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Violence experience by perpetrator and associations with HIV/STI risk and infection: a cross-sectional study among female sex workers in Karnataka, south India.

ABSTRACT: Female sex workers (FSWs) experience violence from a range of perpetrators, but little is known about how violence experience across multiple settings (workplace, community, domestic) impacts on HIV/sexually transmitted infection (STI) risk. We examined whether HIV/STI risk differs by the perpetrator of violence.An Integrated Biological and Behavioural Assessment survey was conducted among random samples of FSWs in two districts (Bangalore and Shimoga) in Karnataka state, south India, in 2011. Physical and sexual violence in the past six months, by workplace (client, police, coworker, pimp) or community (stranger, rowdy, neighbour, auto-driver) perpetrators was assessed, as was physical and sexual intimate partner violence in the past 12 months. Weighted, bivariate and multivariate analyses were used to examine associations between violence by perpetrator and HIV/STI risk.1111 FSWs were included (Bangalore=718, Shimoga=393). Overall, 34.9% reported recent physical and/or sexual violence. Violence was experienced from domestic (27.1%), workplace (11.1%) and community (4.2%) perpetrators, with 6.2% of participants reporting recent violence from both domestic and non-domestic (workplace/community) perpetrators. Adjusted analysis suggests that experience of violence by workplace/community perpetrators is more important in increasing HIV/STI risk during sex work (lower condom use with clients; client or FSW under the influence of alcohol at last sex) than domestic violence. However, women who reported recent violence by domestic and workplace/community perpetrators had the highest odds of high-titre syphilis infection, recent STI symptoms and condom breakage at last sex, and the lowest odds of condom use at last sex with regular clients compared with women who reported violence by domestic or workplace/community perpetrators only.HIV/STI risk differs by the perpetrator of violence and is highest among FSWs experiencing violence in the workplace/community and at home. Effective HIV/STI prevention programmes with FSWs need to include violence interventions that address violence across both their personal and working lives.

SUBMITTER: Beksinska A

PROVIDER: S-EPMC6144389 | biostudies-other | 2018 Sep

REPOSITORIES: biostudies-other

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Violence experience by perpetrator and associations with HIV/STI risk and infection: a cross-sectional study among female sex workers in Karnataka, south India.

Beksinska Alicja A Prakash Ravi R Isac Shajy S Mohan H L HL Platt Lucy L Blanchard James J Moses Stephen S Beattie Tara S TS

BMJ open 20180911 9

<h4>Objectives</h4>Female sex workers (FSWs) experience violence from a range of perpetrators, but little is known about how violence experience across multiple settings (workplace, community, domestic) impacts on HIV/sexually transmitted infection (STI) risk. We examined whether HIV/STI risk differs by the perpetrator of violence.<h4>Methods</h4>An Integrated Biological and Behavioural Assessment survey was conducted among random samples of FSWs in two districts (Bangalore and Shimoga) in Karna ...[more]

PMID: 30206080

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Project description:BackgroundLike other women in India, female sex workers (FSWs) frequently experience violence from their intimate partners (IPs)-a reality that increases their risk of acquiring HIV or other sexually transmitted infections. Less is known about the nature of these intimate relationships or what aspect of the relationship increases the risk of IP violence (IPV). We measured the prevalence and determinants of IPV on FSWs in the context of north Karnataka, India, characterized by high HIV-prevalence and extreme poverty.MethodsOverall 620 FSWs with an IP participated in a baseline survey conducted for an on-going cluster-randomised controlled trial aiming to evaluate the impact of a multi-level intervention on IPV reduction. We characterize the nature of intimate relationships and explored determinants of severe physical and/or sexual IP violence using univariable and multivariable analyses.ResultsThe median age of participants was 35 years with 10 years of duration in an intimate relationship. Though most relationships originated from a sex work encounter, 84% stated that IPs did not know they were currently practicing sex work. In past 6 months, the experience of emotional violence was 49% (95%CI:45.2-53.2), physical 33% (95%CI:29.5-37.1) and sexual violence 7% (95%CI:4.8-8.9), while 24% (95%CI:21.0-27.9) FSWs experienced recent severe physical and/or sexual violence from IPs. Factors associated with recent IPV included experience of physical and/or sexual violence from their clients in last 6 months (AOR 2.20; 95%CI: 1.29-3.75), sexual intercourse in the past 1 month when their IP was under the influence of alcohol (AOR 2.30; 95%CI: 1.47-3.59) and providing financial support to their IP (AOR 2.07; 95%CI: 1.28-3.34).ConclusionsThe association between increased risk of violence and provision of financial support to an IP is indicative of gendered power dynamics as men remain dominant irrespective of their financial dependency on FSWs. Interventions are needed that address inequitable gender norms which makes FSWs tolerate violence even though she is not financially dependent on IP. Higher likelihood of violence in presence of alcohol use and FSWs' previous experience of workplace violence linked to IPV call for strengthening the crisis management systems within community-based organisations that can address all forms of violence and associated risk factors.Trial registrationClinical Trials NCT02807259.

