Abstract
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.
Highlights
While 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
In Solapur there was the most brothel-based and other more transient forms of sex work (p < .001), highest proportion (60% vs. less than 10% in other districts) of client volume more than 10 per week (p < .001), and greatest proportion of women to report having more than 10 sex partners per week (68% versus less than 10% in other districts, p < .001)
Our analysis of a large and representative survey of female sex workers in south India suggests that there are associations between community mobilization, reported levels of individual and collective empowerment, and improved health and social outcomes. These findings provide further evidence to support the hypothesis that community mobilization strategies promote social transformation and HIV risk reduction through the empowerment of FSWs
Summary
While 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. There are an estimated two and half million people living with HIV in India who will require lifelong treatment with antiretroviral therapy (ART) This large burden of infection makes tackling the HIV epidemic in India a health priority. There have been successful examples of community mobilization and empowerment of FSWs, in the Indian context, there remains considerable uncertainty around the mechanism through which community mobilization may impact upon FSWs’ HIV risk [8,14,16,17,18] This creates barriers to replication of successful interventions, and makes it difficult to monitor and evaluate the impact of community mobilization over time
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