Beyond remedicalisation: a community-led PrEP demonstration project among sex workers in India

Abstract

Global health policy-makers have called for demonstration projects to better understand pre-exposure prophylaxis' (PrEP) effectiveness across geographies and populations. Ashodaya, a sex worker collective, initiated a PrEP project in Mysore, India. We conducted a project ethnography to explore the role that community participation played within the project. Although the project proved immensely successful in terms of retention and adherence, to explain these findings we point towards Ashodaya's history of collectivisation around sexual health-a history of community action that has given rise to new spaces of belonging and accumulated knowledges that became instrumental in the formulation of strategies to confront anticipated challenges during the project. These strategies included: (1) the participation of community leaders as the first participants to take PrEP, followed by the sharing of their experiences through testimonials to their peers;(2) the endorsement of PrEP among community leaders living with HIV, to avoid social divisions around HIV status; and (3) ongoing community-level support from outreach workers that went beyond administering PrEP to address the various needs of the community. These community-led approaches demonstrate that communities hold key insights into the delivery of clinicallyoriented interventions, suggesting the vital role they continue to play in planning and implementing new prevention technologies.

HIV prevention in individuals engaged in sex work

“…Nonetheless, recent additions to the arsenal of prevention technology have indeed been impressive. Although male and female condoms and lubricants remain important for sex workers, new tools and ever-increasing formulations and delivery mechanisms increase opportunities for communities to draw together optimal constellations of prevention methods for their needs [53,54 ▪ ,55 ▪▪ ]. Empowering and mobilizing communities thus set a strong foundation for operationalizing all other tools and approaches.…”

HIV awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study

“…A demonstration project among sex workers in India utilized a community-led approach and showed 97.7% (627 of 647 participants) utilization of PrEP over 15 months and no HIV seroconversions [ 16 ]. Facilitators of PrEP utilization in this study included community leaders with consistent and accurate prevention counseling, demonstration of PrEP ingestion by community leaders, and access to full resources such as condoms and a community bank for all members of the sex worker group whether or not they took PrEP [ 17 ]. In the United States, among female participants of a safe syringe program in Philadelphia who initiated PrEP, 71.6% (68 of 95 participants) engaged in transactional sex [ 18 ].…”