Background

A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and

considerations for implementation and scale-up

Deanna Kerrigan, Caitlin E. Kennedy, Ruth Morgan-Thomas, Sushena Reza-Paul, Peninah Mwangi, Kay Thi Win, Allison McFall, Virginia A. Fonner, Jennifer Butler

Background

• Sex workers’ risk for HIV infection occurs within a context characterized by powerful structural constraints

• Sex workers are exposed to multiple forms of stigma, discrimination & violence e.g. occupation, HIV, gender

• Without addressing these factors, the HIV response among sex workers is likely to be limited in its effectiveness

Definition

• Community empowerment-based response to HIV: a process by which sex workers take collective ownership of programs to achieve the most effective HIV outcomes and address social and structural barriers to health & human rights

• It has been a UNAIDS Best Practice for more than a decade

Rationale

• Evaluations of community empowerment efforts have shown it to be a promising approach to reduce HIV among sex workers

• Mathematical modeling suggests comprehensive community empowerment efforts among sex workers can significantly reduce HIV incidence among sex workers and the general adult population

Despite this encouraging

evidence, investment has

been limited

≠

Methods

• Comprehensive review of the peer-reviewed and practice-based literature on the implementation, effectiveness, measurement, and barriers and facilitators of a community empowerment responses to HIV among sex workers globally

• Nested systematic review and meta-analysis (n=30,325 from 22 studies) of the effectiveness of community empowerment on HIV-related outcomes in low- and middle-income countries

• Four case studies highlighting the structural challenges faced by sex workers across settings and their collective responses to reduce their HIV risk and promote health and human rights

Approach

• Community empowerment is an approach, set within a broader health and human rights framework, which shapes and creates synergy across intervention components (biomedical, behavioural, structural)

• Cannot be reduced to a specific activity (e.g., a drop-in-center or other “mobilization” activities)

Implementation

• Community empowerment often starts with the promotion of internal social cohesion and ensuring a safe space to gather

• Mobilization of collective power and action to address the social and structural context of HIV risk

• Sex worker participation in processes to influence access to material resources

Effectiveness

• Community empowerment among sex workers was significantly associated with improvements in all outcomes in meta-analysis

Outcome Combined odds ratio from meta-analysis

95% confidence interval

HIV 0.68 0.52, 0.89

Gonorrhea 0.61 0.46, 0.82

Chlamydia 0.74 0.57, 0.98

High-titre syphilis 0.53 0.41, 0.69

Consistent condom use with:

All clients 3.27 2.32, 4.62

New clients 3.03 1.89, 4.86

Regular clients 2.90 2.22, 3.78

Measurement

• Traditional HIV prevention indicators are still being used:• Access to clinic, peer

educator, educational materials, condoms

• Only a few specific community empowerment measures exist:• Processes of social

cohesion & mobilization• Changes at the community

and structural levelsInnovation in measurement

needed to document pathways

Barriers & Facilitators

Case Study: Ashodaya Samithi

Conclusions

• Community empowerment holds significant promise as an effective approach to reduce HIV risk among sex workers

Evidence is consistent and compelling Integration with combination prevention

• Findings highlight important challenges associated with expanding community empowerment efforts

Changing the global discourse Recognition of sex work as work

• Greater support is needed to enable sex worker groups to more effectively and sustainably overcome barriers identified

Funding for sex worker-led groups Support for practice-based evidence

Acknowledgments

• Thanks to the following people for their contributions:• The sex workers who led and participated in the research

and programmatic efforts which are the basis of this analysis• The experts and members of the NSWP listserv who

responded to our requests for relevant articles and reports• Laura Murray for her help developing the Brazil case study• Gina Dallabetta for her assistance clarifying information

about data from the Avahan project• Andrea Blanchard, Kim Blankenship, and Mandar Mainkar

for providing additional information about their articles included in the review

• The editorial and technical team of the Lancet Series, particularly Zena Nyakoojo and Pam Das