Community Mobilisation and Empowerment Interventions as Part of HIV Prevention for Female Sex Workers in Southern India: A Cost-Effectiveness Analysis

Abstract

BackgroundMost HIV prevention for female sex workers (FSWs) focuses on individual behaviour change involving peer educators, condom promotion and the provision of sexual health services. However, there is a growing recognition of the need to address broader societal, contextual and structural factors contributing to FSW risk behaviour. We assess the cost-effectiveness of adding community mobilisation (CM) and empowerment interventions (eg. community mobilisation, community involvement in programme management and services, violence reduction, and addressing legal policies and police practices), to core HIV prevention services delivered as part of Avahan in two districts (Bellary and Belgaum) of Karnataka state, Southern India.MethodsAn ingredients approach was used to estimate economic costs in US$ 2011 from an HIV programme perspective of CM and empowerment interventions over a seven year period (2004–2011). Incremental impact, in terms of HIV infections averted, was estimated using a two-stage process. An ‘exposure analysis’ explored whether exposure to CM was associated with FSW’s empowerment, risk behaviours and HIV/STI prevalence. Pathway analyses were then used to estimate the extent to which behaviour change may be attributable to CM and to inform a dynamic HIV transmission model.FindingsThe incremental costs of CM and empowerment were US$ 307,711 in Belgaum and US$ 592,903 in Bellary over seven years (2004–2011). Over a 7-year period (2004–2011) the mean (standard deviation, sd.) number of HIV infections averted through CM and empowerment is estimated to be 1257 (308) in Belgaum and 2775 (1260) in Bellary. This translates in a mean (sd.) incremental cost per disability adjusted life year (DALY) averted of US$ 14.12 (3.68) in Belgaum and US$ 13.48 (6.80) for Bellary - well below the World Health Organisation recommended willingness to pay threshold for India. When savings from ART are taken into account, investments in CM and empowerment are cost saving.ConclusionsOur findings suggest that CM and empowerment is, at worst, highly cost-effective and, at best, a cost-saving investment from an HIV programme perspective. CM and empowerment interventions should therefore be considered as core components of HIV prevention programmes for FSWs.

Modeling and Cost-Effectiveness in HIV Prevention

“…In India, the comprehensive Avahan program for FSWs, which includes condom distribution, peer outreach, education, and treatment of sexually transmitted infections (STIs), had a mean ICER of $46/DALY averted at an incremental cost of $785/HIV infection averted when assessed at scale in 22 districts [16]. Adding community mobilization and empowerment to the program came at an incremental cost of approximately $14/DALY averted [17]. …”

The Role of Participatory Learning and Action on Strengthening the Different Domains of Empowerment on Self-medication with Antimicrobials in Nyalenda Informal Settlement, Kisumu County, Kenya

“…This tool was developed by adopting relevant ideas from Growth and Empowerment Measure (GEM) survey [18], the Trocaire awareness index tool [19], a Community Ownership and Preparedness Index (COPI) tool [20], and a summative evaluation type tool [21]. Studies that measured the level of PLA and empowerment [22] and those based on participants perceptions and valuation using etic and emic criteria and analysis [23] were reviewed. Finally, theoretical literature on PLA and empowerment was reviewed.…”

The City of Johannesburg can end AIDS by 2030: modelling the impact of achieving the Fast‐Track targets and what it will take to get there

“…We consider the impact of the South African National Sex Worker HIV Plan 2016 to 2019 [25]. In light of the significant body of evidence demonstrating the impact of structural interventions on the health service use and uptake of biomedical services among sex workers [29,30], we would like to capture the impact of the structural elements of the package, notably the Human Rights Package (comprising law reform, decriminalization, legal literacy and legal service use), the Social Capital Building Package (comprising community empowerment, and collectivization), and the Economic Empowerment Package (comprising skill building, career-path defining, and participation in cooperatives and education interventions). Full-scale financing and implementation of these structural packages in combination with the implementation of the Health Care package is associated with outcomes of: [1] 95% condom use in FSW/client commercial acts in 2020, and [2] provision of PrEP to 3000 HIV-negative FSWs in 2016, with coverage then extended to all HIV-negative FSWs.…”