Parinita Bhattacharjee

Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program.

BackgroundViolence against female sex workers (FSWs) can impede HIV prevention efforts and contravenes their human rights. We developed a multi-layered violence intervention targeting policy makers, secondary stakeholders (police, lawyers, media), and primary stakeholders (FSWs), as part of wider HIV prevention programming involving >60,000 FSWs in Karnataka state. This study examined if violence against FSWs is associated with reduced condom use and increased STI/HIV risk, and if addressing violence against FSWs within a large-scale HIV prevention program can reduce levels of violence against them.MethodsFSWs were randomly selected to participate in polling booth surveys (PBS 2006-2008; short behavioural questionnaires administered anonymously) and integrated behavioural-biological assessments (IBBAs 2005-2009; administered face-to-face).Results3,852 FSWs participated in the IBBAs and 7,638 FSWs participated in the PBS. Overall, 11.0% of FSWs in the IBBAs and 26.4% of FSWs in the PBS reported being beaten or raped in the past year. FSWs who reported violence in the past year were significantly less likely to report condom use with clients (zero unprotected sex acts in previous month, 55.4% vs. 75.5%, adjusted odds ratio (AOR) 0.4, 95% confidence interval (CI) 0.3 to 0.5, p < 0.001); to have accessed the HIV intervention program (ever contacted by peer educator, 84.9% vs. 89.6%, AOR 0.7, 95% CI 0.4 to 1.0, p = 0.04); or to have ever visited the project sexual health clinic (59.0% vs. 68.1%, AOR 0.7, 95% CI 0.6 to 1.0, p = 0.02); and were significantly more likely to be infected with gonorrhea (5.0% vs. 2.6%, AOR 1.9, 95% CI 1.1 to 3.3, p = 0.02). By the follow-up surveys, significant reductions were seen in the proportions of FSWs reporting violence compared with baseline (IBBA 13.0% vs. 9.0%, AOR 0.7, 95% CI 0.5 to 0.9 p = 0.01; PBS 27.3% vs. 18.9%, crude OR 0.5, 95% CI 0.4 to 0.5, p < 0.001).ConclusionsThis program demonstrates that a structural approach to addressing violence can be effectively delivered at scale. Addressing violence against FSWs is important for the success of HIV prevention programs, and for protecting their basic human rights.

Understanding the Social and Cultural Contexts of Female Sex Workers in Karnataka, India: Implications for Prevention of HIV Infection

BACKGROUND The objective of the present study was to compare the sociodemographic characteristics and sex work patterns of women involved in the traditional Devadasi form of sex work with those of women involved in other types of sex work, in the Indian state of Karnataka. METHODS Data were gathered through in-person interviews. Sampling was stratified by district and by type of sex work. RESULTS Of 1588 female sex workers (FSWs) interviewed, 414 (26%) reported that they entered sex work through the Devadasi tradition. Devadasi FSWs were more likely than other FSWs to work in rural areas (47.3% vs. 8.9%, respectively) and to be illiterate (92.8% vs. 76.9%, respectively). Devadasi FSWs had initiated sex work at a much younger age (mean, 15.7 vs. 21.8 years), were more likely to be home based (68.6% vs. 14.9%), had more clients in the past week (average, 9.0 vs. 6.4), and were less likely to migrate for work within the state (4.6% vs. 18.6%) but more likely to have worked outside the state (19.6% vs. 13.1%). Devadasi FSWs were less likely to report client-initiated violence during the past year (13.3% vs. 35.8%) or police harassment (11.6% vs. 44.3%). CONCLUSION Differences in sociobehavioral characteristics and practice patterns between Devadasi and other FSWs necessitate different individual and structural interventions for the prevention of sexually transmitted infections, including human immunodeficiency virus infection.

Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India

Background Despite high HIV prevalence rates among most-at-risk groups, utilisation of HIV testing, treatment and care services was relatively low in Karnataka prior to 2008. The authors aimed to understand the barriers to and identify potential solutions for improving HIV service utilisation. Methods Focus group discussions were carried out among homogeneous groups of female sex workers, men who have sex with men and transgenders, and programme peer educators in six districts across Karnataka in March and April 2008. Results 26 focus group discussions were conducted, involving 302 participants. Participants had good knowledge about HIV and HIV voluntary counselling and testing (VCT) services, but awareness of other HIV services was low. The fear of the psychological impact of a positive HIV test result and the perceived repercussions of being seen accessing HIV services were key personal and interpersonal barriers to HIV service utilisation. Previous experiences of discrimination at government healthcare services, coupled with discriminatory attitudes and behaviours by VCT staff, were key structural barriers to VCT service uptake among those who had not been HIV tested. Among those who had used government-managed prevention of parent to child transmission and antiretroviral treatment services, poor physical facilities, long waiting times, lack of available treatment, the need to give bribes to receive care and discriminatory attitudes of healthcare staff presented additional structural barriers. Conclusions Embedding some HIV care services within existing programmes for vulnerable populations, as well as improving service quality at government facilities, are suggested to help overcome the multiple barriers to service utilisation. Increasing the uptake of HIV testing, treatment and care services is key to improving the quality and longevity of the lives of HIV-infected individuals.

