Delivering community-led integrated HIV and sexual and reproductive health services for sex workers: A mixed methods evaluation of the DIFFER study in Mysore, South India

Abstract

Introduction Women in developing countries continue to face barriers to accessing sexual and reproductive health (SRH) services, with marginalized women facing increased challenges to accessing care. The Diagonal Interventions to Fast-Forward Enhanced Reproductive Health (DIFFER) project implemented a package of interventions for female sex workers and women from the general population which integrated horizontal health services for the general population with existing vertical targeted interventions aimed at sex workers with an aim to improve SRH and HIV services. We present an outcome evaluation of the DIFFER project in terms of uptake rates for SRH services among sex workers in Mysore, India. Methods Ashodaya Samithi, a sex worker-led organization, implemented the DIFFER strategy through their community-based clinic and a Well Women Clinic (WWC), established at a partner private hospital that provided SRH services for women living with HIV. Mixed methods were used to evaluate the intervention that included a baseline (2012–13) and end of project (2015–16) cross sectional surveys (CSS), focus group discussions (FGDs), key informant interviews, and analysis of service statistics from 2013–2016. Results The CSS found that condom use, STI testing, and treatment were high before, and throughout the intervention; cervical cancer screening and treatment increased significantly, from 11.5% to 56% (aOR 9.85, p<0.001) and HIV testing in the last 3 months increased from 26.3% to 73.3% (aOR 7.25, p<0.001). The proportion of sex workers using any SRH service in the past year doubled from 25.7% to 51.4% (aOR 2.91, p<0.001). Service statistics showed similar trends. The FGDs and key informant interviews showed that women and stakeholders held high levels of satisfaction with the strategy, and affirmed potential for scale up. Conclusion The DIFFER strategy demonstrated that SRH service uptake can occur in conjuction with HIV services offered to sex workers. This model of integrated service delivery has been accepted by policy makers and needs further analysis for scaling up.

Integrating services to improve quality of care for women living with HIV: A global systematic review

“…Reza‐Paul et al, in their study analysing the impact of integrating services for FSWs with HIV in India, measured the rate of contraception use after integration. Although there was already a high rate of contraception use at baseline (98%), by the end of the study they noted an increase in hormonal contraception methods (0.6–11%, p = 0.003) [10].…”

“…Reza‐Pual et al’s ‘well woman clinic’ in India found a significant increase in cervical cytology and treatment after integrating services into their HIV clinic for FSWs (11.5–56%, p < 0.001) [10]. Two audits from the UK showed increased rates of cervical smears among women with HIV after integration of services [11,12].…”

“…Two papers measured the impact of integration on prevention. In both cases the studies sought to measure if there was any impact on the rate of unwanted pregnancies; neither study found a statistically significant difference, but in both cases, this was not the primary outcome measure of the study [10,19].…”

Current allocations and target apportionment for HIV testing and treatment services for marginalized populations: characterizing PEPFAR investment and strategy

“…PEPFAR recognized the need to increase focus on KPs when it launched the Key Populations Investment Fund (KPIF) in 2016 [9]. The KPIF is a US$100 million additional investment into KP‐specific programmes meant to close some of the persistent gaps in access to services and follow the evidence that KP‐led organizations are critical partners [10‐12].…”

The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore, India

“…However, condom use continues to remain low with regular partners, such as husbands and boyfriends (Deering et al, 2011;Fehrenbacher et al, 2018;Isac et al, 2017). The results from various surveys in Mysore show that while reported condom use is high in the last sex act with occasional clients, consistent condom use with all clients and partners continues to be a challenge (Reza-Paul et al, 2008;Reza-Paul et al, 2019). PrEP now presents a potential means of addressing this gap (Mayer, Chandhiok, & Thomas, 2016).…”