Psychological Fears among Low-Paid Female Sex Workers in Southwest China and Their Implications for HIV Prevention

Commercial sex plays a critical role in rapidly increasing heterosexual transmission of HIV in China. Low-paid female sex workers (FSWs) are especially vulnerable to HIV/AIDS. Because of the illegality and stigma associated with sex work, FSWs may constantly live with fears in their daily life. Based on cross-sectional study of 794 low-paid FSWs in China we described their psychological fears related to commercial sex and examined the associations between fears and HIV-related behaviors. Fear of HIV infection was significantly associated with consistent use of condoms with clients. However, fear of breaching sex worker identity significantly prevented the FSWs from consistently using condoms with clients and taking HIV tests. Fear of being arrested by the police was positively associated with consistent use of condoms but negatively associated with accessing HIV prevention services. Our findings underlined the importance of examining the triadic interaction of behavioral, psychological and environmental factors in HIV prevention interventions among low-paid FSWs.     

Peer Outreach Work as Economic Activity: Implications for HIV Prevention Interventions among Female Sex Workers

Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers’ economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers’ relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.     

HIV Pre-Exposure Prophylaxis Interest among Female Sex Workers in Guangxi,China

Objectives

Acceptability of pre-exposure prophylaxis (PrEP) and willingness to participate in a clinical trial for both safety and efficacy of PrEP were investigated among female sex workers (FSWs) in Guangxi, China.

Methods

A cross-sectional study was performed in three cities in Guangxi. Structured, self-administered questionnaires were used to assess the acceptability of PrEP and the willingness to participate in a clinical trial. Multivariable logistic regression models were fitted to identify predictors.

Results

Among 405 participants, 15.1% had heard of PrEP. If PrEP was deemed to be effective, safe and provided for free, 85.9% reported that they would accept it, and 54.3% of those who accepted PrEP said that they would participate in a clinical trial. The increased acceptability of PrEP was associated with working in male dominated venues, higher income, a poor family relationship, better HIV/AIDS knowledge, not realizing HIV risk from unfamiliar clients, not being forced to use condoms by the gatekeepers, consistent use of condoms, and use of drugs to prevent STD infection. The increased willingness to participate in a clinical trial was associated with a poor family relationship, better HIV/AIDS knowledge, not realizing HIV risk from unfamiliar clients, a willingness to adhere to daily PreP use, and not being concerned about discrimination by others. The main reason for rejecting PrEP or participating in a clinical trial was the concern about the side effects of PrEP.

Conclusions

Acceptability of PrEP among Guangxi FSWs is relatively high, indicating that PrEP intervention programs may be feasible for Chinese FSWs. Given the fact that most of the participants had never heard of PrEP before, and that family, gatekeepers, and social discrimination could significantly affect its acceptability, a comprehensive mix of multiple interventions is necessary for the successful implementation of a PrEP program among this population in Guangxi.     

Factors Associated with Risky Sexual Practices among Female Sex Workers in Karnataka,India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs'' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.     

Engagement with HIV Prevention Treatment and Care among Female Sex Workers in Zimbabwe: a Respondent Driven Sampling Survey

Objective(S)

To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare.

Design

Respondent driven sampling (RDS) surveys conducted at each site.

Methods

Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method.

Results

870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment.

Conclusions

This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region.     

Social Cohesion,Social Participation,and HIV Related Risk among Female Sex Workers in Swaziland

Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR]  = 2.25, 95% confidence interval [CI]: 1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.     

Community Mobilisation and Empowerment Interventions as Part of HIV Prevention for Female Sex Workers in Southern India: A Cost-Effectiveness Analysis

Background

Most HIV prevention for female sex workers (FSWs) focuses on individual behaviour change involving peer educators, condom promotion and the provision of sexual health services. However, there is a growing recognition of the need to address broader societal, contextual and structural factors contributing to FSW risk behaviour. We assess the cost-effectiveness of adding community mobilisation (CM) and empowerment interventions (eg. community mobilisation, community involvement in programme management and services, violence reduction, and addressing legal policies and police practices), to core HIV prevention services delivered as part of Avahan in two districts (Bellary and Belgaum) of Karnataka state, Southern India.

