware) increased from 49.2% to 61.0%. Street-based FSWs were under-represented and brothel-based FSWs overrepresented in both groups and rounds. Geographic proximity and literacy were associated with programme awareness but not utilisation. The most important factor associated with both forms of intervention exposure across rounds was willingness to be identified in public as a FSWs (OR 2.2–4.8). Conclusion Public visibility is a critical component of CMIs. Such interventions should develop strategies for involving FSWs that allow them to remain invisible, while also working to reduce the threat associated with public visibility. In contexts where sex work occurs in multiple venues, it is important to develop CMIs that include and address the needs of FSWs working in them all.

Substance use gender inequity violence and sexual risk among couples in Cape Town.

Alcohol and other drug use, gender power inequities and violence are key contributors to sexual risks for HIV among South African men and women. Little is known about the intersection between these sex-risk behaviours among couples in established heterosexual relationships. We conducted 10 focus-group discussions with men and women in relationships of 1 year or longer recruited from shebeens (informal taverns) in Cape Town, South Africa. Participants described: high levels of alcohol consumption at shebeens; low levels of condom use with main and casual sex partners; gender roles disfavouring womens condom negotiating power that also promoted economic dependency on male partners; men often spending a portion of the household income on alcohol and other drugs and sex with others in shebeens; loss of household income driving women to trade sex to provide for their families; and sexual violence and the exploitation of women occurring in shebeens. Findings highlight how the social contexts of alcohol and other drug use, gender inequitable norms and gender violence promote HIV risk within established heterosexual relationships in South African communities. Evidence of this kind should inform the design of HIV-risk-reduction interventions tailored to heterosexual couples who drink alcohol in shebeens.

History of sex trafficking, recent experiences of violence, and HIV vulnerability among female sex workers in coastal Andhra Pradesh, India

To estimate the prevalence of sex trafficking as a mode of entry into sex work, and to examine associations between sex trafficking and recent violence experiences and HIV vulnerability among female sex workers (FSWs).