Project description:IntroductionFemale sex workers (FSWs) frequently experience violence, harassment and arrest by the police or their clients, but there is little evidence as to the impact that such factors may have on HIV risk or whether community interventions could mitigate this impact.MethodsAs part of the evaluation of the Avahan programme in Karnataka, serial integrated behavioural and biological assessment (IBBA) surveys (four districts) (2005 to 2011) and anonymous polling booth surveys (PBS) (16 districts) (2007 to 2011) were conducted with random samples of FSWs. Logistic regression analysis was used to assess 1) changes in reported violence and arrests over time and 2) associations between violence by non-partners and police arrest and HIV/STI risk and prevalence. Mediation analysis was used to identify mediating factors.Results5,792 FSWs participated in the IBBAs and 15,813 participated in the PBS. Over time, there were significant reductions in the percentages of FSWs reporting being raped in the past year (PBS) (30.0% in 2007, 10.0% in 2011, p<0.001), being arrested in the past year [adjusted odds ratio (AOR) 0.57 (0.35, 0.93), p=0.025] and being beaten in the past six months by a non-partner (clients, police, pimps, strangers, rowdies) [AOR 0.69 (0.49, 0.95), p=0.024)] (IBBA). The proportion drinking alcohol (during the past week) also fell significantly (32.5% in 2005, 24.9% in 2008, 16.8% in 2011; p<0.001). Violence by non-partners (being raped in the past year and/or beaten in the past six months) and being arrested in the past year were both strongly associated with HIV infection [AOR 1.59 (1.18, 2.15), p=0.002; AOR 1.91 (1.17, 3.12), p=0.01, respectively]. They were also associated with drinking alcohol (during the past week) [AOR 1.98 (1.54, 2.53), p<0.001; AOR 2.79 (1.93, 4.04), p<0.001, respectively], reduced condom self-efficacy with clients [AOR 0.36 (0.27, 0.47), p<0.001; AOR 0.62 (0.39, 0.98), p=0.039, respectively], symptomatic STI (during the past year) [AOR 2.62 (2.07, 3.30), p<0.001; AOR 2.17 (1.51, 3.13), p<0.001, respectively], gonorrhoea infection [AOR 2.79 (1.51, 5.15), p=0.001; AOR 2.69 (0.96, 7.56), p=0.060, respectively] and syphilis infection [AOR 1.86 (1.04, 3.31), p=0.036; AOR 3.35 (1.78, 6.28), p<0.001, respectively], but not with exposure to peer education, community mobilization or HIV testing uptake. Mediation analysis suggests that alcohol use and STIs may partially mediate the association between violence or arrests and HIV prevalence.DiscussionViolence by non-partners and arrest are both strongly associated with HIV infection among FSWs. Large-scale, comprehensive HIV prevention programming can reduce violence, arrests and HIV/STI infection among FSWs.

Project description:Little qualitative research is available on the role of frontline health service providers (FHSPs) in the implementation of clinical trials, particularly in developing countries. This paper presents findings from a qualitative study about the perspectives of FHSPs on future HIV vaccine trials involving female sex workers (FSWs) and men who have sex with men (MSM) in three districts of Karnataka, India. In particular, we explore FHSPs' knowledge of and views on clinical trials in general, and examine their potential willingness to play a role if such trials were introduced or implemented in the region.A field team of four researchers from Karnataka-two of whom self-identified with FSW or MSM communities ("community researchers") and two with backgrounds in social work-conducted in-depth interviews with FHSPs. Including community researchers in the study helped to build rapport with FSW and MSM participants and facilitate in-depth discussions. A coding scheme for transcribed and translated data was developed using a framework analysis approach. Data was then analysed thematically using a combination of a priori and emergent codes.Over half of FHSPs demonstrated limited knowledge or understanding of clinical trials. Despite reported skepticism around the testing of HIV vaccines in developing countries and concerns around potential side effects, most FHSPs strongly advocated for the implementation of HIV vaccine clinical trials in Karnataka. Further, most FHSPs expressed their willingness to be involved in future HIV vaccine clinical trials in varying capacities.Given that FHSPs are often directly involved in the promotion of health and well-being of FSWs and MSM, they are well-positioned to play leadership, ethical, and communicative roles in future HIV vaccine trials. However, our findings reveal a lack of awareness of clinical trials among FHSP participants, suggesting an important area for capacity building and staff development before viable and ethical clinical trials can be set up in the region.