Methods

An ingredients approach was used to estimate economic costs in US$ 2011 from an HIV programme perspective of CM and empowerment interventions over a seven year period (2004–2011). Incremental impact, in terms of HIV infections averted, was estimated using a two-stage process. An ‘exposure analysis’ explored whether exposure to CM was associated with FSW’s empowerment, risk behaviours and HIV/STI prevalence. Pathway analyses were then used to estimate the extent to which behaviour change may be attributable to CM and to inform a dynamic HIV transmission model.

Findings

The incremental costs of CM and empowerment were US$ 307,711 in Belgaum and US$ 592,903 in Bellary over seven years (2004–2011). Over a 7-year period (2004–2011) the mean (standard deviation, sd.) number of HIV infections averted through CM and empowerment is estimated to be 1257 (308) in Belgaum and 2775 (1260) in Bellary. This translates in a mean (sd.) incremental cost per disability adjusted life year (DALY) averted of US$ 14.12 (3.68) in Belgaum and US$ 13.48 (6.80) for Bellary - well below the World Health Organisation recommended willingness to pay threshold for India. When savings from ART are taken into account, investments in CM and empowerment are cost saving.

Conclusions

Our findings suggest that CM and empowerment is, at worst, highly cost-effective and, at best, a cost-saving investment from an HIV programme perspective. CM and empowerment interventions should therefore be considered as core components of HIV prevention programmes for FSWs.     

Partner Violence and Psychosocial Distress among Female Sex Workers in China

Background

Despite recognized vulnerability of female sex workers (FSW), most data on this population are focused on their HIV and STI prevalence; studies on their experience of partner violence and psychosocial distress are limited, especially FSW in China.

Methods and Findings

A cross-sectional survey was administered among 1,022 FSW recruited from 9 different types of commercial sex venues in Southwest China. Partner violence scales were adapted from WHO''s Women''s Health and Domestic Violence scale and psychosocial distress was measured by five indicators, including alcohol intoxication, drug use, suicidal behavior, depression, and loneliness. Random effects modeling was used to control for cluster effects. Findings: About 58% of FSW ever experienced violence from their stable partners, and 45% suffered it from their clients. Partner violence was strongly associated with each of the five measures of psychosocial distress, even after controlling for potential confounders.

Conclusion

This study is one of the first to examine the association between partner violence and psychosocial distress among FSW in China. The high prevalence of violence experience and distress in this population suggests urgency for intervention. The public health programs targeting FSW should go beyond the focus on HIV/STI prevention and care for the fundamental health and human rights of millions of FSW in China.     

Scale-Up,Retention and HIV/STI Prevalence Trends among Female Sex Workers Attending VICITS Clinics in Guatemala

Background

Since 2007, Guatemala integrated STI clinical service with an HIV prevention model into four existing public health clinics to prevent HIV infection, known as the VICITS strategy. We present the first assessment of VICITS scale-up, retention, HIV and STI prevalence trends, and risk factors associated with HIV infection among Female Sex Workers (FSW) attending VICITS clinics in Guatemala.

Methods

Demographic, behavioral and clinical data were collected using a standardized form. Data was analyzed by year and health center. HIV and STI prevalence were estimated from routine visits. Retention was estimated as the percent of new users attending VICITS clinics who returned for at least one follow-up visit to any VICITS clinic within 12 months. Separate multivariate logistic regression models were conducted to investigate factors associated with HIV infection and program retention.

Results

During 2007–2011 5,682 FSW visited a VICITS clinic for the first-time. HIV prevalence varied from 0.4% to 5.8%, and chlamydia prevalence from 0% to 14.3%, across sites. Attending the Puerto Barrios clinic, having a current syphilis infection, working primarily on the street, and using the telephone or internet to contact clients were associated with HIV infection. The number of FSW accessing VICITS annually increased from 556 to 2,557 (361%) during the period. In 2011 retention varied across locations from 7.7% to 42.7%. Factors negatively impacting retention included current HIV diagnosis, having practiced sex work in another country, being born in Honduras, and attending Marco Antonio Foundation or Quetzaltenango clinic sites. Systematic time trends did not emerge, however 2008 and 2010 were characterized by reduced retention.

Conclusions

Our data show local differences in HIV prevalence and clinic attendance that can be used to prioritize prevention activities targeting FSW in Guatemala. VICITS achieved rapid scale-up; however, a better understanding of the causes of low return rates is urgently needed.     