An integrated structural intervention to reduce vulnerability to HIV and sexually transmitted infections among female sex workers in Karnataka state, south India

BackgroundStructural factors are known to affect individual risk and vulnerability to HIV. In the context of an HIV prevention programme for over 60,000 female sex workers (FSWs) in south India, we developed structural interventions involving policy makers, secondary stakeholders (police, government officials, lawyers, media) and primary stakeholders (FSWs themselves). The purpose of the interventions was to address context-specific factors (social inequity, violence and harassment, and stigma and discrimination) contributing to HIV vulnerability. We advocated with government authorities for HIV/AIDS as an economic, social and developmental issue, and solicited political leadership to embed HIV/AIDS issues throughout governmental programmes. We mobilised FSWs and appraised them of their legal rights, and worked with FSWs and people with HIV/AIDS to implement sensitization and awareness training for more than 175 government officials, 13,500 police and 950 journalists.MethodsStandardised, routine programme monitoring indicators on service provision, service uptake, and community activities were collected monthly from 18 districts in Karnataka between 2007 and 2009. Daily tracking of news articles concerning HIV/AIDS and FSWs was undertaken manually in selected districts between 2005 and 2008.ResultsThe HIV prevention programme is now operating at scale, with over 60,000 FSWs regularly contacted by peer educators, and over 17,000 FSWs accessing project services for sexually transmitted infections monthly. FSW membership in community-based organisations has increased from 8,000 to 37,000, and over 46,000 FSWs have now been referred for government-sponsored social entitlements. FSWs were supported to redress > 90% of the 4,600 reported incidents of violence and harassment reported between 2007-2009, and monitoring of news stories has shown a 50% increase in the number of positive media reports on HIV/AIDS and FSWs.ConclusionsStigma, discrimination, violence, harassment and social equity issues are critical concerns of FSWs. This report demonstrates that it is possible to address these broader structural factors as part of large-scale HIV prevention programming. Although assessing the impact of the various components of a structural intervention on reducing HIV vulnerability is difficult, addressing the broader structural factors contributing to FSW vulnerability is critical to enable these vulnerable women to become sufficiently empowered to adopt the safer sexual behaviours which are required to respond effectively to the HIV epidemic.

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.

Variability in the sexual structure in a rural Indian setting: implications for HIV prevention strategies

Objectives: To describe the sexual structure, including numbers and distribution of female sex workers (FSWs) and male sexual behaviours in the Bagalkot district of the state of Karnataka in south India. Methods: Village health workers and peer educators enumerated FSWs in each village by interviewing key informants and FSWs. Urban FSW populations were estimated using systematic interviews with key informants to identify sex work sites and then validating FSW populations at each sex work site. Male sexual behaviours were measured through confidential polling booth surveys in randomly selected villages. HIV prevalence was estimated through a community-based survey using randomised cluster sampling. Lorenz curves and Gini coefficients were used to describe the degree of clustering of FSW populations. Results: Of an estimated 7280 FSWs in Bagalkot district (17.1/1000 adult males), 87% live and work in rural areas. The relative size of the FSW population varies from 9.6 to 30.5/1000 adult males in the six subdistrict administrative areas (talukas). The FSW population was highest in the three talukas with more irrigated land and fewer and larger villages. FSW populations are highly clustered; 93 (15%) of the villages accounted for 54% of all rural FSWs. There is a high degree of FSW clustering in all talukas, and talukas with fewer and larger villages have larger clusters and more FSWs overall. General population HIV prevalence is highest in the taluka with the highest relative FSW population. Conclusions: Prevention programmes in India should be scaled up to reach FSWs in rural areas. These programmes should be focused on those districts and subdistrict areas with large concentrations of FSWs. More research is required to determine the distribution of FSWs in rural areas in other regions of India.

