Abstract
BackgroundFemale sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.MethodsIn November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.ResultsOf 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.ConclusionsMost FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.
Highlights
Sex workers are highly vulnerable to health and social problems, including sexually-transmitted infections (STIs), unintended pregnancy, violence, exploitation, discrimination and substance abuse [1]
To assess Female sex workers (FSWs) community empowerment in African settings, this paper considers the extent to which projects undertake activities that facilitate the processes defining each stage of this framework
Conclusions there are clearly lessons to be learnt from previous experiences, there is currently insufficient evidence within the academic literature to support the scale up of any particular model of community empowerment within sexual and reproductive health (SRH) interventions in African settings
Summary
Sex workers are highly vulnerable to health and social problems, including sexually-transmitted infections (STIs), unintended pregnancy, violence, exploitation, discrimination and substance abuse [1]. In the early 1990s, the Sonagachi Project in West Bengal, India implemented one of the first developing country models of sex worker services that incorporated community and societal-level theories of change into HIV/ STI prevention interventions [13]. Other sex worker-led organisations such as Ashodaya Samithi in Mysore (hereafter ‘Ashodaya’) have integrated the Sonagachi approach into broader community-led interventions to reduce violence and the structural underpinnings of HIV vulnerability. This model has since been rolled out across six states as part of the Avahan India AIDS Initiative [14]. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation
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