Non-Cationic Proteins Are Associated with HIV Neutralizing Activity in Genital Secretions of Female Sex Workers

ObjectiveCationic proteins found in cervicovaginal secretions (CVS) are known to contribute to the early antiviral immune response against HIV-infection in vitro. We here aimed to define additional antiviral factors that are over-expressed in CVS from female sex workers at high risk of infection.MethodsCVS were collected from Kenyan HIV-seronegative (n = 34) and HIV-seropositive (n = 12) female sex workers, and were compared with those from HIV-seronegative low-risk women (n = 12). The highly exposed seronegative (HESN) sex workers were further divided into those with less (n = 22) or more (n = 12) than three years of documented sex work. Cationic protein-depleted CVS were assessed for HIV-neutralizing activity by a PBMC-based HIV-neutralizing assay, and then characterized by proteomics.ResultsHIV neutralizing activity was detected in all unprocessed CVS, however only CVS from the female sex worker groups maintained its HIV neutralizing activity after cationic protein-depletion. Differentially abundant proteins were identified in the cationic protein-depleted secretions including 26, 42, and 11 in the HESN>3yr, HESN<3yr, and HIV-positive groups, respectively. Gene ontology placed these proteins into functional categories including proteolysis, oxidation-reduction, and epidermal development. The proteins identified in this study include proteins previously associated with the HESN phenotype in other cohorts as well as novel proteins not yet associated with anti-HIV activities.ConclusionWhile cationic proteins appear to contribute to the majority of the intrinsic HIV neutralizing activity in the CVS of low-risk women, a broader range of non-cationic proteins were associated with HIV neutralizing activity in HESN and HIV-positive female sex workers. These results indicate that novel protein factors found in CVS of women with high-risk sexual practices may have inherent antiviral activity, or are involved in other aspects of anti-HIV host defense, and warrant further exploration into their mode of action.     

HIV Infection,Risk Factors,and Preventive Services Utilization among Female Sex Workers in the Mekong Delta Region of Vietnam

Background

Risk behaviors among female sex workers (FSW) are considerable drivers of HIV infections in Vietnam, especially transmission between high-risk and low-risk groups. We assessed HIV prevalence and its correlates among FSWs, and the use of preventive services among this community in the Mekong Delta region, southern Vietnam.

Methods

A cross-sectional survey of 1,999 FSWs was carried out in five provinces including Ben Tre, Hau Giang, Kien Giang, Tien Giang, and Vinh Long between June, 2006 and June, 2007. We interviewed participants face-to-face in order to elicit information about their lives and potential risk factors, and we tested their sera to determine their HIV status. We then performed multivariate logistic regression analyses to investigate factors associated with HIV infection.

Results

Seventeen percent of the participating FSWs were street-based sex workers (SSWs) and the rest (83%) were entertainment establishment-based sex workers (ESWs). Unprotected sex with regular and casual clients in the past month was frequent among study participants (40.5% and 33.5% respectively). However, few respondents (1.3%) had ever injected drugs. Only 2.1% (95% confidence interval (CI): 1.6%–2.8%) of FSWs were found to be infected with HIV. HIV prevalence among SSWs was greater than among ESWs (3.8% vs. 1.8%, p = 0.02, respectively). Increased risk for HIV infection was significantly associated with the number of clients per month (adjusted odd ratio (aOR) = 2.65, 95% CI: 1.26–5.59).

Conclusions

Interventions to reduce unsafe sex and drug injection, and to increase uptake of HIV testing among FSWs are necessary. Differences in HIV prevalence and its correlates by type of sex work emphasize the importance of constrained contexts in shaping risk behaviors among FSWs; that should be considered in designing HIV prevention programs.     

A Qualitative Exploration of Barriers to Condom Use among Female Sex Workers in China

Background

Sex workers in China continue to engage in unprotected sex acts that put them at risk for contracting HIV (Human Immunodeficiency Virus) and other STIs (Sexually Transmitted Infections). The purpose of this study was to explore women’s work history, the context of sex work, condom use, HIV testing services, and potential barriers to condom use in a sample of FSWs (female sex workers) in Guangzhou, China.

