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

Vandana Gurnani,James F Blanchard,Hl Mohan,John Anthony,Parinita Bhattacharjee,Janet Bradley,Aparajita Ramakrishnan,Tisha Wheeler,Shajy Isac,Stephen Moses,Tara Sh Beattie,Bm Ramesh

doi:10.1186/1471-2458-10-476

Abstract

BackgroundViolence 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.MethodsFSWs 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).Results3,852 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).ConclusionsThis 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.

Highlights

Violence against female sex workers (FSWs) can impede human immunodeficiency virus (HIV) prevention efforts and contravenes their human rights
Study population and experience of violence in the past year 3,852 FSWs participated in Integrated behavioural and biological assessments (IBBAs) surveys in 4 districts (1,882 FSWs at baseline and 1970 at follow-up); and 7,638 FSWs participated in 691 polling booth surveys (PBS) in 13 districts (2006: 1,659 FSWs, 176 Polling Booth Surveys (PBS); 2007: 2,865 FSWs, 255 PBS; 2008: 3,114 FSWs, 260 PBS)
Experience of violence in the past year and sociodemographic associations Socio-demographic data were collected for FSWs participating in the IBBAs only (Table 1)

Summary

Introduction

Violence against female sex workers (FSWs) can impede HIV prevention efforts and contravenes their human rights. 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. The advent of the human immunodeficiency virus (HIV) pandemic has led to increased awareness about the violence experienced by women [1,2] and by female sex workers (FSWs) worldwide [3,4]. Research on domestic violence from developing countries suggests that anywhere from 10-60% of married women of reproductive age report experiencing some form of domestic violence [2], and that domestic violence is strongly associated with physical and mental health morbidity, including homicide, suicide, physical injuries and emotional distress [5,6], as well as HIV seropositivity [1,7,8]. As well as negatively impacting on their mental health and emotional wellbeing [11,13], violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs) through multiple mechanisms: (i) coerced sex is rarely protected; (ii) coerced sex can result in injuries that can increase the transmission of STIs, which in turn can increase the risk of HIV transmission [14]; (iii) men who are sexually violent may be more likely to have multiple partners and be infected with HIV and/or STIs [8,15,16]; (iv) sex work is usually illegal, and reporting of sexual and physical violence to the authorities is difficult [3,11], meaning violence can continue unchecked; (v) the fear of violence from regular partners (husbands/lovers) resulting from inadvertent disclosure of sex work can deter sex workers from negotiating condom use with these partners and from accessing sexual health services [13,17]; and (vi) mental health morbidity arising from violence can reduce the ability of sex workers to negotiate condom use and to access STI services for testing and treatment

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Conclusion