Shamshad Khan

Going beyond the clinic: confronting stigma and discrimination among men who have sex with men in Mysore through community-based participatory research

Community-based participatory research (CBPR) has gained considerable popularity in recent decades given its ability to address social inequities, improve health outcomes and enhance community participation and ownership with respect to various health-related interventions. This paper describes the engagements of a community of self-identified men who have sex with men, most of whom also identified as male sex workers, in a long-term iterative and systematic process of knowledge production, reflection, and action. The project took place in 2006 in Mysore, South India, under the larger umbrella of an HIV intervention formed by the University of Manitoba and the sex workers collective known as Ashodaya Samithi, funded by the Bill & Melinda Gates Foundation (Avahan). CBPR is revealed as uniquely suited for tackling stigma and discrimination as subjects of scientific inquiry and as key methodological obstacles. As the community cultivated their own analysis around stigma, the concept became a key rallying point for increasing equity with respect to access to health services for this community. CBPR proved highly effective in mobilizing community participation and increasing access to sexual health services, over the long-term, because it was supported by and was able to feed community insights into a much larger infrastructure that sought to mobilize sexual minorities. More broadly, by highlighting various positive effects arising from CBPR, we have sought to further emphasize the greater possibilities of public health practitioners working more democratically with disenfranchised and highly stigmatized communities.

Beyond internalised stigma: daily moralities and subjectivity among self-identified kothis in Karnataka, South India.

The Bill and Melinda Gates Foundation has poured a tremendous amount of resources into epidemic prevention in Indias high HIV prevalence zones, through their Avahan initiative. These community-centred programmes operate under the assumption that fostering community-based organisational development and empowering the community to take charge of HIV prevention and education will help to transform the wider social inequalities that inhibit access to health services. Focusing on the South Indian state of Karnataka, this paper explores a troubling set of local narratives that, we contend, hold broader implications for future programme planning and implementation. Although confronting stigma and discrimination has become a hallmark in community mobilisation discourse, communities of self-identified kothis (feminine men) who were involved in Avahan programme activities continued to articulate highly negative attitudes about their own sexualities in relation to various spheres of social life. Rather than framing an understanding of these narratives in psychological terms of ‘internalized stigma’, we draw upon medical anthropological approaches to the study of stigma that emphasise how social, cultural and moral processes create stigmatising conditions in the everyday lives of people. The way stigma continues to manifest itself in the self-perceptions of participants points to an area that warrants critical public health attention.

Manufacturing Consent?: Media Messages in the Mobilization Against HIV/AIDS in India and Lessons for Health Communication

Despite repeated calls for a more critical and “culture-centered” approach to health communication, textual analysis of televised public service advertising (PSA) campaigns has been largely neglected, even by critical communication scholars. In the case of “developing” countries in particular, there is an acute shortage of such literature. On the other hand, following the outbreak of major public health diseases such as AIDS, most countries have adopted PSA campaigns as the most preferred means of communicating messages. Drawing on insights from cultural studies (especially Antonio Gramsci and Stuart Hall), this article engages in textual analysis of the televised PSA campaigns launched by the Indian state to prevent HIV/AIDS between 2002 and 2005. Through such analysis, it argues that although few diseases in Indian history have spurred such massive and creative efforts for mass mobilization as AIDS, these efforts, in terms of their ethical implications, have been far from emancipatory. In fact, they have constructed and perpetuated the logic of domination and control along class, gender, sexuality, and knowledge systems, often contradicting and potentially harming the very goal of HIV prevention and of health promotion and empowerment. This article also holds that assessing public health campaigns through textual analysis, a highly neglected tool in health communication, can shed important light on a far more complex and changing nature of the state and public policy, especially in the developing world, thereby opening up space for alternative theorizing for health communication and social change.

Dutiful daughters: HIV/AIDS, moral pragmatics, female citizenship and structural violence among Devadasis in northern Karnataka, India

ABSTRACT Decades of research have documented how sex workers worldwide, particularly female sex workers (FSWs), shoulder a disproportionate burden of the HIV epidemic. In India, although a substantial progress has been made in controlling the epidemic, its prevalence among FSWs and the Devadasis (also called traditional sex workers) in northern Karnataka is still significantly high. On the other hand, much of the HIV prevention research has focused on their mapping and size estimation, typologies, bio-behavioural surveillance, condom use and other prevention technologies. In this article, drawing on critical theoretical perspectives, secondary historical sources and in-depth interviews, we unravel wider social, cultural and political economic complexities surrounding the lives of Devadasis, and specifically illuminate the moral pragmatics that shed light on their entry into sex trade and vulnerability to HIV. Findings from this research are extremely important since while much is known about Devadasis in social sciences and humanities, relatively little is known about the complexities of their lives within public health discourses related to HIV. Our work has direct implications for ongoing HIV prevention and health promotion efforts in the region and beyond.

