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

ABSTRACT: BACKGROUND: Violence 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. METHODS: FSWs 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). RESULTS: 3,852 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). CONCLUSIONS: This 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

"You are wasting our drugs": health service barriers to HIV treatment for sex workers in Zimbabwe.

BACKGROUND: Although disproportionately affected by HIV, sex workers (SWs) remain neglected by efforts to expand access to antiretroviral treatment (ART). In Zimbabwe, despite the existence of well-attended services targeted to female SWs, fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. We conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition. METHODS: Three focus group discussions (FGD) were conducted in Harare with HIV-positive SWs referred from the 'Sisters with a Voice' programme to a public HIV clinic for ART eligibility screening and enrolment. Focus groups explored SWs' experiences and perceptions of seeking care, with a focus on how managing HIV interacted with challenges specific to being a sex worker. FGD transcripts were analyzed by identifying emerging and recurring themes that were specifically related to interactions with health services and how these affected decision-making around HIV treatment uptake and retention in care. RESULTS: SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs' marginalised socio-economic position. CONCLUSION: Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. Programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW

Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men

<p>Abstract</p> <p>Background</p> <p>Sex motivated by economic exchange is a public health concern as a driver of the Sub-Saharan African HIV epidemic. We describe patterns of engagement in transactional sexual relationships and sex with women in prostitution of South African men, and suggest interpretations that advance our understanding of the phenomenon.</p> <p>Methods</p> <p>Cross-sectional study with a randomly-selected sample of 1645 sexually active men aged 18–49 years who completed interviews in a household study and were asked whether they had had sex with a woman in prostitution, or had had a relationship or sex they took to be motivated by the expectation of material gain (transactional sex).</p> <p>Results</p> <p>18% of men had ever had sex with a woman in prostitution, 66% at least one type of transactional sexual relationship, only 30% of men had done neither. Most men had had a transactional relationship/sex with a main partner (58% of all men), 42% with a concurrent partner (or <it>makhwapheni</it>) and 44% with a once off partner, and there was almost no difference in reports of what was provided to women of different partner types. The majority of men distinguished the two types of sexual relationships and even among men who had once-off transactional sex and gave cash (n = 314), few (34%) reported that they had had sex with a ‘prostitute’. Transactional sex was more common among men aged 25–34 years, less educated men and low income earners rather than those with none or higher income. Having had sex with a woman in prostitution varied little between social and demographic categories, but was less common among the unwaged or very low earners.</p> <p>Conclusions</p> <p>The notion of ‘transactional sex’ developed through research with women does not translate easily to men. Many perceive expectations that they fulfil a provider role, with quid pro quo entitlement to sex. Men distinguished these circumstances of sex from having sex with a woman in prostitution. Whilst there may be similarities, when viewed relationally, these are quite distinct practices. Conflating them is sociologically inappropriate. Efforts to work with men to reduce transactional sex should focus on addressing sexual entitlement and promoting gender inequity.</p