Maryam Shahmanesh

Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review

Objective  To systematically review the evidence for effectiveness of HIV and sexually transmitted infection (STI) prevention interventions in female sex workers in resource poor settings.

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

OBJECTIVES We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India. METHODS Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants. RESULTS Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child. CONCLUSIONS Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. Indias widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.

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

BackgroundWhile community mobilization has been widely endorsed as an important component of HIV prevention among vulnerable populations such as female sex workers (FSWs), there is uncertainty as to the mechanism through which it impacts upon HIV risk. We explored the hypothesis that individual and collective empowerment of FSW is an outcome of community mobilization, and we examined the means through which HIV risk and vulnerability reduction as well as personal and social transformation are achieved.MethodsThis study was conducted in five districts in south India, where community mobilization programs are implemented as part of the Avahan program (India AIDS Initiative) of the Bill & Melinda Gates Foundation. We used a theoretically derived “integrated empowerment framework” to conduct a secondary analysis of a representative behavioural tracking survey conducted among 1,750 FSWs. We explored the associations between involvement with community mobilization programs, self-reported empowerment (defined as three domains including power within to represent self-esteem and confidence, power with as a measure of collective identity and solidarity, and power over as access to social entitlements, which were created using Principal Components analysis), and outcomes of HIV risk reduction and social transformation.ResultsIn multivariate analysis, we found that engagement with HIV programs and community mobilization activities was associated with the domains of empowerment. Power within and power with were positively associated with more program contact (p < .01 and p < .001 respectively). These measures of empowerment were also associated with outcomes of “personal transformation” in terms of self-efficacy for condom and health service use (p < .001). Collective empowerment (power with others) was most strongly associated with “social transformation” variables including higher autonomy and reduced violence and coercion, particularly in districts with programs of longer duration (p < .05). Condom use with clients was associated with power with others (p < .001), while power within was associated with more condom use with regular partners (p < .01) and higher service utilization (p < .05).ConclusionThese findings support the hypothesis that community mobilization has benefits for empowering FSWs both individually and collectively. HIV prevention is strengthened by improving their ability to address different psycho-social and community-level sources of their vulnerability. Future challenges include the need to develop social, political and legal contexts that support community mobilization of FSWs, and to prospectively measure the impact of combined community-level interventions on measures of empowerment as a means to HIV prevention.

The burden and determinants of HIV and sexually transmitted infections in a population based sample of female sex workers in Goa, India

Background: Interventions targeting sex workers are central to the National AIDS Control programme of India’s third 5-year plan. Understanding the way in which societal and individual factors interact to shape sex workers’ vulnerability would better inform interventions. Methods: 326 female sex workers, recruited throughout Goa using respondent-driven sampling, completed interviewer-administered questionnaires. Biological samples were tested for Trichomonas vaginalis, Neisseria gonorrhoea, Chlamydia trachomatis and antibodies to herpes simplex virus type 2 (HSV-2) and HIV. Multivariate analysis was used to define the determinants of HIV infection and any bacterial sexually transmitted infection (STI). Results: Infections were common, with 25.7% prevalence of HIV and 22.5% prevalence of bacterial STI; chlamydia 7.3%, gonorrhoea 8.9% and trichomonas 9.4%. Antibodies to HSV-2 were detected in 57.2% of women. STI were independently associated with factors reflecting gender disadvantage and disempowerment, namely young age, lack of schooling, no financial autonomy, deliberate self-harm, sexual abuse and sex work-related factors, such as having regular customers and working on the streets. Other factors associated with STI were Goan ethnicity, not having an intimate partner and being asymptomatic. Having knowledge about HIV and access to free STI services were associated with a lower likelihood of STI. HIV was independently associated with being Hindu, recent migration to Goa, lodge or brothel-based sex work and dysuria. Conclusion: Sex workers working in medium prevalence states of India are highly vulnerable to HIV and STI and need to be rapidly incorporated into existing interventions. Structural and gender-based determinants of HIV and STI are integral to HIV prevention strategies.

