Monica Biradavolu

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.

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.

Challenging the stigmatization of female sex workers through a community-led structural intervention: learning from a case study of a female sex worker intervention in Andhra Pradesh, India

Abstract Structural interventions represent a potentially powerful approach to HIV prevention among female sex workers (FSW) that focus on changing the social context of risk rather than individual behavior. Community-led structural interventions (CLSI) represent a particular form of structural interventions whereby the collective energy of FSW is directed toward action to address the contextual factors that promote their risk. Among these different contextual factors that may be the target of CLSI, are social norms that stigmatize FSW and their work. Drawing from ethnographic data collected as part of an ongoing analysis of the implementation and impact of a CLSI in coastal Andhra Pradesh, India, we present a case study of the challenges and opportunities faced by a CLSI seeking to confront stigmatization of FSW through its interactions with a government-sponsored AIDS education program targeted to the general public. The government program promoted slogans that stigmatized FSW by attributing HIV/AIDS to them. Through participation in the program, the CLSI was complicit in promoting this same stigmatization. Yet it also used participation in the program as an opportunity to raise awareness among FSW of the CLSI and to mobilize FSW. In addition, the CLSI organized an alternative public rally, outside of but parallel to the government program, where they reframed FSW not as the carriers of HIV but as public health workers combating it. With this case study, we suggest that CLSI for HIV prevention among FSW are implemented in a context of inequality that constrains their actions, but they can still employ strategies that have the potential to transform that context.

Structural stigma, sex work and HIV: contradictions and lessons learnt from a community-led structural intervention in southern India

Background Recent theorisation has pushed stigma research in new directions, arguing for a need to challenge the unequal power relations that impact groups most at risk for HIV-related stigma rather than locate stigma in the individual. Such a conceptualisation resonates with the growing emphasis on structural interventions for HIV prevention that attempt to alter the social context of risk. Methods The paper predominantly relies on longitudinal interviews conducted three times over a 2-year period with sex workers with varying degrees of involvement with the non-governmental organisation (NGO) and community-based organisation. Results Recognising that stigma is socially constructed and structurally reproduced, the NGO helped mobilise marginalised and hitherto scattered female sex workers to form community-based organisations to challenge their disadvantaged status in society. The authors show how stigma alleviation strategies presented a contradiction: emboldening one group of female sex workers to self-identify as sex workers while making others reluctant to access the intervention-run clinic. Conclusion The paper builds on a growing body of research that acknowledges the struggles in implementing structural interventions, particularly for NGOs working in regions with a diverse population of sex workers with varying needs. The authors argue that intervention goals of reducing stigma and increasing the use of sexually transmitted infection services do not have to conflict and, in fact, must go hand-in-hand for an implementation to be considered a structural intervention.

Migration/mobility and risk factors for HIV among female sex workers in Andhra Pradesh, India: implications for HIV prevention

We examined the relation between high mobility/migration (sex work in three or more villages/towns within the past year) and HIV risk factors among a sample of female sex workers (FSWs) in Andhra Pradesh, India. We recruited FSWs aged ≥18 years (n = 673) through respondent-driven sampling for a survey on HIV risk. Adjusted logistic and linear regression models assessed high mobility in relation to sexual and physical victimization, sexually transmitted infection (STI) symptoms and treatment, condom use and negotiation, number and/or types of sex trades, number of clients and number of days worked. Twelve percent (n = 82) of FSWs were highly mobile; those with high mobility were more likely to report recent HIV risk factors: sexual violence (adjusted odds ratio [AOR] = 5.2; 95% confidence interval [CI]: 3.0–8.9), physical violence (AOR = 1.7; 95% CI: 1.1–2.7), unprotected sex for more money (AOR = 1.7; 95% CI: 1.1–3.0), at least one STI symptom (AOR = 1.9; 95% CI: 1.1–3.1), a greater number of vaginal sex trades (β = 3.9, P = 0.003), a greater number of clients (β = 2.5, P = 0.02) and anal sex with clients (AOR = 2.4; 95% CI: 1.4–4.1). Findings from this study underscore the violence and HIV-related vulnerability faced by mobile/migrant FSWs and highlight the need to inform and tailor related prevention strategies.

Client-perpetrated and husband-perpetrated violence among female sex workers in Andhra Pradesh, India: HIV/STI risk across personal and work contexts

Objectives This study examines violence experienced in work and personal contexts and relation to HIV risk factors in these contexts among female sex workers (FSW) in Andhra Pradesh, India. Methods FSW at least 18 years of age (n=2335) were recruited through three rounds of respondent-driven sampling between 2006 and 2010 for a survey on HIV risk. Using crude and adjusted logistic regression models, any sexual/physical violence (last 6 months) perpetrated by clients and husbands were separately assessed in association with accepting more money for sex without a condom (last 30 days), consistent condom use with clients and husbands (last 30 days), and sexually transmitted infection (STI) symptoms (last 6 months). Results The mean age among participants was 32, 22% reported being currently married, and 22% and 21% reported physical/sexual violence by clients and husbands, respectively. In adjusted logistic regression models, FSW who experienced client violence were more likely to report accepting more money for unprotected sex trades (adjusted OR (AOR)=1.7; 95% CI 1.4 to 2.2), less likely to report consistent condom use with clients (AOR=0.6; 95% CI 0.5 to 0.7) and more likely to report STI symptoms (AOR=3.5; 95% CI 2.6 to 4.6). Women who reported husband violence were more likely to report accepting more money for unprotected sex trades (AOR=2.1; 95% CI 1.2 to 3.7), less likely to report consistent condom use with clients (AOR=0.5; 95% CI 0.3 to 0.8) and more likely to report STI symptoms (AOR=2.6; 95% CI 1.6 to 4.1). Conclusions Among FSW, experiences of violence in work and personal contexts are associated with sexual HIV risk behaviours with clients as well as STI symptoms.

Non-barrier contraceptive use and relation to condom use behaviour by partner type among female sex workers in Andhra Pradesh, India.

Objective The study assessed non-barrier contraceptive use among female sex workers (FSW) in Andhra Pradesh, India and relation to inconsistent condom use among commercial and non-commercial male sexual partners. Methods FSW at least 18 years of age (n=2338) were recruited through respondent-driven sampling for an HIV risk survey. Analysis was restricted to women of childbearing age (n=2197). Crude and adjusted logistic regression models were used to assess non-barrier contraceptive use and relation to inconsistent condom use with husbands or regular male partners (i.e. non-clients), regular clients and occasional clients. Results Non-barrier methods of contraception included contraceptive pills (3.8%) and sterilisation (68.4%). In logistic regression models adjusted for relevant demographics, FSW using contraceptive pills were more likely to report inconsistent condom use with a regular client (past week) [adjusted odds ratio (AOR) 2.2, 95% confidence interval (CI) 1.2–4.0] and with an occasional client (past week) (AOR 2.6, 95% CI 1.6–5.3), as well as accepting more money for sex without a condom (past 30 days) (AOR 2.5, 95% CI 1.5–4.3). No significant associations were found between pill use and inconsistent condom use among womens non-client partners, potentially related to small sample sizes within these subgroups. Reporting sterilisation, which was more common among FSW who were older in age, was not associated with inconsistent condom use with client or non-client sexual partners. Conclusions Findings document potential unmet need for modern, spacing contraceptives (i.e. pill, intrauterine device), but also indicate the importance for family planning services, particularly those promoting modern contraceptive methods to be provided alongside HIV prevention among FSW in Andhra Pradesh, India.