Methodology/Principal Findings

In-depth, semi-structured, face-to-face interviews were conducted with 24 FSWs in Guangzhou, China. Informants were recruited using a purposive sampling technique. Qualitative data were coded and analyzed using NVivo 8.0. The majority of respondents were internal economic migrants who had entered the sex industry in pursuit of greater financial reward. Most women in the study were married or had steady boyfriends, and were young, with secondary education and limited knowledge about HIV and STIs. Most were not satisfied with their current living conditions and expressed a desire to leave the sex industry. Women reported that they were more likely to use condoms during sex acts with commercial partners than with non-commercial partners. The potential stigma of being seen as a sex worker prevented many from accessing HIV testing. Three key factors put these FSWs at risk for HIV and STIs: unreasonable trust toward clients, stereotypes and assumptions about customers, and financial incentives.

Conclusions/Significance

These findings suggest that social and economic factors play an important role in shaping sexual decision-making among female sex workers in Guangzhou. We argue that greater insight into and attention to these factors could enhance the success of HIV prevention efforts.     

Determinants of Heterosexual Adolescents Having Sex with Female Sex Workers in Singapore

Objectives

We assessed the proportion of and socio-ecological factors associated with ever having had sex with female sex workers (FSWs) among heterosexual adolescents. We also described the characteristics of the adolescents who reported inconsistent condom use with FSWs.

Methods

This is a cross-sectional study (response rate: 73%) of 300 heterosexually active male adolescents of 16 to 19 years attending a national STI clinic in Singapore between 2009 and 2014. We assessed the ecological factors (individual, parental, peer, school and medial influences) and sexual risk behaviors using a self-reported questionnaire. Poisson regression was used to obtain the adjusted prevalence ratios (aPR) and confidence intervals (CI).

Results

The proportion of heterosexual male adolescents who had ever had sex with FSWs was 39%. Multivariate analysis showed that significant factors associated with ever having had sex with FSWs were sex initiation before 16 years old (aPR 1.79 CI: 1.30–2.46), never had a sexually active girlfriend (aPR 1.75 CI 1.28–2.38), reported lower self-esteem score (aPR 0.96 CI: 0.93–0.98), higher rebelliousness score (aPR 1.03 CI: 1.00–1.07) and more frequent viewing of pornography (aPR 1.47 CI: 1.04–2.09). Lifetime inconsistent condom use with FSWs was 30%.

Conclusions

A significant proportion of heterosexual male adolescents attending the public STI clinic had ever had sex with FSWs. A targeted intervention that addresses different levels of influence to this behavior is needed. This is even more so because a considerable proportion of adolescents reported inconsistent condom use with FSWs, who may serve as a bridge of STI transmission to the community. National surveys on adolescent health should include the assessment of frequency of commercial sex visits and condom use with FSWs for long-term monitoring and surveillance.     

The Impact of Syphilis Screening among Female Sex Workers in China: A Modelling Study

Background

In China, female sex workers (FSWs) are at high risk of syphilis infection, but are hard to reach for interventions. Point-of-care testing introduces opportunities for expanding syphilis control measures. Modelling is used to estimate the impact of using rapid tests to screen FSWs for syphilis. In other settings, modelling has predicted large rebounds in infectious syphilis following screening, which may undermine any impact achieved.

Methods

A deterministic syphilis transmission model among FSWs and clients was fitted to data from Yunnan Province (FSW syphilis prevalence = 7.5%), and used to estimate the impact of rapid syphilis testing and treatment for FSWs. Impact projections were compared for different model structures that included risk heterogeneity amongst FSWs, incoming syphilis infections amongst new FSWs and clients and re-infection from FSWs'' regular non-commercial partners. The rebound in syphilis prevalence after screening ceased was explored.

Results

All model structures suggest yearly syphilis screening could substantially reduce (by 72–88%) syphilis prevalence amongst FSWs in this setting over five years. However, incoming syphilis infections amongst new FSWs and clients or re-infections from regular non-commercial partners of FSWs can considerably reduce (>30%) the proportion of infections averted. Including heterogeneity in risk amongst FSWs had little effect upon the proportion of infections averted. In this setting, the rebound in syphilis prevalence after screening ceased is predicted to be slight, but it could be large in high prevalence settings.