Contraceptive practices, sexual and reproductive health needs of HIV-positive and negative female sex workers in Goa, India

Objectives In India, female sex workers (FSWs), suffer from high HIV prevalence and abortions. Contraceptive use among general population women is well understood. However, FSWs contraceptives practices and reproductive health needs are under-researched. We investigated contraceptive practices among HIV-positive and negative FSWs in Goa, India and explored its association with socio-demographic and sex work related factors. Methods Cross-sectional study using respondent driven sampling recruited 326 FSWs. They completed an interviewer-administered questionnaire and were screened for STI/HIV. Multivariable logistic regression was used to explore factors associated with sterilisation relative to no contraception. Results HIV prevalence was high (26%). Of the 59 FSWs planning pregnancy, 33% were HIV-positive and 5–7% had Gonorrhoea, Chlamydia and Trichomonas. 25% and 65% of FSWs screened-positive for Syphilis and Herpes simplex virus type 2 antibodies respectively. Among the 260 FSWs analysed for contraceptive use, 39% did not use contraceptives, and 26% had experienced abortion. Half the FSWs had undergone sterilisation, and only 5% used condoms for contraception. Among HIV-positive FSWs, 45% did not use contraceptives. Sterilisation was independently associated with older age, illiteracy, having an intimate non-paying male partner, having children and financial autonomy. Exposure to National AIDS Control Organisations HIV-prevention interventions was reported by 34% FSWs and was not significantly associated with contraceptive use (adjusted odds ratio 1.4, 95% CI 0.7 to 2.9). Conclusion HIV-prevention interventions should promote contraception, especially among young and HIV-positive FSWs. Integrating HIV treatment and care services with HIV-prevention interventions is vital to avert HIV-positive births.

Targeting commercial sex-workers in Goa, India: time for a strategic rethink?

At 0700 h June 14 2004 bulldozers shattered our dream of an evidence-based participatory intervention for HIV prevention with sex-workers in Goa India. Under the pretext of a High Court order to rehabilitate commercial sexworkers (CSWs) the government of Goa demolished the red-light area of Baina. The demolition occurred during the monsoon rains and the government provided no rehabilitation or relief for the thousands of people it rendered homeless. A day’s work demolished a decade of HIV prevention and made the newly homeless destitute women even more vulnerable to HIV. After a decade of HIV prevention efforts by non-governmental organisations (NGOs) CSWs regularly turned to peer educators and NGOs for condoms and treatment of sexually transmitted infections (STIs). The CSWs’ active participation invigorated the HIV prevention programme. (excerpt)

A Study Comparing Sexually Transmitted Infections and Hiv Among Ex-red-light District and Non-red-light District Sex Workers After the Demolition of Baina Red-light District

Objectives:In June 2004, the red-light area of Goa was demolished. We compare HIV and sexually transmitted infections (STIs) between sex workers who had been based in Baina red-light district (ex-RLD-SWs) with sex workers who had never worked in Baina (non-RLD-SWs). Methods:Three hundred twenty-six sex workers recruited using respondent-driven sampling, completed interviewer-administered questionnaires, and were tested for Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, and antibodies to HIV. The association between ever working in Baina red-light area and HIV and STIs was examined using multivariate analysis. Results:Non-RLD-SWs made up 55.3% (n = 201) of the sample, 48% of whom had entered sex work since the demolition. Non-RLD-SWs more likely to be less than 20 years old, Goan, have experienced sexual and intimate partner violence, to work part time, from home or the streets, and to have fewer clients. Ex-RLD-SWs were less likely to have curable STIs adjusted odds ratio of 0.27 (95% confidence interval: 0.10 to 0.73) and were more likely to have been exposed to HIV prevention and report consistent condom use with clients. Conclusions:Non-RLD-SWs were more likely to be engaged in high-risk sexual activity. Although partly explained by lack of exposure to HIV prevention and inconsistent condom use, social and professional isolation and greater experience of intimate partner and sexual violence may play a role.

Understanding the role of peer group membership in reducing HIV-related risk and vulnerability among female sex workers in Karnataka, India

In Karnataka state, South India, we analyzed the role of membership in peer groups in reducing HIV-related risk and vulnerability among female sex workers (FSWs). Data from three surveys conducted in Karnataka, a behavioral tracking survey and two rounds of integrated biological and behavioral assessments (IBBAs), were analyzed. Using propensity score matching, we examined the impact of group membership on selected outcomes, including condom use, experience of violence, access to entitlements, and the prevalence of sexually transmitted infections, including HIV infection. Focus group discussions were conducted with the FSWs to better understand their perceptions regarding membership in peer groups. Peer group members participating in the IBBAs had a lower prevalence of gonorrhea and/or chlamydia (5.2 vs 9.6%, p<0.001), and of syphilis (8.2 vs 10.3%, p<0.05), compared to non-members. The average treatment effect for selected outcome measures, from the propensity score matching, showed that FSWs who were members of any peer group reported significantly less experience of violence in the past six months, were less likely to have bribed police to avoid trouble in the past six months, and were more likely to have obtained at least one formal identification document in the past five years, compared to non-members. In focus group discussions, group members indicated that they had more confidence in dealing with situations of forced sex and violence. Including community mobilization and peer group formation in the context of HIV prevention programing can reduce HIV-related risk and vulnerability among FSWs.