Project description:BackgroundFemale sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations.MethodsSamvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these 'intimate' relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017.ConclusionsThis is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence.Trial registrationClinical Trials NCT02807259 Jun 24 2016 (retrospectively registered).

Project description:BACKGROUND:Research has increasingly documented the important role that violence by clients and the police play in exacerbating HIV vulnerability for women in sex work. However few studies have examined violence in the intimate relationships of women in sex work, or drawn on community partnerships to explore the social dynamics involved. A community-based participatory research study was undertaken by community and academic partners leading intimate partner violence (IPV) and HIV prevention programs in Bagalkot district, Karnataka state, India. The purpose was to explore the experience and understandings of intimate partner violence and HIV/AIDS among women in sex work and their intimate partners in Bagalkot that would inform both theory and practice. METHODS:A community-based, interpretive qualitative methodology was used. Data was collected between July and October 2014 through in-depth interviews with 38 participants, including 10 couples, 13 individual female sex workers, and 5 individual male intimate partners. Purposive sampling was done to maximize variation on socio-demographic characteristics. Thematic content analysis was conducted through coding and categorization for each interview question in NVivo 10.0, followed by collaborative analysis to answer the research questions. RESULTS:The results showed that an array of interrelated, multi-level factors underlay the widespread acceptance and perpetuation of violence and lack of condom use in participants' intimate relationships. These included individual expectations that justified violence and reflected societal gender norms, compounded by stigma, legal and economic constraints relating to sex work. The results demonstrate that structural vulnerability to IPV and HIV must be addressed not only on the individual and relationship levels to resolve relevant triggers of violence and lack of condom use, but also the societal-level to address gender norms and socio-economic constraints among women in sex work and their partners. CONCLUSION:The study contributes to a better understanding on the interplay of individual agency and structural forces at a time when researchers and program planners are increasingly pondering how best to address complex and intersecting social and health issues. Ongoing research should assess the generalizability of the results and the effectiveness of structural interventions aiming to reduce IPV and HIV vulnerability in other contexts.

Project description:BackgroundStudies have demonstrated the significance of commercial sex work in the ongoing transmission of HIV and other sexually transmitted infections (STIs) in India. Clients of female sex workers (FSWs) are thought to be an important bridging population for HIV/STIs. However, there is a lack of information on basic characteristics of sex work clients. This study sought to describe the prevalence of HIV and other STIs, as well as examine the determinants of these pathogens among a sample of clients in south India.MethodsData were from a cross-sectional biological and behavioural survey of FSW clients from six districts in Karnataka State, India. The prevalence of HIV, syphilis, herpes simplex virus type 2 (HSV-2), chlamydia (CT) and gonorrhoea (NG) among clients was examined. Multivariable logistic regression models were used to analyse the socio-demographic, sexual behaviour and sex-work related characteristics related to the prevalence of each pathogen. Sampling weights and appropriate survey methods were utilized in regression models to account for complex sampling design.ResultsThe total sample size was 2,745. The average age of clients was 30.4 (SE:0.3). Across the total sample, the prevalence of HIV, HSV-2, syphilis and CT/NG was 5.6%, 28.4%, 3.6% and 2.2%, respectively. The prevalence of HIV/STIs varied substantially across districts, reaching statistical significance for HIV (p<.0001) and CT/NG (p=.005). In multivariable models, duration of paying for commercial sex was associated with increased risk for HIV and HSV-2 (AOR: 1.1; 95%CI: 1.0-1.1, p<.0001). Clients with brothels as a main FSW solicitation site were associated with increased risk of HIV (AOR: 2.4; 95%CI: 1.2-4.7, p=.001), while those frequenting lodges were at increased risk for CT/NG (AOR: 6.3; 95%CI: 1.9-20.6, p=.03). Examining co-infections, clients with HSV-2 infections were at substantially higher risk of being HIV-positive (AOR: 10.4; 95%CI: 6.1-17.7, p<.0001).ConclusionsThis study fills in important gaps in knowledge regarding clients in southern India. The strong association between HIV and HSV-2 infections highlights the complications in designing effective prevention, intervention and management programs of this well-hidden population.

Dataset Information

Violence experience by perpetrator and associations with HIV/STI risk and infection: a cross-sectional study among female sex workers in Karnataka, south India.

Publications

Violence experience by perpetrator and associations with HIV/STI risk and infection: a cross-sectional study among female sex workers in Karnataka, south India.

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