Violence and Hiv Risk Among Female Sex Workers in Southern India

Background This study characterized the type and frequency of violence against female sex workers (FSWs) perpetrated by their clients and their main intimate or other nonpaying partner (NPP) and examined the relationship between violence and inconsistent condom use (ICU, <100%). The factors associated with client violence were also assessed. Methods Data were analyzed from cross-sectional surveys of FSWs in Karnataka state (2007–2008), India. Multivariable logistic regression was used to assess the following: (1) relationship between client or NPP violence (physical and/or sexual) and ICU by occasional/repeat clients or the NPP and (2) relationship between social and environmental factors and client violence. Results Of 1219 FSWs, 9.6% (111) and 3.7% (42) reported experiencing violence by clients and the NPP, respectively. In multivariable analysis, after adjusting for social and environmental factors, the odds of ICU by occasional clients were significantly higher for women who had experienced client violence (adjusted odds ratio [AOR], 2.7; 95% confidence interval (CI), 1.6–4.4). Similar results were found with repeat clients (AOR, 2.2; 95% CI, 1.4–3.4). Nonpaying partner violence was not significantly associated with ICU by the NPP. In multivariable analysis, only being recently arrested remained significantly associated with experiencing client violence (AOR, 1.8; 95% CIs, 1.0–3.3). Conclusions The findings from this study provide evidence of a relationship between experiencing client violence and ICU by occasional and repeat clients, and a relationship between being arrested and client violence. Comprehensive structural/policy programming for FSWs, including within HIV-focused prevention programs, is urgently needed to help reduce FSWs’ vulnerability to violence.

Factors Associated with Sexual Violence against Men Who Have Sex with Men and Transgendered Individuals in Karnataka, India

Objectives There is a lack of information on sexual violence (SV) among men who have sex with men and transgendered individuals (MSM-T) in southern India. As SV has been associated with HIV vulnerability, this study examined health related behaviours and practices associated with SV among MSM-T. Design Data were from cross-sectional surveys from four districts in Karnataka, India. Methods Multivariable logistic regression models were constructed to examine factors related to SV. Multivariable negative binomial regression models examined the association between physician visits and SV. Results A total of 543 MSM-T were included in the study. Prevalence of SV was 18% in the past year. HIV prevalence among those reporting SV was 20%, compared to 12% among those not reporting SV (p = .104). In multivariable models, and among sex workers, those reporting SV were more likely to report anal sex with 5+ casual sex partners in the past week (AOR: 4.1; 95%CI: 1.2–14.3, p = .029). Increased physician visits among those reporting SV was reported only for those involved in sex work (ARR: 1.7; 95%CI: 1.1–2.7, p = .012). Conclusions These results demonstrate high levels of SV among MSM-T populations, highlighting the importance of integrating interventions to reduce violence as part of HIV prevention programs and health services.

Concepts and strategies for scaling up focused prevention for sex workers in India

Objectives: To describe the concepts, strategies and field results of a project to scale up prevention programmes and services for female sex workers (FSWs) in Karnataka, India. Methods: A strategy was developed to scale up urban sex worker interventions in 18 districts in the southern Indian state of Karnataka. Macro-level coverage objectives were defined by mapping the urban locations where FSWs operate and estimating their population size. Prevention programmes were initiated in the urban locations that contained at least 90% of the estimated urban FSW population in each district. Within each location, a micro-planning process was used by FSW peer educators and outreach workers to design local outreach and service delivery plans. Results: An estimated 48 973 FSWs were distributed across 1551 locations and 6232 spots. Outreach was conducted by 1043 peer educators. Services were provided through 170 drop-in centres, 93 programme-run clinics, 110 outreach clinics and 157 referral clinics. Within the first 3 years of the programme the cumulative number of individual FSWs contacted at least once was >78 000, with monthly contact established with 81% of the in situ population; >45 000 FSWs had visited a clinic and >10 000 visited monthly. Direct and indirect condom distribution by the programme amounted to more than 30 per contacted FSW, which is estimated to meet the condom requirement. Conclusions: A strategy that involves geographically defined coverage and micro-level outreach planning can rapidly and effectively provide outreach and services to large dispersed FSW populations.

The HIV prevention cascade: integrating theories of epidemiological, behavioural, and social science into programme design and monitoring

Theories of epidemiology, health behaviour, and social science have changed the understanding of HIV prevention in the past three decades. The HIV prevention cascade is emerging as a new approach to guide the design and monitoring of HIV prevention programmes in a way that integrates these multiple perspectives. This approach recognises that translating the efficacy of direct mechanisms that mediate HIV prevention (including prevention products, procedures, and risk-reduction behaviours) into population-level effects requires interventions that increase coverage. An HIV prevention cascade approach suggests that high coverage can be achieved by targeting three key components: demand-side interventions that improve risk perception and awareness and acceptability of prevention approaches; supply-side interventions that make prevention products and procedures more accessible and available; and adherence interventions that support ongoing adoption of prevention behaviours, including those that do and do not involve prevention products. Programmes need to develop delivery platforms that ensure these interventions reach target populations, to shape the policy environment so that it facilitates implementation at scale with high quality and intensity, and to monitor the programme with indicators along the cascade.