Conclusions

Rapid test screening could dramatically reduce syphilis prevalence amongst hard-to-reach groups, but strategies to reduce re-infection from regular non-commercial partners are needed to maximise impact.     

Filling the Knowledge Gap: Measuring HIV Prevalence and Risk Factors among Men Who Have Sex with Men and Female Sex Workers in Tripoli,Libya

Background

Publications on Libya’s HIV epidemic mostly examined the victims of the tragic nosocomial HIV outbreak in the 1990s and the related dispute about the detention of foreign medical workers. The dispute resolution in 2003 included an agreement with the European Union on humanitarian cooperation and the development of Libya’s first National HIV Strategy. As part of this we conducted Libya’s first bio-behavioural survey among men having sex with men (MSM) and female sex workers (FSW).

Methods

Using respondent-driven sampling, we conducted a cross-sectional study to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and related risk factors among 227 MSM and 69 FSW in Tripoli (FSW recruitment ended prematurely due to the political events in 2011).

Results

For MSM we estimated an HIV prevalence of 3.1%, HBV prevalence of 2.9%, and HCV prevalence of 7.3%, and for FSW an HIV prevalence of 15.7%, HBV prevalence of 0%, and HCV prevalence of 5.2%. We detected high levels of risk behaviours, poor HIV-related knowledge, high stigma and lack of prevention programmes. These results must be interpreted in the context of the political situation which prohibited reaching an ideal sample size for FSW.

Conclusion

There is urgent need to implement an effective National HIV Strategy informed by the results of this research. The risk of transmission within different risk groups and to the general population may be high given the recent military events that led to increased violence, migration, and the disruption of essential HIV-related services.     

Risk Behaviours among Female Sex Workers in China: A Systematic Review and Data Synthesis

Background

Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW.

Method

Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman''s rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews.

Results

A total of 583 articles (44 English, 539 Chinese) investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%.

Conclusion

During the first decade of 2000, Chinese FSWs’ self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs.     

HIV Risk Perception and Behavior among Sex Workers in Three Major Urban Centers of Mozambique

HIV risk perceptions and behaviors of 236 commercial sex workers from three major Mozambican urban centers were studied using the International Rapid Assessment, Response and Evaluation (I-RARE) methodology. All were offered HIV testing and, in Maputo, syphilis testing was offered as well. Sixty-three of the 236 opted for HIV testing, with 30 (48%) testing positive for HIV. In Maputo, all 30 receiving HIV tests also had syphilis testing, with 6 (20%) found to be positive. Results include interview excerpts and qualitative results using I-RARE methodology and AnSWR-assisted analyses of the interviews and focus group sessions.     

Role of Community Group Exposure in Reducing Sexually Transmitted Infection-Related Risk among Female Sex Workers in India

Background

Empowering female sex workers (FSWs) to address structural barriers and forming community groups (CGs) through community mobilization are seen as essential components of HIV prevention programs in India. Taking the membership of a CG as an exposure intervention, we hypothesized whether participation in a CG lead to reduced sexually transmitted infections (STIs) and increased treatment-seeking behavior among FSWs in three selected states of India — Andhra Pradesh, Maharashtra and Tamil Nadu.

Methods and Findings

The propensity score matching (PSM) approach examined the effect of CG membership, as against no membership, on STI-related risk, described as selected outcome measures — presence of any STI, self-reported STI symptoms, and treatment-seeking behavior among FSWs. A cross sectional bio-behavioral survey was administered in 2009–2010 and covered 7,806 FSWs through two-stage probability-based conventional and time location cluster sampling in 23 administrative districts of Andhra Pradesh, Maharashtra and Tamil Nadu. Only 2,939 FSWs were reported to be members of a CG and among them 4.5% had any STIs. A majority of FSWs were aged above 24 years (86.4%), had ever been married (73%), operated from a public place for solicitation (81.5%), and had ever received HIV test results (75.6%). The average effect of CG exposure was reduction in STI prevalence by 4%, while self-reported STI symptom treatment-seeking behavior increased by 13.7%.

Conclusion

FSWs who were exposed to a CG were at a substantially lower risk of STIs than those who were unexposed. The FSWs exposed to a CG had a higher chance of seeking STI treatment from public and private health facilities. Collectivization related challenges must be overcome to provide access to tailored STI prevention and care services.