Young people’s perceptions of smartphone-enabled self-testing and online care for sexually transmitted infections: qualitative interview study

BackgroundControl of sexually transmitted infections (STI) is a global public health priority. Despite the UK’s free, confidential sexual health clinical services, those at greatest risk of STIs, including young people, report barriers to use. These include: embarrassment regarding face-to-face consultations; the time-commitment needed to attend clinic; privacy concerns (e.g. being seen attending clinic); and issues related to confidentiality.A smartphone-enabled STI self-testing device, linked with online clinical care pathways for treatment, partner notification, and disease surveillance, is being developed by the eSTI2 consortium. It is intended to benefit public health, and could do so by increasing testing among populations which underutilise existing services and/or by enabling rapid provision of effective treatment. We explored its acceptability among potential users.MethodsIn-depth interviews were conducted in 2012 with 25 sexually-experienced 16–24 year olds, recruited from Further Education colleges in an urban, high STI prevalence area. Thematic analysis was undertaken.ResultsNine females and 16 males participated. 21 self-defined as Black; three, mixed ethnicity; and one, Muslim/Asian. 22 reported experience of STI testing, two reported previous STI diagnoses, and all had owned smartphones.Participants expressed enthusiasm about the proposed service, and suggested that they and their peers would use it and test more often if it were available. Utilizing sexual healthcare was perceived to be easier and faster with STI self-testing and online clinical care, which facilitated concealment of STI testing from peers/family, and avoided embarrassing face-to-face consultations. Despite these perceived advantages to privacy, new privacy concerns arose regarding communications technology: principally the risk inherent in having evidence of STI testing or diagnosis visible or retrievable on their phone. Some concerns arose regarding the proposed self-test’s accuracy, related to self-operation and the technology’s novelty. Several expressed anxiety around the possibility of being diagnosed and treated without any contact with healthcare professionals.ConclusionsRemote STI self-testing and online care appealed to these young people. It addressed barriers they associated with conventional STI services, thus may benefit public health through earlier detection and treatment. Our findings underpin development of online care pathways, as part of ongoing research to create this complex e-health intervention.

Systematic review and meta-analysis of L1-VLP-based human papillomavirus vaccine efficacy against anogenital pre-cancer in women with evidence of prior HPV exposure.

Background It is unclear whether L1-VLP-based human papillomavirus (HPV) vaccines are efficacious in reducing the likelihood of anogenital pre-cancer in women with evidence of prior vaccine-type HPV exposure. This study aims to determine whether the combined results of the vaccine trials published to date provide evidence of efficacy compared with control (hepatitis A vaccine/placebo). Methods A systematic review and meta-analysis was conducted. Randomized-controlled trials (RCTs) were identified from MEDLINE, Embase, Web of Science, PubMed, Cochrane Central Register of Controlled Trials and references of identified studies. The bivalent vaccine containing HPV-16 and 18 VLPs from GlaxoSmithKline Biologicals (Rixenstart, Belgium), the quadrivalent vaccine containing HPV-6, 11, 16, and 18 VLPs from Merck & Co., Inc., (Whitehouse Station, NJ USA), and the HPV-16 monovalent vaccine from Merck Research Laboratories (West Point, PA USA) were evaluated. Findings Three RCT reports and two post-trial cohort studies were eligible, comprising data from 13,482 women who were included in the vaccine studies but had evidence of HPV infection at study entry. Data on efficacy was synthesized using the Mantel-Haenszel weighted fixed-effect approach, or where there was heterogeneity between studies, the DerSimonian and Laird weighted random-effect approach. The mean odds ratio (OR) and 95% confidence interval (CI) for the association between Cervarix, Gardasil and HPV-16 monovalent vaccine and HPV-associated cervical intraepithelial neoplasia grade 3 or worse was 0·90 (95% CI: 0·56, 1·44). For the association between Gardasil and HPV-associated vulval/vaginal intraepithelial neoplasia grades 2–3, the overall OR and 95% CI was 2.25 (95% CI: 0·78, 6.50). Sample size and follow-up were limited. Conclusions There was no evidence that HPV vaccines are effective in preventing vaccine-type HPV associated pre-cancer in women with evidence of prior HPV exposure. Small effects of vaccination however cannot be excluded and a longer-term benefit in preventing re-infection remains possible.