Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India.

Tara S Beattie,Parinita Bhattacharjee,Charlotte Watts,Martine Collumbien,Stephen Moses,D L Kavitha,James F Blanchard,Sapna Nair,Calum Davey,Lori Heise,T Raghavendra,Shajy Isac,Prakash Javalkar,Satyanarayana Ramanaik

doi:10.1186/s12889-016-3356-7

Abstract

BackgroundFemale sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations.MethodsSamvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these ‘intimate’ relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017.ConclusionsThis is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence.Trial registrationClinical Trials NCT02807259 Jun 24 2016 (retrospectively registered).Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3356-7) contains supplementary material, which is available to authorized users.

Highlights

Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk
In this paper we present the protocol for a cluster randomised control trial in northern Karnataka state in South India, to evaluate a multi-level intervention called Samvedana Plus which works with FSWs, intimate partners (IPs), sex worker community-based organisations (CBOs), and the wider community where FSWs and their IPs live, to reduce violence and increase consistent condom use within the intimate relationships of FSWs
Evaluation question This study aims to assess the impact of Samvedana Plus on FSW vulnerability to HIV and intimate partner violence (IPV)

Summary

Introduction

Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. The mechanisms through which violence operates to enhance vulnerability are multiple and complex, with HIV transmission risk occurring directly during coerced sex, as well as indirectly: FSWs who experience violence are less likely to visit STI/HIV clinics or use condoms, and more likely to experience condom breakage, report anal sex and have a concurrent STI infection, compared to FSWs who don’t experience violence [25,26,27,28,29,30,31,32,33,34,35] They are more likely to report mental health morbidity, including alcohol and drug use, which in turn can reduce their ability or will to negotiate condoms with their sexual partners [36,37,38,39,40,41]. In the context of female sex work, women can experience violence from a variety of perpetrators, both in their working lives (from the police, clients, pimps and street criminals) [3, 25, 45, 53,54,55], as well as in their ‘domestic’ lives from their non-paying, IPs (husband/lover) [35, 39, 56]

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