Contextualizing willingness to participate: recommendations for engagement, recruitment & enrolment of Kenyan MSM in future HIV prevention trials

BackgroundThe HIV epidemic among men who have sex with men (MSM) continues to expand globally. The addition of an efficacious, prophylactic vaccine to combination prevention offers immense hope, particularly in low- and middle- income countries which bear the greatest global impact. However, in these settings, there is a paucity of vaccine preparedness studies that specifically pertain to MSM. Our study is the first vaccine preparedness study among MSM and female sex workers (FSWs) in Kenya. In this paper, we explore willingness of Kenyan MSM to participate in HIV vaccine efficacy trials. In addition to individual and socio-cultural motivators and barriers that influence willingness to participate (WTP), we explore the associations or linkages that participants draw between their experiences with or knowledge of medical research both generally and within the context of HIV/AIDS, their perceptions of a future HIV vaccine and their willingness to participate in HIV vaccine trials.MethodsUsing a social network-based approach, we employed snowball sampling to recruit MSM into the study from Kisumu, Mombasa, and Nairobi. A field team consisting of seven community researchers conducted in-depth interviews with a total of 70 study participants. A coding scheme for transcribed and translated data was developed and the data was then analysed thematically.ResultsMost participants felt that an HIV vaccine would bring a number of benefits to self, as well as to MSM communities, including quelling personal fears related to HIV acquisition and reducing/eliminating stigma and discrimination shouldered by their community. Willingness to participate in HIV vaccine efficacy trials was highly motivated by various forms of altruism. Specific researcher responsibilities centred on safe-guarding the rights and well-being of participants were also found to govern WTP, as were reflections on the acceptability of a future preventive HIV vaccine.ConclusionStrategies for engagement of communities and recruitment of trial volunteers for HIV vaccine efficacy trials should not only be grounded in and informed by investigations into individual and socio-cultural factors that impact WTP, but also by explorations of participants’ existing experiences with or knowledge of medical research as well as attitudes and acceptance towards a future HIV vaccine.

‘No one was there to care for us’: Ashodaya Samithi's community-led care and support for people living with HIV in Mysore, India

ABSTRACT Under the umbrella of the Bill and Melinda Gates-funded HIV initiative in India, the Mysore-based sex workers’ (SWs) collective Ashodaya Samithi focused on improving its members’ living and working conditions through community-led structural interventions, including community mobilisation, advocacy, peer-led support, and health promotional activities. Based on four months of ethnographic fieldwork, this article examines the care and support activities of one of its sub-wings, Ashraya, which specifically focuses on people living with HIV and AIDS (PLHIV). We first discuss the stigma-related perceptions and experiences of participants in relation to health-care settings and work environment, families and communities, and within varied HIV support networks. We then explore how Ashrayas community-led interventions attempt to challenge the structural forces feeding on and creating stigma. We argue that the current policy focus on the involvement of SWs’ collectives in sexually transmitted infection (STI) prevention in India is rather limited and should be expanded along the continuum of care and support offered to PLHIV. As suggested in this paper, SWs’ organisations may have greater potential to contribute to more than STI prevention work, both within and outside their communities, than currently recognised.

Frontline Health Service Providers’ Perspectives on HIV Vaccine Trials among Female Sex Workers and Men Who Have Sex with Men in Karnataka, South India

