Addressing vulnerabilities of female sex workers in an HIV prevention intervention in Mumbai and Thane: experiences from the Aastha project

Abstract

BackgroundIt is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility, and literacy, for effective human immunodeficiency virus (HIV) prevention. This paper describes and examines the association of the Aastha HIV/sexually transmitted infection (STI) prevention project in Mumbai and Thane, India, on the relationship between vulnerability and behavioral outcomes.Materials and methodsData were drawn from the Behavioural Tracking Survey, a cross-sectional behavioral study conducted in 2010 with 2,431 FSWs recruited in Mumbai and Thane. The key independent measures used were program exposure and “vulnerability index”, a composite index of literacy, factors of dependence (alternative livelihood options, current debt, and children), and aspects of sex work (mobility and duration in sex work). Dependent measures included service uptake, self-confidence, self-identity, and individual agency. Logistic regression analysis was used to examine the study objectives.ResultsOf the analytical sample of 2,431 FSWs, 1,295 (53.3%) were categorized as highly vulnerable. Highly vulnerable FSWs who were associated with the Aastha program for more than a year were more likely to have accessed crisis-response services in the past 6 months (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.4–3.6; P<0.001), to have visited a clinic to get a checkup for STI symptoms (AOR 2.4, 95% CI 1.2–4.8; P<0.015), not to be ashamed to disclose identity as an FSW to health workers (AOR 2.1, 95% CI 1.2–3.5; P<0.008), and to be confident in supporting a fellow FSW in crisis (AOR 1.7, 95% CI 1.0–2.8, P<0.033) compared to those less vulnerable with similar exposure to the Aastha program.ConclusionIt is critical for HIV/STI interventions to consider vulnerabilities of FSWs at project inception and address them with focused strategies, including a segmented service-delivery model and community involvement, in order to strengthen the structural response to HIV prevention.

Measuring vulnerability among female sex workers in India using a multidimensional framework

“…Moreover, it indicates that reducing vulnerabilities among FSWs would eventually contribute to a reduction in their risk-taking behavior. This is in-line with the past research in India which suggests that addressing vulnerabilities among sex workers could lead to increase in their safe sex behaviors [ 4 , 6 , 7 , 10 , 24 , 25 ]. While sex workers enter into sex work due to increasing financial burden, trafficking and coercion, their vulnerabilities increase after getting into sex work due to the non-conducive policies and institutional arrangements.…”

“…FSWs in India face multiple vulnerabilities by the nature of their profession; hence, identification and measurement of vulnerability in a robust way is necessary for reaching the vulnerable population. As the extent and nature of vulnerabilities vary considerably depending on the definition, measurement approaches and interpretation [ 7 ], it can be perplexing at-times to stakeholders and implementers. In this context, this study suggests a more comprehensive way of measuring vulnerability among FSWs by adopting an approach used mostly to measure poverty.…”

“…The study also found a negative relationship between vulnerability and STI check-up and HIV testing which is contradicting the earlier study in Mumbai, India which suggested that high vulnerability of FSWs (though measured differently than this study) linked to higher service uptake. The difference can be due to the fact the earlier study was conducted among individuals who were part of the targeted HIV prevention intervention and the intervention prioritized providing services to the highly vulnerable ones [ 7 ]. Therefore, the earlier study showed a positive relationship between vulnerability and service uptake.…”

“…Vulnerability among female sex workers (FSWs) is a widely researched area [ 1 – 5 ]; however, the definition and use of the term “vulnerability” vary considerably with a clear agreement that HIV vulnerability is different from HIV risk [ 6 , 7 ]. While HIV risk refers to behaviors or situations that directly increase the probability of HIV transmission, HIV vulnerability refers to the context governing individual’s ability to prevent oneself from getting HIV infection [ 7 ]. These vulnerabilities can be in various forms ranging from personal attributes to financial, environmental and cultural norms including stigma and discrimination at various levels.…”

“…Vulnerability measurement revolves around two frameworks: unidimensional and multidimensional. A review of existing literature suggests that most researchers have adopted a unidimensional framework to identify vulnerability [ 7 , 12 – 14 ]. Only two Indian studies have considered the multi-dimensional nature of vulnerability by creating a composite index of vulnerability.…”