Background Little qualitative research is available on the role of frontline health service providers (FHSPs) in the implementation of clinical trials, particularly in developing countries. This paper presents findings from a qualitative study about the perspectives of FHSPs on future HIV vaccine trials involving female sex workers (FSWs) and men who have sex with men (MSM) in three districts of Karnataka, India. In particular, we explore FHSPs’ knowledge of and views on clinical trials in general, and examine their potential willingness to play a role if such trials were introduced or implemented in the region. Methods A field team of four researchers from Karnataka—two of whom self-identified with FSW or MSM communities (“community researchers”) and two with backgrounds in social work—conducted in-depth interviews with FHSPs. Including community researchers in the study helped to build rapport with FSW and MSM participants and facilitate in-depth discussions. A coding scheme for transcribed and translated data was developed using a framework analysis approach. Data was then analysed thematically using a combination of a priori and emergent codes. Results Over half of FHSPs demonstrated limited knowledge or understanding of clinical trials. Despite reported skepticism around the testing of HIV vaccines in developing countries and concerns around potential side effects, most FHSPs strongly advocated for the implementation of HIV vaccine clinical trials in Karnataka. Further, most FHSPs expressed their willingness to be involved in future HIV vaccine clinical trials in varying capacities. Conclusion Given that FHSPs are often directly involved in the promotion of health and well-being of FSWs and MSM, they are well-positioned to play leadership, ethical, and communicative roles in future HIV vaccine trials. However, our findings reveal a lack of awareness of clinical trials among FHSP participants, suggesting an important area for capacity building and staff development before viable and ethical clinical trials can be set up in the region.

Ecologies of security: On the everyday security tactics of female sex workers in Nairobi, Kenya

ABSTRACT This paper highlights important environmental dimensions of HIV vulnerability by describing how the sex trade operates in Nairobi, Kenya. Although sex workers there encounter various forms of violence and harassment, as do sex workers globally, we highlight how they do not merely fall victim to a set of environmental risks but also act upon their social environment, thereby remaking it, as they strive to protect their health and financial interests. In so doing, we illustrate the mutual constitution of ‘agency’ and ‘structure’ in social network formations that take shape in everyday lived spaces. Our findings point to the need to expand the focus of interventions to consider local ecologies of security in order to place the local knowledges, tactics, and capacities that communities might already possess on centre stage in interventions. Planning, implementing, and monitoring interventions with a consideration of these ecologies would tie interventions not only to the risk reduction goals of global public health policy, but also to the very real and grounded financial priorities of what it means to try to safely earn a living through sex work.

Intervening in masculinity: work, relationships and violence among the intimate partners of female sex workers in South India

Abstract Although health researchers have begun to examine the forms of violence and power dynamics that play out in the intimate relationships of female sex workers (FSWs) in India, this knowledge has tended to focus on the perspectives of women, leaving men’s motivations and attitudes relatively unexamined. This paper examines the contours of masculinity and gender norms from the perspective of the intimate partners of FSWs. Based on six months of ethnographic research in Northern Karnataka, the study employed two focus group discussions (FGDs) with Devadasi FSWs (N = 17), as well as four FGDs (N = 34) and 30 in-depth interviews with their intimate partners. Given the precarious labour conditions in this region, tensions developed in the participants’ relationships with FSWs, as these men were unable to meet local ideals of manhood. Violence became a way that men attempted to re-secure a sense of control in their relationships with women, and to fulfil fantasies of male power. We recommend that programs engaging men not only address intimate partner violence but also attend to the social and structural realities surrounding these men’s daily lived experiences.

O13.4 An Ethnographic Mapping Study of “Money Boys” and the Male Sex Trade Industry in Chengdu, South West China

Background HIV prevalence studies have found that male sex workers (MSWs) in China have high HIV prevalence, ranging from 5% to 9%. These “money boys” have been identified as a particularly vulnerable population, and it is imperative to develop effective programmes for HIV prevention in this population. Objectives The study had 4 objectives: (1) to describe the operation of the male sex work industry; (2) to identify the environmental and structural factors that shape the risk practises of MSWs (3) to map solicitation venues and estimate the size of the MSW population to guide programme design and focus. Method Ethnographic and geo-mapping techniques were combined to locate, enumerate and contextualise different aspects of the male sex trade industry. MSWs, network operators and brothel owners provided size estimates of MSWs for specific hotspots. Participant observation and key informant interviews were employed to understand the risk practises described by participants. Results According to the ethnographic findings, MSWs are often recruited from rural villages via labour markets and from the urban gay community; they had high client volumes and were mobile within the city and between cities throughout China. Thirty MSW venues were mapped and 23 venues were validated. Systematic review and validation of gay websites revealed 48 brothels. Local prevention programmes reached only 16 venues. Five public toilets, 4 bathhouses and 7 parks, where MSWs frequented, were also mapped. The majority of venues were located within the commercial core, with easy access to public transportation. The MSW population was estimated between 373 and 1200. Some MSWs (n = 97) advertised on gay websites and through cell phone applications. Conclusion Despite criminalization, there is a thriving male sex trade in Chengdu. Local efforts to reach these communities need to be scaled up to address programme coverage gaps.